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Why is health so important to us in the Caribbean?

Beyond the natural human quest for the highest level of health and happiness possible, given one's genetic makeup, environment, and life choices, we are concerned about health because of its impact on social stability and economic viability of the Region.

This article, briefly reviews the health status of the Region and examines implications for policy, including the health promotion approach necessary to successfully implement change to improve health, unleash intellectual and economic productivity, and decrease avoidable health care costs.

Economies of the Caribbean depend highly upon a healthy population and workforce. Societies depend on healthy individuals, families and communities for sustainability. The impact of compromised health is felt both in increased health service costs for treating avoidable illness and in the decline in productivity, loss of employability, etc.

While disease prevention and treatment will remain critical, and have played a significant role in our health status gains, greater emphasis on health and well being will be needed as well as systems to monitor them. However, they will not replace traditional mortality and morbidity indices, which are needed to monitor impact.

Social health must receive focus and intervention. Changing social norms related to violence, avoidable injuries, responsible sexual behaviour, and a clean environment, for example, will become more critical. Use of appropriate interventions: information, communication, legal and fiscal measures and persuasion, will necessitate new ways of working and new partners with whom to work, in the public and private sector.

In this article, the following are reviewed in order to discuss health status: relevant demographic changes; some mortality and morbidity data as measures of the impact of ill health; indices of communicable and chronic disease; the behaviour patterns that underlie much ill health; and emerging health challenges.

The main sources of data reviewed are the Health Conditions in the Caribbean, Caribbean Tourism Organisation Statistics and Projections, and data from Caribbean Epidemiology Centre (CAREC) surveillance systems and country reports.

Demographic and social

The countries of the Caribbean are undergoing a demographic transition. Today, both men and women live longer than in the past, with women living on average four to six years longer than men.

The overall population has doubled in the last 50 years, but the proportion of the population aged less than 15 years has been declining, while the population aged more than 60 years has been increasing (figure - 1995 population pyramid).

This has implications for increasing rates of chronic non-communicable diseases, and an increasing need for care of the elderly, who will approach one fifth of the population early in the next century.

Along with the aging population, urbanisation is a major demographic influence on health status. In Jamaica and Trinidad and Tobago, for example, most of the population live in urban areas.

This is an increasing trend in many countries of the region, which is often accompanied by inadequate housing, overcrowding, fewer job opportunities, and over taxed water and sanitation services.

Education is inextricably linked to health conditions. A healthier population is more capable of educational achievement. Conversely, the success of many health programs depends on education in personal hygiene, the development of health skills, and the timely use of preventive health services. Thus, universal access to basic and secondary education, along with high rates of literacy are fundamental determinants of good health and essential in sustainable development.

Poverty and economic factors also play a major role in determining health status. They help to determine general levels of income and expenditure, and access to health care and social services. Many analysts put poverty and ignorance, as the fundamental causes of health inequities.

Mortality

Statistics on death are more complete and reliable than most sources of data, so it is conventional to consider causes of death in any description of health status. In addition, the common causes of death also tend to be common causes of sickness and admission to a hospital, though this does not hold for some conditions, such as mental ill health and arthritis.

Based on data reported to CAREC by countries of the English-speaking Caribbean and Suriname, the following major conclusions can be made. Crude death rates per thousand population have gradually fallen over the last 10-15 years and potential life lost (YPLL) from birth to age 65 years have also fallen. The latter is an indicator that takes into account age at death and therefore gives a heavier weighing to causes of death among infants, children and young adults.

Overall, chronic non-communicable diseases are the leading cause of death, with heart disease, strokes, diabetes, cancer, and injuries being among the top causes of death. Mortality from communicable diseases, however, after years of decline, has been rising since the late 1980s, linked to the epidemic of HIV/AIDS.

In childhood, while infections have decreased as a cause of death, nutritional deficiencies have increased. In early adulthood, diabetes, suicide and homicide have increased markedly as causes of death in the past 10-15 years.

In some countries, suicide and homicide now surpass traffic fatalities. In males HIV/AIDS as a cause of death is increasing rapidly, and in several countries, AIDS is now the leading cause of death among men 15-44 years old. In few countries, that is true for women as well.

