In 1978, cholera swept across the Maldives, with one in 12 of the country's 140,000 population affected. Urgent requests were made to the World Health Organisation (WHO) and UNICEF for transportation, medical equipment and vaccines which were promptly administered – sometimes by force – to the islanders. Two hundred had died by the time the epidemic was declared under control five months later.
"Medicines, trained medical personnel, and funds were all insufficient," noted a report at the time from the US Office of Foreign Disaster Assistance, which contributed to the international community's USD 670,000 relief effort.
While the 1978 epidemic is part of living memory of older Maldivians it would be like ancient history for most of the country's population – around 45 percent of whom are under 25 years old. The country, relatively unknown to outsiders in the late 1970s, now has a population of 350,000. Rapid development has transformed the society and its healthcare, with communicable diseases all but eradicated within a few years.
Having been the scourge of many seafarers due to its hazardous reefs and infamous fevers, the country now welcomes over one million tourists every year. While the Maldives is now classed as a developed country – one of only four to graduate from the UN's 'less developed' tier – ailments more often associated with underdeveloped societies abound, leaving health authorities with a unique blend of challenges. Malnourishment in the atolls exists, alongside an obesity epidemic among other segments of society, while sex education for a youthful nation is blocked by conservative voices in this '100 percent Islamic nation'.
Appearing on state television recently, a government minister noted that the country had the highest GDP per capita in Southasia, and that life expectancy had increased by 30 years since 1977. The minister also spoke about infant and maternal mortality rates that had both dropped by 95 percent in the last four decades. Similarly, in February 2016, President Abdulla Yameen wrote an op-ed for the Washington Post pointing out the country's record on extreme poverty and hunger reduction, which has improved by 94 and 57 percent respectively since 1998, he said.
Both Yameen and his minister were of course using these statistics to assure outside observers that the country was no 'banana-republic', a conclusion one could easily reach when viewing the increasingly tyrannical actions of their embattled government. As the Maldives strives to develop a stable, modern democracy, the population's health needs are also becoming more diverse, requiring good governance and progressive leadership that the creeping authoritarianism will struggle to address.
Shifting sands
The Ministry of Health's 2014 'Health Profile' noted that the Maldivian healthcare system was going through an "epidemiological transition", with the dual challenge of: "controlling non-communicable diseases and addressing social determinants of health while also continuing to strengthen preparedness and control of emerging and re-emerging communicable diseases."
Until a few decades ago, periodic epidemics of bodu roaga (big disease) as well as external shocks to global trade would lay bare the Maldives' extreme vulnerability, with local influenza outbreaks and global conflict sending infant mortality rates soaring in the 1940s. While cardiovascular diseases, chronic respiratory illness, and cancers are now the leading causes of death, the 2014 report displayed the growing complexity of the health burden in the archipelago. It showed that two in five people were affected by acute respiratory infection in 2014, around one in six by viral fever, and that one in 18 suffered from gastroenteritis. Scrub typhus and toxoplasmosis were described as endemic.
As communicable diseases receded into the past, Maldivians discovered a new plague in their midst, with the genetic blood disorder thalassemia now found to affect one in five Maldivians –the highest incidence rate in the world. The selective survival advantage of this anaemia-like illness increases its perpetuation among small populations, such as the Maldives island communities, which traditionally avoided inter-island marriages. The condition causes iron overload and bone deformities and requires careful management and regular blood transfusions.
The isolation of most parts of the archipelago has always made provision of basic health care problematic. With 187 inhabited islands, spread over tens of thousands of kilometres, the Maldives contains one of the most dispersed populations on the planet. Indeed, the success of the country's tourism industry in recent decades came despite warnings from experts that such isolated island resorts could not be sustainable. Infrequent transport links within and between atolls have persisted despite the tourism boom, however, with around 40 percent of the country's tourist beds located within the same atoll as the cramped capital city. Also squeezed into the five square kilometre island of Male are the only two tertiary hospitals in the country, the state-run Indira Gandhi Memorial Hospital (IGMH) – established by India in the 1990s, and the privately run ADK Hospital.
