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5 Chapter 1 Introduction and Historical Background This book examines the history, ethnography, and medical anthropology of tobacco in the world region known as Oceania or the Pacific Islands. Part one draws together historical material on the introduction and spread of tobacco in Island Oceania and explores the ways Islanders have incorporated tobacco into their lives as reported by ethnographers. In part two, attention turns to the health problems linked to tobacco—particularly to the smoking of industrially manufactured cigarettes—and the huge burden of sickness this places on individuals, communities, and the various Pacific Island countries and territories (PICTs) in the twenty-first century. The medical anthropological focus in the second part of the book draws on a variety of clinical, epidemiological, nutritional, and public health research plus a good dose of the multidisciplinary work that is devoted to tobacco control. The main causes of death for Pacific Islanders today are from noncommunicable diseases (NCDs) such as coronary heart disease, cancer, diabetes, and chronic obstructive pulmonary disease (COPD). Prior and Tasman-Jones (1981) refer to this collection of maladies as “the smoking diseases,” and I appropriate their phrase as a cover term in what follows. These ailments have multiple causes, many of which reflect the profound changes that have occurred in Islanders’ lives, especially over the past half-century, including a new diet high in saturated fats, sugar, and salt, much lower levels of physical exercise that contribute to obesity, heavy use of alcoholic beverages, and the widespread smoking of industrially manufactured cigarettes. In examining the negative health impact of smoking in Oceania I make use of a relatively new concept called a syndemic. 6 Chapter 1 The word syndemic has yet to appear in dictionaries, probably because it has only recently taken root in such fields as medical anthropology and public health. The term was invented by Merrill Singer in the early 1990s as an outgrowth of his medical anthropological research on the AIDS pandemic (see, e.g., Singer and Clair 2003). In his words, this concept “focused attention on the multifaceted interactions that occur among the health of a community, political and economic structures, and the encompassing physical and social environment” (Singer 2009, xiii). Singer introduced the idea of a syndemic as a way to examine multiple diseases and their interactions along with the social contexts of disease production. Essentially, a syndemic is the synergistic interaction of two or more afflictions that contributes to excess burden of disease in a population (Milstein 2002). In the book you are about to read I apply the idea of a syndemic to the current health crisis affecting Pacific peoples, and I make a case that the smoking of tobacco—especially industrially manufactured cigarettes—is the keystone of the contemporary syndemic in Oceania. This does not mean that were smoking suddenly to cease in the islands all NCDs now plaguing Pacific peoples would magically disappear . But it does mean that tobacco smoking is the major linking factor that interconnects and exacerbates this congeries of ailments, including many diseases not usually associated with smoking, such as diabetes. A syndemic is a higher-order phenomenon than an epidemic, and “Syndemics occur when health-related problems cluster by person, place, or time” (Milstein 2002, 2). Practitioners of clinical medicine and public health typically focus on one ailment at a time and treat its symptoms with whatever palliatives or interventions seem recommended. While partially effective for the particular disease being addressed, such an approach ignores the fact that NCDs frequently co-occur and are interlinked—they form a syndemic —and “To prevent a syndemic, one must prevent or control not only each affliction but also the forces that tie those afflictions together” (ibid.). Milstein observes that the crux of the syndemic idea is “seeing more than one problem at a time,” and he suggests viewing “syndemics as structured constellations of affliction” (2008, 44). This is one goal of Drinking Smoke. It is important to bear in mind that the afflictions comprising a syndemic are not simply a set of diseases but rather a constellation of health threats that also include such things as poverty, discrimination and racism, poor living conditions, environmental contaminants, and limited access to health care. Syndemics occur in deleterious sociopolitical and physical environmental contexts that increase vulnerability, and a syndemic approach requires a biosocial rather than a purely biological understanding of disease. It is partially for such reasons that the idea of a syndemic has become influ- [18.118.145.114] Project...

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