One conclusion of the above is that while chronic non-communicable diseases are the leading cause of death overall, it is HIV/AIDS, injuries and violence that are the leading causes of death in people of young age.

These are largely preventable conditions. For example, a significant impact could be rapidly made on traffic fatalities and injuries, with an attendant decrease in health care costs, through the enactment, promotion, and enforcement of seatbelt legislation in all countries.

Risk factors

What are some of the factors underlying the major causes of death and ill health in our populations? At one level, the major determinants of the epidemic of circulatory disease may be said to be hypertension, diabetes, and obesity. In the landmark St. James cardiovascular survey nearly twenty years ago in T&T, hypertension affected one in four to six persons, and diabetes affected one in six to ten, depending on race. In Barbados, the results of two national surveys, some ten years apart, have shown that adults have become more obese, and that this affects women more than men. Since obesity is a major risk factor for diabetes, it is understandable that diabetes mortality and morbidity is also higher in women than men.

What however, underlies the high level of hypertension, diabetes and obesity? Studies from the Caribbean and all over the world show that habitual diet and levels of physical activity are the fundamental determinants which provide the necessary confluence of factors for these epidemics to occur. These same factors, plus tobacco use, underlie many preventable cancers and heart disease. With respect to diet, a fundamental issue is that Caribbean populations consume fat greatly in excess of CFNI nutrient composition targets for the Caribbean.

Viewed from this perspective, a few classes of behaviour are the underlying determinants of much of the preventable ill health and unrealised economic productivity in today's population. Three have already been mentioned: habitual diet, physical activity, and tobacco use. The latter is the second commonest substance of abuse; the first being alcohol; marijuana and cocaine ranking third and fourth, respectively, in several population-based surveys.

If we add sexual health behaviour, e.g., condom use with non-regular partners; personal hygiene and environmental sanitation behaviour; road use behaviour, e.g., seat belt use; and conflict resolution, then we have covered most of the behavioural determinants. A final class of behaviour may be termed health-seeking behaviour, e.g., vaccination, cervical cancer smears, hypertension checks, STD treatment, which facilitate prevention and reduction of the impact of the disease.

Thus we can see that after access to basic needs are met, such as housing, safe food and water, and sanitation, human behaviours are the fundamental determinants of preventable ill health services, as part of the health sector reform, that needs to be taken on board.

Emerging and re-emerging infectious diseases

In examining this area, let us look very briefly at the tourism industry, the major engine of economic development of the region. This is an industry that is exquisitely sensitive to news of outbreaks. In the past two years, our investigations of several outbreaks in major hotels have shown the significant human and economic impact that these situations can have on the hotel, and on the destination. The potential for an inordinate impact has also increased following the advent of the Internet in the Caribbean and the enactment of the European Commission Directive on Package Tours.

In 1996, tourism accounted for some US$33 billion in gross output, 30 percent of the GDP, and most of the hard currency earnings, making the Caribbean the most tourism dependent region in the world. One in four to five jobs were in the travel and tourism industry. Fourteen million stay-over arrivals, seven million cruise ship arrivals, and over 1,200 hotels are at the heart of the industry. Predictions are for this to double in the next 15 years. But the future is not guaranteed.

High energy costs, importation of most supplies and equipment, concerns about safety, health and environmental issues all challenge the industry in an increasingly competitive global environment. In addition, travelers are more quality and litigation conscious than ever where health and environment issues are concerned. Against this background, therefore, we can consider the situation with communicable diseases.

Among the diseases subject to the International Health Regulations, only yellow fever and cholera are a real concern to us. Though yellow fever has not occurred in humans in the Caribbean since the 1978/9 out break in Trinidad, the yellow fever virus has been detected in monkeys in Trinidad on a cyclical basis in 1988/9 and in 1995.

New cruise ship links with Brazil and South America also increase the risk of introduction to the islands, and all countries except Cayman Islands, Bermuda, have the Ae. Aegypti mosquito, which can transmit the disease.

Regarding cholera, outbreaks occurred in Guyana, Suriname and Belize in the early 1990s, but transmission has only persisted in Belize in some rural areas, particularly near Guatemala. For both cholera and yellow fever, the possibility of importation into the islands exists and continued vigilance is needed.

