Oby: From the campus of Harvard Medical School, this is ThinkResearch, a podcast devoted to the stories behind clinical research. I'm Oby, your host. ThinkResearch is brought to you by Harvard Catalyst, Harvard University's Clinical and Translational Science Center, and by NCATS, the National Center for Advancing Translational Sciences.

Join us as we talk to Dr. Nile Nair about his work studying the effects of climate change and the accelerated nutrition transition on Indigenous populations. Dr. Nair is trained as a clinical geneticist and surgical researcher. He is an international postdoctoral research fellow from Fiji in the nutrition and global health program at Harvard T.H. Chan School of Public Health.

Hi Nile. Welcome to the show. Great to have you here today.

Nile Nair: Pleasure.

Oby: Can you just start by introducing yourself and telling us a little bit about where you're from, where did you grow up, the history that led you to the work you're doing now and to Harvard?

Nile Nair: My name is Dr. Nilendra Nair. I go by Nile. I'm originally from the Fiji Islands. I'm an international postdoctoral fellow currently at Chan. So I grew up surrounded by a rich cultural heritage, beautiful landscapes. We don't usually leave home. But I left Fiji at 17 to pursue studies abroad.

We were a British colony. So we have the same education system. We go high school directly into professional training so med school, law school, whatever. But I wanted to move beyond prescriptive medicine mainly because the medical education system, having gone through it in Fiji-- these are remnants of a colonial past and even our textbooks are sort of outdated. And I wanted to move beyond just prescriptive medicine to actually get to the root causes of the problems I'm seeing a lot of our Indigenous and Pacific Islander communities facing.

And so I left home at 17. I was given a scholarship to go to an amazing institution. There are 15 of these around the world. It's kind of hush hush, but not really. It's called the United World College, and I went to the United World College in Canada. Our then President was Nelson Mandela and after his passing and currently, I think still is the queen of Jordan. The whole point of the school is to bring together people from all around the world. It's on a scholarship and sort of force us to live together.

It was founded in the Cold War era with the whole notion of we don't know each other and hence why there's so much war, poverty, strife, and sustainability. And so we are sort of caretakers of our school. We run our campuses. We're really, really remotely located. So the Canadian one was in the middle of a Canadian rainforest.

Oby: Oh, wow.

Nile Nair: Six hours by foot to the nearest bus stop-- really isolated pocket.

Oby: Truly.

Nile Nair: And it was a great experience because our program-- we go through the International Baccalaureate diploma, but the institution itself is affiliated with the top 200 universities and colleges around the world. And so we sort of have a price tag, if you will, that we are guaranteed almost free bachelor's programs or undergraduate degrees should we choose any of these top 200 universities that are affiliated. So I decided to take that path because, again, we don't have a system that supports or allows us credibility to join American institutions.

We don't have the AP program or the A-levels or O-levels. And so this was the only way, I guess, that I could see myself leveraging the American education system in terms of going beyond prescriptive medicine.

And so I went to an undergraduate institution here at Skidmore College for four years, did a lot of research, published my work, got noticed by Mount Sinai Hospital in New York. So I joined after graduating as a clinical geneticist, and due to my medicine background, I was able to get a year's worth of training at the Mayo Clinic and do surgical assistantship at Mount Sinai. So a lot of my research was initially looking at the genetic architecture of inflammatory diseases, particularly in the gastro world so inflammatory bowel disease for the most part, and eventually realized that there was an important intersection between what I had seen in terms of translational research, taking what we see from the bench to the bedside.

I then wanted to explore something that was closer to home and answering problems closer to home. I had gotten genetic experience. I've got surgical experience. And then I was like, OK, for a population such as Pacific Islanders, I need to have methods or some sort of research acumen in looking at population level health. And so I decided to apply to a lot of PhD programs, particularly in translational research or population health research, and somehow landed into Harvard as the first Fijian PhD in its 400-year history. And yeah, I've just graduated with this PhD and now starting my postdoc.

Oby: Well, congratulations on graduation and thank you for giving us all that background. I mean, so much in there already-- why don't we step into a little bit about what your research is about and then I'll probably have some questions to ask and tease out as we go through that conversation.

Nile Nair: I initially began my work at Harvard in nutritional epidemiology. I was particularly interested in focusing on climate change and the intersection of-- or the Nexus of planetary and human health. Because growing up in Fiji, I witnessed firsthand the impacts of climate change and environmental degradation on small island communities. To this day, it still affects us in a myriad of ways increased intensity of storms and natural disasters, sea level rise, the sea level rise leading to contamination of drinking water sources and so salinity equals hypertension and these other diseases.