The latter's managing director, Ahmed Affal, believes that the country may struggle to make the changes needed to combat the challenges of a modern nation-state. He argues that the switch to curative healthcare has left the country exposed to recurrences of illnesses such as dengue fever, spread by mosquitoes. The last case of malaria in the country was recorded in the early 1980s, with the Maldives becoming the first in the Southasia to be declared officially malaria-free in 2015. Months before the declaration, however, an outbreak of dengue fever had forced the government to shut down schools as thousands of cases were reported.
"We have more resources now, but have not been able to do enough," remarks Affal on the disease which claimed a record high of 12 lives in 2011. He argues that there is an excessive reliance on foreign donors for awareness-raising programmes, while the country's eligibility for such schemes, from which it has already benefited disproportionately in recent decades, is waning.
Health tourists
Concurrent with the Maldives meteoric economic growth – to its current position as the richest economy in Southasia (per capita) – the state has one of the best doctor-to-patient ratios in the region (1:609), while health expenditure per head is also among the best in Southasia. All of the health-related Millennium Development Goals were achieved, but there are fears that treatment abroad, preferred by the rich, may have begun to harm the development of healthcare in the archipelago.
The 2014 'Maldivians Travelling Abroad' survey showed that nearly 60 percent of those questioned at the airport were found to be leaving for medical treatment, with India and Sri Lanka as the main destinations. National health insurance covers treatment at selected hospitals overseas, with Maldivians employed to facilitate their compatriots seemingly limitless desire for treatment. "Over the years – through our insurance system – we have encouraged a lot of people to seek care abroad," said Affal. "If you look at the amount of money we have put into the Indian and Sri Lankan health sector, they have developed on Maldivian expenditure."
The first Indian health expo was held in Male in February, with 18 hospitals parading their services to the public. This trend of foreign treatment is also said to impede data collection on public health, further hindering a government that is not known for evidence-based policy making.
Despite the bankruptcy of the state's first free health insurance scheme within months of its introduction in 2012, one of the first acts of the present government was to introduce an unlimited scheme two years later, including free transport overseas. Cathy Waters was the CEO of IGMH in Male during the introduction of the universal healthcare scheme titled 'Aasandha'. Initially offering USD 6500 free healthcare for every citizen, the scheme saw 11 percent of the population seek treatment in the first 14 days.
This first experience with universal health care demonstrated the need to reduce the health burden with a greater understanding of personal health. With outpatients reportedly still making up around 70 percent of expenditure in the scheme, there have been calls for greater education on self-care and health education. "There is very little emphasis on self management of illness and health, and little focus on health promotion and chronic disease management," explained Waters, whose attempts to introduce a triage system, a process to determine the priority of patient, were hindered by the general hysteria that accompanies relatively minor injuries.
"Maldivians tend to panic about things you or I would describe as fairly minor healthcare issues," Waters told Minivan News in 2012. "If you were to cut your finger and it bled, you would probably hold a tissue on it, wrap something around it and deal with it yourself. Here, people panic at the slightest bit of blood."
Both Affal and Waters argue that one of the major issues facing the country is the lack of regional facilities, and the poor utilisation of local resources. While the Maldives has six regional and 13 atoll level hospitals, the decentralising plans of previous governments have been rolled back. With enhanced regional transport links also a casualty of the country's recent political flux, the hub of Male continues to be the main port of call for all but the most basic treatments. A number of tragic incidents in the outlying facilities sparked public protests and criticism of the system, prompting healthcare officials to point to chronic underfunding. In one notable incident, a heart-attack victim in the northern atolls passed away when her oxygen tank ran out, after having waited for two days to be transferred to Male.
Highlighting the general disparity between the quality of life in the islands and in the capital, the UNDP's 2014 Human Development Index noted that those in the islands were falling further behind in the face of non-communicable diseases. "Many of the islands have impressive buildings but the health resources are missing. Quality of service is largely constrained by the lack of competent doctors and nurses available and their willingness to reside in the islands. Other issues include the lack of maintenance of infrastructure and machinery in the health facilities on these islands," the report stated.
