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A Transnational Syndemic: Cook Islanders and Their Experiences of TB and Diabetes

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A Transnational Syndemic: Cook Islanders and Their Experiences of TB and Diabetes http://researchspace.auckland.ac.nz ResearchSpace@Auckland Copyright Statement The digital copy of this thesis is protected by the Copyright Act 1994 (New Zealand). This thesis may be consulted by you, provided you comply with the provisions of the Act and the following conditions of use: • Any use you make of these documents or images must be for research or private study purposes only, and you may not make them available to any other person. • Authors control the copyright of their thesis. You will recognise the author's right to be identified as the author of this thesis, and due acknowledgement will be made to the author where appropriate. • You will obtain the author's permission before publishing any material from their thesis. To request permissions please use the Feedback form on our webpage. http://researchspace.auckland.ac.nz/feedback General copyright and disclaimer In addition to the above conditions, authors give their consent for the digital copy of their work to be used subject to the conditions specified on the Library Thesis Consent Form and Deposit Licence. A Transnational Syndemic: Cook Islanders and their experiences of TB and diabetes Evelyn Marsters A thesis submitted in fulfilment of the requirement for the degree of Doctor of Philosophy in Development Studies, University of Auckland, August 2013 ABSTRACT This thesis focuses on the influence transnationalism has upon the health of Cook Islanders. Central to this enquiry is the relationship between Cook Islanders’ population mobility and the unequal burden of diseases such as TB and type 2 diabetes. The research explores the contextual and mechanistic impact transnationalism has within the Cook Islands TB and type 2 diabetes syndemic. I argue that a syndemic orientation to health research allows potential health risks to be investigated within a constellation of interacting biological, socioeconomic, cultural and political conditions. From the outset, TB and diabetes are considered to interact in ways beyond the biological, and harmful social conditions, to act synergistically to increase the burden of disease. This research is significant and timely because the type 2 diabetes epidemic has recently been acknowledged as a significant factor in accelerating the rate of TB globally, and in the Western Pacific region. In simple terms, TB triggers diabetes or when diabetes is already present, diabetes acts as a risk factor for the development of TB. The interaction between TB and diabetes poses a particular threat for the Cook Islands population given suspected high levels of latent TB within older cohorts of the population and existing high levels of type 2 diabetes. Although current case numbers of TB are low in the Cook Islands and among Cook Islanders in New Zealand, this thesis provides evidence that active transmission of TB does exist. Drawing on empirical qualitative data drawn from interviews and observation this research is able to conclude that poverty, poor nutrition, stigma, delayed diagnosis and household overcrowding are significant factors that act synergistically within this syndemic to exacerbate illness. Central to this research are the health and mobility stories of Cook Islanders who have experienced either or both diseases. In order to capture the transnational behaviours and the possible implications they have for their health, participants were interviewed in multiple locations in New Zealand and the Cook Islands. Purposively transnational in design, this research incorporates the perspectives of Cook Islanders living in the Pacific Islands of Aitutaki and Rarotonga, and the metropolitan suburbs of Avondale, Otara, Glen Innes and Porirua. It explores the transnational social field with regards to health and health service access for Cook Islanders in each of these places. The complexities of health ii and mobility stories lend themselves to narrative analysis and pictograms as a way of illustrating that a Cook Islands TB-diabetes-transnationalism syndemic exists. That this syndemic exists leads to a discussion on the relationship between health, development and transnationalism. This debate throws light on the limitations of nation- centred approaches to health services and highlights both the linkages and gaps in health services for the Cook Islands population. By looking more deeply at the inherent connections between diseases it raises questions about the way in which health research is framed, who our research is for, and whether or not such a view is sustainable for the future. Keywords: transnationalism, syndemics, New Zealand, Cook Islands, health, TB, type 2 diabetes iii ACKNOWLEDGEMENTS This research project would not have been possible without financial support from the Health Research Council of New Zealand and the University of Auckland. The ‘Transnational Health in the Pacific through the Lens of TB’ project provided the platform for this research and contributed to important contemporary understandings of transnational people in New Zealand and the Pacific. The project members provided me with both the knowledge and the confidence to undertake this study. Special thanks to Professor Julie Park, Associate Professor Judith Littleton, Sagaa Malua, Dr Jennifer Hand, Debbie Futter-Puati and Tufoua Panapa for providing the sounding board for my on-going conceptualisations of this research. At the centre of my academic support network were my three supervisors. Professor Julie Park is such a skilled PhD advisor that I feel very privileged to have been under the guidance of such an accomplished academic. Dr Yvonne Underhill-Sem and Dr Ward Friesen have inspired me in the realm of Pacific research for some time. It was a pleasure and an advantage to work so closely with regional experts. Meitaki Maata. Several organisations were instrumental in connecting me with interview participants and developing my contextual understanding of the research project. A huge thanks to the Ministry of Health in New Zealand and the Cook Islands, The Pacific Paramedical Training Centre, The Auckland District Health Board, Public Health Nurses Kathy, Metua and Teremona, and Social Welfare Officer Kitiona. I am also grateful for the Cook Islands Health Network Advocacy group for their support and assistance with the scoping phase of this research. Many thanks also to Damon Keen from 3 Bad Monkeys who provided the technical and design skills to transform my case studies, maps and conceptual figures into imagery. I would also like to acknowledge the copy editing work of Pauline Herbst. The participants of the interviews were generous with their time and their stories. Meitaki maata no to'ou tauturu. To my colleagues at the Centre for Development Studies, thank you for the reciprocal exchanges of the trials and tribulations of PhD life. Thank you especially to Hilary, Akiko, Tufoua and Sue for your friendship. iv I would also like to make a special tribute to my Cook Islands family for assisting me through my research and identity journeys over the last 10 years. This includes Aunty Stella (Dawn), Aunty Noni, Uncle Arthur, extended family in Avatiu and of course my Grandmother Mama Sarah Marsters. This thesis is part of a very powerful moment in my life. Amazing family and friends have eased the tension, given time and extended support when needed. My parents Simon and Jennifer and parent-in-laws Dave and Sue, without your support and enthusiasm for life long education this would not have been possible. This degree represents just one of the ways I have grown as a person since meeting my husband Dylan. We work so well together that even the ridiculously challenging appears to be a fun opportunity. Thank you for understanding the importance of my work. To my children, Abel Jackson and Nina Pearl, the spirit you bring to our family puts everything into perspective. Thank you for the distraction and the joy. Lastly, this thesis is dedicated to a transnational health worker I met during my Master’s research in Mauke, the Cook Islands. Dr Colleen Lal from Myanmar worked extensively in the outer Cook Islands and has a deep respect and love for the Cook Islands people. She transformed many Cook Islanders lives, including my own. Thank you Aunty Colleen for sparking my interest in Cook Islands health and development. v TABLE OF CONTENTS ABSTRACT ___________________________________________________________________________________ ii ACKNOWLEDGEMENTS _____________________________________________________________________ iv TABLE OF CONTENTS _______________________________________________________________________ vi LIST OF FIGURES _____________________________________________________________________________ ix LIST OF ABBREVIATIONS AND GLOSSARY _________________________________________________ x CHAPTER ONE Background to the research ________________________________________________ 1 TB as a lens ________________________________________________________________________________ 3 Why diabetes? _____________________________________________________________________________ 5 The research question _____________________________________________________________________ 6 Research participants ______________________________________________________________________ 7 Cook Islanders in New Zealand ____________________________________________________________ 8 Cook Islanders in the Cook Islands ________________________________________________________ 8 Cook Islands research participants _______________________________________________________ 11 Thesis structure ___________________________________________________________________________
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