At the same time, for most island communities we are so dependent on the seafood so to the fruits of the sea, [non-english]. And what we are seeing is with the rise in ocean temperatures, not only are our coral reefs dying, but the habitat that it provided for traditional sources of seafood are now moving away from the equator towards temperatures that they're used to. So what I really wanted to explore at Harvard was this intersection of dietary colonialism that was already established in the Pacific Islands and how the climate change crisis was accelerating the nutrition transition because we're now unable to grow traditional food sources.

So we are now moving into consuming much more processed goods, which was causing a disproportionate burden of diet related non-communicable diseases. That was what I started off doing. I also wanted to explore the genetic architecture of diseases and Indigenous Pacific Islanders because no one's actually mapped out our genetics or looked at it in that way.

I started off with that in 2019. And the pandemic quickly happened in my first semester causing a lot of hiccups along the way in terms of that research because we had a project in one of these small Pacific Islands, but we couldn't get the DNA extracted and do the genetic analysis. So I had to switch my research plan and my projects. And I moved towards looking at the Nexus of planetary and human health in a few other ways.

Primarily, my dissertation and my doctoral work focused on creating a dietary index that measured adherence to a planetary health diet that was based on recommendations of the EAT-Lancet Commission of 2019. And so the lead author, Dr. Walter Willett, was one of my key advisors, together with Dr. Shilpa Bhupathiraju, Dr. Mia Stanford, and Dr. Kyu Ha Lee. I created this index in a minority population in the US, a minoritized population, if you will.

It was a population of South Asians living mostly on the West Coast. And a lot of the criticisms for the planetary health diet is that the equity lens is missing. We cannot ask somebody in sub-Saharan Africa, for example, to stop consuming cattle if that is their source of protein and micronutrients. With that in mind, I said I want to create this index that can measure the adherence to the planetary health guide, but also include the equity lens.

Of the 15 food groups that comprise the planetary health diet-- instead of saying stop completely consuming this one food group, we came up with feasible ranges of consumption that was within both planetary bounds of production but also within optimal human health should we stay within this range per day. My entire work was looking at validating that new index in a minority population but also looking at the health outcomes in this population. Should they adhere to this diet, does it lead to better health outcomes? It does.

So the planetary health diet was a great success in the South Asian population that has a disproportionate burden of cardio metabolic diseases. There's actually a bill out in Congress right now that specifically is looking at disaggregating data and specifically looking at South Asian cardiovascular disease risk because, again, the US tends to lump a lot of ethnicities under huge racial umbrellas that make no sense because why are Pacific Islanders and Asians and Indians one umbrella? That makes no sense. We all have different dietary trends and disease outcome trends.

That was the main work that I was doing through my doctoral work. But I was also a climate and health equity research fellow at the FXB Center. And there I was looking at the social determinants of health that were at the crux of the focus of the disproportionate burden of climate change on marginalized populations in the US. So mortality is related to extreme heat and every other climate related calamity, looking at not only how do we envision a systems approach to health equity. In that position, I also became a climate change ambassador for Harvard through the SEA change program. And there, we worked on the SEA change toolkit for front line clinics. And this is informing both physicians as well as patients and clinics in low resource settings, primarily that take Medicare and Medicaid, how to respond to certain climate disasters for their population and what to be aware of in terms of comorbidities or certain specific demographics and how extreme heat, for example, would impact a pregnant woman who is on antipsychotics versus an elderly person who has other comorbidities.

That was some of the work on inequities and social determinants. And then I was lucky enough to also participate in a accelerator with Dr. Kari Nadeau, the chair of the Environmental Health Department, where we came up with federal policy suggestions that envisions or incorporates climate considerations in medical education in the US using the Center for Medicare and Medicaid and sort of re-envisioning what we think about first and second year medical education. So a lot of different things that was done but surrounding climate change.

Oby: Totally. Wow, I mean, so many arms of work that you were involved in, so many things you're bringing to a higher level and then talking about policy changes. I wanted to step back and ask you about a couple of things. Obviously, from the words I'm about to ask you about, I can draw the conclusion about the definitions, but I just want to plainly ask you. So you talked about dietary colonialism, and I wanted to sit on that for a minute and maybe define that and give a little more depth to that before I go into some other questions I may have for you.