Minister of Health Iruthisham Adam recently reported that extensive infrastructure work has been completed across the islands, and that the government has introduced sea ambulances for the first time. She said the government has plans to more than double the number of islands with proper sewerage systems, bringing the total to around 50 percent of communities. As far as the tourist resorts are concerned, they invariably have a medical team for basic first aid, while for emergencies guests are evacuated to Male.
Access to vital blood transfusions, required monthly by the Maldives' more than 600 thalassemia patients, has improved in recent years. There are now over 80 transfusion centres across the atolls and recently opened state pharmacies bring the prospect of better access to drugs that rid the body of harmful excess iron. As with other more complex treatments, however, patients have to travel to the capital regularly for tests and treatment.
"Most blood examinations are not available in the atolls," explains Abdul Muiz Hassan, a volunteer at the Thalassaemia Society of Maldives. While treatment and travel costs are supposed to be covered by the government under the 2012 Thalassaemia Act, Muiz says that citizens are still being forced to pay for flights on the national carrier – a result of administrative inertia, he adds. Other problems have accompanied the recent turbulences in the halls of power, with Muiz suggesting that previous awareness raising campaigns had been disrupted by political upheavals in the capital, hitting the islanders hardest. "Most are struggling in the atolls because they are not aware of the effects [of thalassaemia] on the body. It is easier to raise awareness in Male." But even Male does not provide the specialist resources to carry out certain tests required to gauge the damage caused to vital organs by iron overload. For this, patients must travel abroad, while a select few have travelled to Italy for bone-marrow transplants, paid from the central zakat fund.
It would seem that the precarious reality of life in the scenic atolls can be alleviated but never overcome. More hazardous to health than the country's beautifully awkward geography, however, may be the lifestyles adopted by its citizens.
Island life
The anthropologist Clarence Maloney visited the atolls in 1975, later producing the first modern study of Dhivehi society, which had only just begun to open itself up to the world after millennia of relative isolation. In the preface to the second edition of the remarkable People of the Maldive Islands – published in 2013 – he noted that "massive changes in just one generation" meant that his work now served more as a historical snapshot of a rapidly evolving society.
Such changes have combined old and new health challenges as the community of mostly isolated fisherfolk has transformed almost overnight into one with globally connected consumers. The population is adjusting gradually to modern medicine, with traditional beliefs continuing alongside the thirst for modern healthcare. Indeed, President Yameen himself seems to be a firm follower of the traditional practice of fanditha – a mystic blend of superstition and herbal medicine, with a number of bizarre incidents recently ascribed to attempts to improve his own health and to damage that of his enemies. By and large, however, such beliefs are less common than in previous decades – particularly among the Male elite.
Yet one old-fashioned feature of Maldivian health that has remained unchanged is the poor diet. The difficulty in obtaining sufficient nutrition in the middle of the Indian Ocean is now taking on new importance in a territory consisting of 99 percent water. Fishing has always been the main source of nutrition for Maldivians, and tuna has been the staple of both the economy and the dinner table long before tourists arrived. The coconut palm, traditionally used for everything from boat building to fuel, provides the second half of the somewhat binary cuisine, besides gracing the national emblem. The sparse arable land in the country has proved less than fertile, never developing beyond subsistence levels. (Dhivehi terms for 'farming' and 'agriculture' have only been added recently to the official dictionary.)
Unsurprisingly, high rates of malnutrition and vitamin deficiency continue to be reported today, particularly in the more isolated parts of the country. Despite the improvement in hunger reduction, government surveys in 2009 revealed that around 20 percent of under-five-year-olds showed evidence of stunting, while more than half showed iron and Vitamin A deficiencies. Government research in 2015 noted that the risk of malnutrition was "alarmingly high" among elderly people, while a country-wide health screening of Grade Seven pupils indicated that most health problems were due to children being underweight. Significant disparities in malnourishment have been noted between the islands and Male.
