Health workers accused of ‘fiapalagi’ – study finds

Samoans who try and insist on healthy, fresh foods are often criticised for being “fiapalagi” (trying to be European).

That’s what an American health researcher, Jessica Hardin, has found in her study titled “Everyday translation: Health practitioners’ perspectives on obesity and metabolic disorders in Samoa.”

The American is from the Department of Anthropology, Brandeis University, Waltham, MA, USA.

In her study, she found that fa’asamoa was often used as a reason or explanation for obesity, poor diet, not exercising and failing to seek or follow medical advice.

One leading example were health workers themselves.

“Most health practitioners reported struggling with their weight; they shyly laughed about how they shared these problems with their patients,” said Ms. Hardin.

Four of the interviewees each said “Look at me!”, indicating their own obesity.

They often framed themselves as “hypocrites”, said Ms. Hardin, which they felt made it difficult to advise patients about weight loss.

“They explained, in jest, their personal paradox: how could they advise patients when they themselves could not lose weight?”

Aligning health advice with health behaviors was critical for health practitioners, as they felt they could not advise their patients without making changes in their own lives.

One nurse explained the difficulties she faced in adopting an exercise routine and changing her diet.

She was criticised “for bringing vegetable platters or salads to family meals, many dismissed her as fiapalagi.”

A doctor told Ms. Hardin that, “changing food practices was difficult, even for health practitioners, because accusations of fiapoto or fiapalagi implicitly questioned their Samoanness.”

In his case, he decided to stop eating so many fatty meats, hoping that it would save his family from spending so much money on food.

The doctor, “who mentioned a love of food”, started to refuse food gifts from his family to make healthier dietary choices.

“He refused fatty tinned meats, pork, and salt-preserved beef. This also unburdened his family from the expense, which he hoped would provide them more resources to spend on health,” Ms. Hardin says in her report.

“However, his refusal led his family to call him fiapoto (wanting to be smart). Fiapoto insultingly suggests one is not acting appropriately to cultural expectations and implicitly questions Samoanness.”

His refusal of good gifts “also explicitly criticized fa’asamoa by not accepting gifts.”

Even within events held by Health workers themselves, “morning tea was served with copious amounts of sugar and panikeke (fried bread).”

Often, she said, morning tea or lunch is orchestrated by groups at the workplace, where those who provide are socially evaluated based on how much food they serve.

“The best foods to serve are mea’ai lelei, (good food), which are associated with expense, sweetness, fattiness, or saltiness. Mea’ai lelei are almost never mea’ai paleni (balanced/healthy food), including fruits and vegetables.”

Outside of the health sector, in the wider community, Fa’asamoa also held people back from achieving healthier lifestyles.

Activity including walking around and working outside was seen as a low status activity, whereas sitting down, inside a house or fale indicated higher status – that there were other people to do the work, she said, quoting earlier studies.

Those who did want to exercise might be frowned upon for walking through a village.

“Fa’asamoa also influences physical activity,” writes Ms. Hardin.

“Stillness is an embodied mode of wellness that indicates status. As Samoan people age they engage in less physical activity, encouraging those beneath them to do the chores and agricultural labor.

Health practitioners also indicated that physical activity changes after men and women start a family – that they are expected to not do as much plantation work, or leisure activity such as rugby, said Ms. Hardin.

“Others noted that walking, jogging, or running are seen as a disruption to village life.

For many, walking is stigmatized, suggesting the inability to buy a car or petrol. Physical activity, especially for non-youth, also has the potential to elicit ‘fear of ridicule and shame’ because this activity challenges ‘dignified and controlled comportment’.”

Ms. Hardin has previously written on health in Samoa, including through the Centre for Samoan Studies at the National University of Samoa.

This research built on nearly two years of fieldwork in Samoa and overseas communities between 2008 and 2012.

During 14 months of fieldwork in Samoa, she participated and observed in clinical environments including hospitals, two urban clinics, and nursing home-visits.

“I observed clinical encounters and health education and assisted with daily administration at a diabetes clinic. I also participated in, and observed at public health meetings and community programming, including jazzercise.”

Ms. Hardin developed key relationships with six health practitioners, who she interviewed up to 12 times each.

Over that timeframe, she identified reluctance among health workers to tell people they were obese, instead referring to symptoms rather than causes.

“In everyday clinical practice and conversation, obesity is rarely referred to but ma’i suka (diabetes) and toto maualuga (high blood pressure) are discussed.”

Instead, doctors, nurses and other health workers campaigned for top-down change, trying to encourage community leaders, including those in the church, village councils and politics to adapt a more healthy lifestyle.

Some had heard of pastors overseas limiting food at church events to fruits and vegetables.

“They considered this desirable because: (1) leadership demonstrated health priorities, (2) congregants could offer these healthier options without fear of reproach, and (3) the community rallied around health.

In this example, leadership exhibited a change in orientation towards health, encouraging the meanings associated with body size and food to also change. They felt that if leadership publicly ate and accepted food gifts differently, then perhaps food meanings could change, without challenging culturally relevant notions of love, respect, and service” – alofa, fa’aaloalo and tautua.

Ms. Hardin said that focusing on health problems through a cultural lens could hide bigger problems.

“When health practitioners focus on culture, they make structural inequalities difficult to see and, therefore, alleviate,” she wrote.

Structural inequalities include an inability of patients to get to medical centres, a failure by health practitioners to encourage patients away from risky behaviour, a flood of imports such as rice, tinned fish and corned beef, and frozen meats, such as chicken, turkey tails, and mutton flaps, sausages, along with snack foods, ice cream and cakes.

“These prestige foods have become essential to sustaining extended family networks; however, they have also been identified as contributors to rising metabolic disorders.”

Focusing on culture and communities, however, pulled attention away from global changes to food chains.

“This in turn obscures the inequities of the global food trade.”

Health practitioners do not explain global trends, including increasing transnationalism, dependence on the cash economy, a move away from customary agriculture, and the incorporation of foreign imported foods as prestige foods, she said.

She calls for an “unlinking” of health debate from discussion of culture; of Fa’asamoa, and “bridging approaches” towards health initiatives that focus on bigger pictures of health.