Nile Nair: Dietary colonialism is so central to the way that colonialism itself happened throughout the world. One of the major impetuses for the expansion of the British Empire outside of just conquering and amassing more wealth was also to start these sugar cane plantations, mainly to produce alcohol that was a direct descendant of the Atlantic slave trade. And so on a whim, for whatever reason, the British crown decided to take one vessel headed to the West Indies, a.k.a. The Caribbean, and diverted this one shipment of indentured servants from India to the Pacific Islands.

It was because they had just gotten a few of the islands, and there was a big division in the Pacific between Germany. French-- the French had colonized Polynesia. US had a big presence with Guam, Marshall Islands, and Hawaii. And as they moved the Indians to Fiji that they had just acquired, they started changing the plantation habits of the Indigenous population. They had learned their lesson sort of in Australia, which they had colonized at least 100 years prior to moving to the smaller islands in the Pacific.

So with the Australians, they had what was called the Lost Generation. The Indigenous population was sort of eugenically bred out. That was their plan. They wanted to breed them out until they were white. And so they started stealing, physically removing children from all of these tribes, and putting them into their version of reservations, which was pretty much schooling for them to become house servants. So they weren't allowed to speak their Native tongue. They were only allowed to speak English. And eventually for least 150 years, they were practicing this in the Pacific Islands.

When they moved to New Zealand, they were met with a lot more resistance from the natives. But when they came to Fiji eventually, they just decided to leave the natives alone. So dietary colonialism comes into play when you have two displaced populations sort of mingling together under one colonizer that dictating what they're supposed to grow and eat. And so with the Indians that came in to the Pacific Islands, they started-- well, they tried to grow what they were used to and whatever seeds they were able to bring, much like transatlantic slaves to the US South.

The Indigenous iTaukei Fijians were sort of not mingling with them as much, but a lot of what the British crown was doing was asking for all the land that was fertile to now focus on sugar cane plantations. And so what crops they were able to grow in certain parts of the region started dying out. Then there became a higher reliance on all of the goods that the British imported for their own workforce but then also sold to these indentured servants and to the Indigenous Fijians.

And eventually what we've seen is changes in cropping practices, loss of Indigenous knowledge around medicine and other herbs and food production systems. And much like what happened in the US South, again, what they were given, they tried to appropriate as best as they could and make it as nutritious as they could based on whatever culinary experiences they had. And so certain items that were part of this colonial period became ingrained in this new culture that this displaced population and the native population eventually started mingling made.

Fiji now defines itself as a secular country. We were colonized in the late 1800s and gained independence in the 70s. But a lot of our diet is still being shaped by the imports or the dumps that a lot of these countries are using. So the US does this with Guam and Marshall Islands and American Samoa, where they will dump turkey tails that nobody else consumes that are high in fat and very low in nutrition.

And the same thing with Australia and New Zealand. They'll dump their lower cuts of lamb and other meats into the Pacific Islands. And that sort of has changed not only dietary habits but also our disease transmission and the burden of disease that we see.

Nine of the top 10 obese countries and the top 10 countries with diabetes are all Pacific Islands. We have really small populations. And so when you say half the population is obese, that could be anywhere from 50,000 to 150,000. And that might not be significant in terms of the Global North, but that's an entire half of a nation.

Oby: Goodness. So much information here and so you were talking about climate change. You're specifically talking about the things that may have been eaten before, the things that may have been grown before, coupled with what you were just talking about, this dietary colonialism. And I can imagine so many ways this speaks to a number of different cultures. But how do you see your research improving health care? I've heard you talk about some of that. Improving the research field and everyday life for a myriad of people-- I know that you are focused in the South Pacific and you've talked about smaller islands, but how do you see this really speaking to a number of different demographics of people?

Nile Nair: That's a great question, especially when it comes to improving health care because that's the ultimate goal. I'm hoping that my research will contribute to more equitable and sustainable health care practices, particularly for Indigenous and minoritized populations. The big impetus of my work is when we already have these prevalent statistics and we already have the descriptive statistics in terms of disproportionate burdens of certain diseases on certain vulnerable and minoritized populations, I'm hoping that I can highlight the health impacts of climate change and dietary transitions by looking at this planetary health diet.

Right now, having done work on one minority population in the context of a Western country in the US, I now want to look at these populations in their native lands in terms of what they're able to access and what they're able to do with that. Currently, with my postdoctoral work, I will be based out of continental Africa, mainly East African countries, and looking at the intersection, again, of planetary health of food systems and how climate change is affecting this and how much of a utility a planetary health diet could have in such interesting settings. I wouldn't say dire. There's abundance in various ways. And I guess we just have to change our perspective on how we define what healthy means for populations that have been on the fringe.