The cultural barriers to introducing more nutritional value into eating habits, developed over centuries with very few fruits and vegetables, have been highlighted by the WHO. It found that in 2011 around 94 percent of Male residents consumed only one of the recommended five portions of fruits and vegetables per day despite the capital having the only fresh produce market in the country. The report suggested that these patterns represented a lack of nutritional awareness besides affordability issues.
Another symptom of poor diet can be seen in the opposite trend, that of obesity. With few natural sources of carbohydrates native to the Maldives, the import of rice and wheat from the mainland had long been considered a luxury. But the relative abundance of calorie-dense products today has proven harmful when combined with the increasingly sedentary lifestyle of Maldivians. Statistics from the WHO suggest that nearly half of the population is not getting the recommended daily level of physical activity, particularly in Male. In short, the Maldives has become the most overweight nation in the SAARC region, with 17 percent of women and nine percent of men reported to be obese.
Dr Hassan Ugail, better known as the Maldives' only professor of science, recently turned his attention to healthy lifestyles, publishing the Dhivehi language book Sihhee Hadhiyaa (The gift of health). In it, he expounds the benefits of non-processed food diets as well as active and stress-free lifestyles, arguing that the nation's health may be going backwards. "We have imported all the bad eating habits from the developed world," says Ugail, who works as the Professor of Visual Computing at the University of Bradford, but writes regularly on scientific matters for Dhivehi readers.
"In the Maldives, 50 years ago, Maldivians were extremely healthy people, but malaria and other such diseases were still present," he says, suggesting there is an urgent need to promote healthy and traditional lifestyles among the small and vulnerable population. Meanwhile, Maloney cites foreign doctors' who in the 1970s had observed generally low levels of cholesterol and an absence of hypertension among Maldivians (the very ailment which inspired Dr Ugail to investigate the topic).
There has been a steady move towards modern concepts of health and fitness in recent years, with a number of gyms popping up across the capital. The current government has made positive steps to open up the island's endangered public spaces, recently redeveloping Male's west side to include an outdoor gym. Pledges were also made to introduce a running track for joggers who currently have to compete with heavy traffic.
The matrifocal nature of island life would have previously seen women managing the home, while fishing was a near universal activity among males (today, just one in 20 men work as fishermen). It can be argued that modern trade links may even have harmed nutritional health as a growing demand for imported goods along with the arrival of refrigerated ships in the 1970s saw the amount of fish consumed by Maldivians fall in favour of exporting fresh catch.
Of particular concern is the apparent rise of diabetes in the country as a result of poor diet, which threatens to put an intolerable strain on public health resources as sufferers' become more prone to strokes, cancers, and heart diseases. The Diabetes Society of Maldives, who are currently analysing the results of the first nationwide diabetes survey, has previously found prevalence rates of 8.1 percent for type 2 diabetes. More alarming was the discovery that, of the 19,521 people surveyed, 82 percent were considered 'high-risk', which meant there were strong indicators that they would succumb to diabetes.
"If we are not able to intervene, this is going to be a huge burden on the system," says the society's CEO Aishath Shiruhana, revealing that obtaining insulin has already become a problem for the import-dependent Maldives. She noted that awareness levels of the disease were low, with few in particular making the link between health and diet. She also pointed out a tendency to turn to exercise only after developing illness.
Future well-being
The lifestyles of the under-25 youth category of the population warrant particular attention. Constituting just under 50 percent of the population, they dictate both the country's present and future well-being. A 2014 World Bank report blamed the healthcare system for failing to meet the needs of the youth, focusing too heavily on curative care and sidestepping sexual health issues.
Nearly half of all Maldivian men smoke, and smoking rates among young Maldivians are among the highest in Southasia, with over 40 percent of those aged 20-24 regularly lighting up; this points to a future health burden of cancers and lung disease.