I'm also hoping that I'm able to inform, like you mentioned, these policy decisions that promote healthier and more sustainable food systems to begin with by raising these awareness on structural inequalities. And the one thing that comes to mind immediately is there has been this big shift and big emphasis, a huge emphasis actually, on looking at blue foods and looking at fish or seafood as an alternative to protein sources coupled with definitely with plant-based proteins. But what we see, again, is the Global North sort of does its dirty work in the Global South while espousing these qualities of sustainability.

What I mean by this is there's this huge emphasis on aquaculture and aquaculture products that mainly the ponds for this or the actual culture grounds are set up in the South. These countries now are funneling their resources into, let's say, growing more fish. But they export those out, and there's less to be consumed within the country and its context. When it comes to the other work that I'm doing in terms of that toolkit for front line clinics, there is currently sponsorship from Johnson & Johnson for us to take the toolkit that we launched in the US to look at the Philippines.

And, again, a lot of the work that we're doing there currently in this initial stage is to do the literature review for the epidemiology as well as emergency medicine practices specific to these disasters that are so endemic to that region. So for Philippines, we're looking at typhoons, rising sea levels, hurricanes, maybe earthquakes depending on how we are able to tie them together. Even extreme heat in the Philippines is very different from the extreme heat that is faced by, let's say, continental US.

By expanding on that work in that part of the world, I'm able to then also extrapolate that into similar islands or similar geographies, especially for disproportionately burdened populations such as Pacific Islanders. And so I want to raise awareness about the structural inequalities that exacerbate health disparities. And hopefully with my research, I'm able to advocate for more inclusive and just approaches to health care and environmental policy.

Oby: I really love what you're saying about structural inequalities. Even when I think about the US and the different areas of the US and even within a state, it can be so different.

Nile Nair: 100%, yeah.

Oby: Do you have any thoughts about that as you talk about this on a more global level? And what, I guess, what we can take away from that and what we can be thinking about when we think about community to community?

Nile Nair: Absolutely, the reason that I base a lot of my work out of the US is if I'm able to provide empirical evidence for this country, that sort of is a trendsetter when it comes to how other countries are receptive towards certain policies related to climate change. What we do see, again, in terms of these structural inequalities, they not only marginalize people from access to health care, they're structural in a way that has already minoritized them even if they are marginalized.

And so this quadrupling of burdens of disease is very interesting, especially when we look at food security and access to nutrition. When you have a marginalized community, let's say a majority Black Indigenous people of color who are red lined or red zoned, not only are those physical infrastructure inadequate to actually support human health, they exacerbate the levels of extreme heat or the levels of environmental disparities that these communities experience.

For example, majority of these populations, these marginalized minoritized populations, will find themselves in pockets or in spaces where they don't have enough foliage or green cover. That makes their concrete at least 10 to 20 degrees hotter compared to the ambient temperature. They don't have access to actual green spaces that would be beneficial to their mental health.

It came a point where in my practice it was easier for me to diagnose my patients that were coming in for asthma based on their zip codes than it was to actually look at their genetics. That speaks volumes to exactly how where people live and work affects so much of their own health and disease outcomes. There is a lot to be said and a lot to be done for structures that already exist that people don't know about.

So what I mean by this is there was the introduction of social determinants of health as part of the ICD-10 coding system. And this coding system is what a doctor would put on your chart so that insurance can bill you appropriately. Part of my work that was looking at federal policy was to teach medical students and graduates and continuing learners about better coding practices so that they can actually have their patients take advantage of these social determinants of health.

For example, if your doctor is able to put down a prescription saying I prescribed for this patient an air conditioner, which is covered by that ICD-10 code and then can be billable to insurance, that allows access to a resource that is lifesaving in our day and age. The question about equity when it comes to actual access to electricity or the electric bill is something else to be considered. But there are these programs that the EPA, that the USDA have put out that communities just don't know about to take advantage of.

And that's the other issue, these bureaucratic roadblocks that impede access to things that they think they have structured or altruistically created but nobody's able to benefit from. So there are these structural inequalities that do exist that go beyond something that that's so obvious as living in a dilapidated house but goes back to just policies that informed why you live in that house and why there haven't been repairs and why you continue to be in this never ending cycle.

Oby: I really appreciate that you ended on the idea of a cycle. As an individual when I think about these things sometimes I'm so focused on one piece that I'm not understanding the full scope of what is happening. A lot of the things that you're talking about and honestly that you're researching and studying feel like it could help break that cycle. And you were starting to tell us what's next.

And I think you said you were moving to do some research. Or I don't know if you are physically moving or just doing some work in Eastern Africa so can you talk to us a little bit more about that if you can and what's going to be happening there?

Nile Nair: With this research on the Nexus of planetary and human health, I'm advancing our understanding to move beyond nutrition and food systems in the context of East Africa. I'm also trying to explore critical areas such as the impact of environmental pollution on respiratory or cardiovascular disease, the effects of climate change on mental health, especially for these Indigenous populations, or its effect on infectious disease patterns, again, in these populations with disproportionate burden who have not contributed to the climate crisis as much.

And so just looking at within their own context-- let's say if there is a drought, how does that affect zoonotic diseases as well as nutrition, and how do we balance this double burden of disease? The way that we learn epidemiology in the beginning is just the phases of an epidemiological transition. So moving from infectious disease to birth rates and death rates decreasing and increasing and then moving to diseases that aren't infectious because we have come up with preventions for them or cures for them and now we're in a state of diseases that are due to lifestyle.

How do we balance that in a country that has both? That double burden of disease that's both lifestyle because of an acceleration of nutrition transition but now we are having a resurgence of infectious and zoonotic diseases, given pandemics and everything else going around. So with a double burden of disease and a changing environment that might be affecting these patterns, how do we best advocate for or protect the resilience of a population against it?

Additionally, I'm hoping to explore the benefits of not only a planetary health diet but also how these changing patterns of environmental factors affecting health on the entire spectrum of everything that we can think of be it mental, physical, cardiovascular. Beyond just my own research, I also have the South Pacific Foundation that a close friend of mine and I have started back home in Fiji.

We noticed that every time that we went back to our maternal village or our traditional lands, the people weren't prospering or moving further from the same disease burden. If anything, it was getting worse. And we realized that not only was it because they didn't have access to clean drinking and safe drinking water-- ironically, for a country that exports Fiji Water, we don't have access to clean drinking water in our own backyard. We're seeing that due to sea level rise that the natural spring systems or their water sources have been contaminated with salt.

It's this insidious factor that's causing a rapid rise in a lot of cardiovascular or hypertensive diseases. And what we're trying to do is-- and we've started doing this-- is leveraging Indigenous knowledge. So using our knowledge from our elders, we've created a three-step filtration system that uses locally sourced materials that are resistant to climactic disasters. And we're training elders as well as creating a system within the village where they are the stewards of this system. But we sort of are just the conduit of providing resources and connecting with donors. But the entire power lies with the Indigenous community.

We work according to what their needs are. So we started off by introducing this filtration system to schools first because that's where children spend most of their time. And then we started introducing it into the villages themselves. And what we were seeing was women are now freeing up a lot more time and are having a lot less respiratory diseases, mainly because they're spending half their day collecting firewood to boil the water. They would sit near this boiling water and just inhale all the fumes that come from burning the wood.

They were doing this multiple times a day just to get drinking water within their own households. So freeing that up for them is allowing them to focus on a lot more things, including entrepreneurship, where they're going back to traditional weaving patterns or going back to traditional sources of livelihoods and selling their wares in local markets.

We're trying to address this on a more personal level. I'm more about climate adaptation than bolstering resilience because 95% of all funding goes towards resilience bolstering. And it makes no sense for me to think about carbon capture or electric vehicles when the reality of my people and for my population is even if we stop emitting carbon dioxide right now, what we have emitted is still going to be in our atmosphere for the next 10 or more decades.

So what do we do to adapt in a world riddled with climate change and its effects as opposed to thinking about stopping future one, which is great. We should. But what about living with our realities right now?

Oby: Thank you so much. This has been so rich. We have to have you back. We want to hear what's going to happen with your research. We will certainly link your foundation in our podcast notes. And thank you for joining us to have this conversation. It's really been a pleasure having you here and hearing about, first of all, your incredible wealth of knowledge but also where your research is going to take us. So thank you.

Nile Nair: Thank you, Oby.

Oby: Thank you for listening. We are always looking to connect and collaborate with the research community and would like to hear from you. Please feel free to email us at OnlineEducation.Catalyst.Harvard.edu to inquire about being a guest on the podcast.