A more recent dietary issue exclusive to the youth market is that of energy drinks. The average Maldivian youth is rarely seen without the telltale can in his hand as the number of brands vying for market share has reached double digit figures. Sponsorship of events and brash promotional shows draw in the youth market, many of whom seek to alleviate lethargy induced by poor diet and physical inactivity by consuming copious amounts of energy drinks.
A growing international body of evidence linking high consumption of energy drinks to cardiovascular disease is augmented by recent incidents of young men suffering heart attacks in the Maldives. While many believe such drinks are consumed more readily in Muslim countries where alcohol consumption is illegal (outside of the resorts in Maldives), it appears that this choice of beverage is also damaging the overall health of the nation.
Moreover, being born into a more modern nation-state has not shielded young Maldivians from the country's many contradictions. The public refusal to openly discuss sexual health certainly does not protect them from sexually transmitted diseases.
Clarence Maloney noted the prevalence of venereal disease, describing the stark contrast between idealised and actual sexual behaviour as "cultural schizophrenia". He wrote more than 40 years ago, "Prudishness is seen as piety," the statement still rings true. Saudi-inspired religious conservatism has intensified while the burgeoning youth population makes the need for honest discussions about sex more important than ever.
Conservative religious beliefs have been cited with regards to the failure of women to seek appropriate reproductive healthcare, while unsafe abortions are another long-standing problem that festers beneath the veneer of Islamic piety. Religious law has traditionally met the practicalities of island life half-way, with six months still considered the minimum legal term of pregnancy, giving those caught out by pre-marital trysts an opportunity to avoid a public flogging. Attempting to obtain contraception for unmarried people can be perilous, and research suggests that up to 90 percent of sexually active young people are not taking safe-sex precautions, while just a quarter of married couples are using modern forms of contraception.
Indeed, most young people will have had little or no formal sex education before they attend mandatory pre-nuptial marriage classes at the Family Court. Eager young couples are subsequently terrorised with images of diseased genitalia, while being asked not to report what they have witnessed to friends and family. While theoretically committing to lives of monogamy, most of these couples are likely to have multiple sexual partners in their lives; the Maldives divorce rate remains the highest in the world, with marriage registration forms leaving 14 lines on which to list ex-wives and ten for ex-husbands.
While still relatively rare in the country, the issue of HIV/AIDS, first diagnosed in the Maldives in 1991, has long prompted fears due to the high-risk behaviour of the youth. Once described by authorities as a 'time bomb', the issue has again highlighted the conflicts that every culturally conservative nation has to face. "We can simply stay inactive and keep talking for any amount of time by assuming the moral high ground," said former Minister of Health, Dr Ahmed Jamsheed, while in office. "That is to claim that we are Muslims, and by living in a Muslim state, in Muslim ways, we are doubtless protected from this disease. But that is never the reality anywhere in the world."
As well as the higher-than-acknowledged levels of promiscuity and the continued criminalisation of homosexuality, the relatively modern issue of narcotics use is regarded as the activity most likely to detonate the HIV/AIDs explosion. While the reality of hard-drug use in the islands was played down for many years after it emerged in the 1990s, the government has finally accepted that illegal narcotics, heroin in particular, have become a major issue in Maldives. The country's first National Drug Use Survey, in 2012, revealed there were 7500 drug users in the country. The majority are aged between 15 and 24, with 40 percent of them using heroin.
Political drama
Unfortunately, no story about Maldivian society is complete without reference to the country's politics. While recent events have made headlines, they merely serve as a continuation of the fractious soap opera that has always touched on all areas of life in the islands.
Indeed, the healthcare system has become a regular player in the drama, with the powerful and well-connected able to utilise the country's limited services to evade prison sentences handed down in a seemingly arbitrary fashion from the country's much-maligned courts. The most famous case recently has been that of former President Mohamed Nasheed, who was allowed to seek treatment part-way through his 13-year prison sentence despite the home minister's protestations that the required operation could be performed in Male. But his is not the first instance of its type as medical leave seems to have replaced banishment to distant islands as the political elite's way of purging the capital of those deemed persona non grata.
While the long-term affliction of dictatorship appeared to have abated in 2008, an apparent relapse suggests that endemic corruption will continue. Elections continue to be waged using the old fashioned levers of patronage, as fat cats from the capital descend on the islanders, offering refrigerators, air conditioners, and medical assistance. While additional hospitals are continually promised in the north and south, those in the remote islands continue to face a choice between home and accessible tertiary health care.
Male's rulers have long recognised that power in the sparse archipelago can only be maintained by concentrating services in the capital, enforcing fealty as a few families maintain their grip on the islands. While the previous government had promised to divide the country into regions, and introduced political decentralisation, a messy transfer of power in 2012 saw a return to traditional hierarchy, with autonomous councils and plans for improved transport links giving way to grandiose schemes for the capital.
While President Yameen has sought to improve public spaces in the capital, acknowledging that Maldivians should not have to 'seek shelter in a concrete jungle', he has also stated that public services cannot be sustained in all inhabited islands, urging young people to relocate to the artificial island Hulhumale – a part of Greater Male. Dubbed the 'youth city', the project was started during the rule of Yameen's half-brother Maumoon Abdul Gayoom, whose strict system of centralised patronage saw him tame the country's wild politics for three decades between 1978 and 2008.
While cramming the entire population into the ever-sprawling Male may ease access to curative health care, the long term benefits for public health are questionable, as islanders give up life in the atolls for the cramped and polluted metropolis. Since the cholera outbreak in 1978, the capital's population has increased by an average of 14 percent a year, with Male now housing four in every 10 citizens (up from two in 10 in 1978). Apologetic artificial beaches now bookend the capital's main thoroughfare, though the fumes of 50,000 vehicles burn the throat of anyone travelling between the two. Indeed, there is a strong argument that the cramped quarters and mazy streets are in fact increasing the latent danger of communicable disease.
Affal of ADK Hospital argues that better city planning is needed to promote healthy lifestyles, decrying the failure to develop specialised services outside of Male: "There are some who still feel all major services should be located in Male. I personally do not believe that, but political will has been lacking over many years."
Furthermore, the over-reliance on foreign healthcare alongside the government's often dismissive attitude to foreign partners often leaves the public's health at risk. Indian anger, nominally at the persistent mistreatment of its expatriate workers (though more likely caused by the unlawful eviction of one of its largest investors) saw visa regulations tightened in 2012. Similarly, after playing fast and loose with Sri Lankan extradition laws while the Male government was hunting political opponents last year, Maldivians are facing greater difficulties when passing through immigration procedures at Colombo.
The influx of tourist money and the transition to democracy have contributed to the public's heightened expectations on healthcare. Wild promises and lavish spending have positioned the government's curative health policy as a cure-all for the country's declining health, but the reality is that the modern medical issues facing Maldivians will not wait for political stability. Heart disease will not wait for official corruption to be tamed and diabetes does not much care whether a house is painted pink or yellow on election-day.
From antidote to affliction
The Maldives has largely overcome many of the traditional health problems facing a modernising country, and in an impressively short time. Now it faces the task of developing curative services that can handle the approaching tidal wave of 'lifestyle' diseases.
Government intervention has been effective in dealing with non-communicable illnesses, introducing a strong vaccination culture and ridding the country of the malaria and other illnesses that had in the past made these pristine isles so deadly. But continued development of the healthcare system will be needed to provide for the growing demands of a young nation. In a country as isolated as the Maldives, people will always have to travel to obtain good care, and outbreaks of new illnesses will always test the quality of health services. But having to come to Male or overseas is unacceptable for a middle-income country, and new curative services will not remove the need for preventive community-level care that cuts through old stigmas.
In terms of public health, only time will tell whether the Maldives' rapid development will be transformed from antidote to affliction.
~Daniel Bosley is a journalist in the Maldives.
This is an article from our print issue, 'At the cost of Health'. See more from the issue here.