Observing the three diseases subject to global surveillance, AIDS cases and HIV infection rates in several countries, places the Caribbean second to sub-Saharan Africa in terms of HIV prevalence and incidence. In Jamaica, T&T, Guyana, Barbados, The Bahamas, the trends of HIV seroprevalence in groups at high risk and the general population have been going up and this does not augur well. HIV/AIDS models, developed by CAREC in collaboration with the health economics unit at UWI, suggest that if we do not have more success with prevention efforts, AIDS will have a very significant impact on mortality in the coming two decades, and that 3-5 percent of the GNP could be spent on AIDS. This is as much as some countries spend currently on health overall.

In considering HIV/AIDS, the issue of the conventional Sexually Transmitted Diseases, which "open the door" to the AIDS virus must be considered. Surveys in several countries have shown that 10-15 percent of sexually active women have chlamydia. Doctors need to know this and treat accordingly.

In the face of this rising problem we look at the lessons learned from elsewhere which suggest that it is possible to successfully combat this epidemic.

The main lessons

Tuberculosis, after years of decline, began to increase around the turn of the decade. If we study the trends, we can see that there have been nearly 600 excess TB cases in the past few years, compared with the previous downward trend. Six countries have had consistently higher rates and these have been the focus of special attention – Suriname, Guyana, Belize, T&T, Jamaica, St Lucia. In addition, St, Kitts and Nevis and the Turks and Caicos Islands, have had significant outbreaks in the past year.

What underlies this increase in tuberculosis and what needs to be done? While HIV/AIDS has contributed to increased TB, a 1993/4 CAREC survey of national programs showed that the infrastructure had weakened, trained staff had left, and high level commitment and funding had waned. This may have been in reaction to the downward trends in previous years and the common (and mistaken) perception that we had "conquered communicable diseases".

What needs to be done?

We have identified seven key areas and are incorporating them into a proposal for funding. These include advocacy, enhanced surveillance and laboratory capacity (particularly smear microscopy), availability of drugs, directly observed therapy, training, and applied research. We have made progress in improving lab capacity and the availability of smear microscopy in several countries. However, there is quite a way to go, and additional resources are urgently needed to address this public health problem and to reverse the upward trend.

At the global level, malaria is perhaps the most important vector borne disease, though dengue fever is more common. Within the Caribbean, malaria is endemic in Guyana, Suriname, Belize, Haiti, and the Dominican Republic.

Imported cases are reported every year in the islands. Of particular concern too in recent months and years, however, has been the occurrence of malaria outbreaks and clusters in three "malaria-free" countries, two of which are heavily dependent on tourism.

Field investigation by the MOH/ CAREC showed that local transmission had occurred due to Anopheline mosquito species, which are present in nearly all islands. Thus, the need for vigilance and a high index of suspicion continues in order to facilitate early recognition, appropriate treatment, and the prevention of spread. We cannot afford to have malaria re-established, both for the health of local people and visitors.

The vaccine preventable diseases are one area where we have been, and continue to be, very successful. Thus we can boast of higher rates of childhood vaccination than the USA. We have eliminated smallpox and polio, and have been the first region in the world to eliminate indigenous measles, with huge human and economic savings. In this regard, the leadership of the Pan American Health Organisation must be noted. Of concern now is the occurrence of rubella and Congenial Rubella Syndrome I in several countries, which can be prevented by a vaccination campaign. Studies at CAREC have shown that such a campaign would have a high benefit cost ratio.

Of the diseases of special Caribbean interest, dengue fever, a mosquito borne viral disease, outbreaks have been increasing in frequency and intensity in the past 10 years. This is a disease that has consequences for the local population and for the tourism industry, given the ubiquitous presence of the vector, the Aedes aegypti mosquito. There are four dengue virus types, dengue 1-4, of which three types, 1,2, and 4, have been present in the Caribbean in recent years.

Last year, three countries experienced dengue fever outbreaks, with T &T having its first major outbreak of Dengue Hemorrhagic Fever. New analyses of our data of the last 25 years show that anyone type tends to recur every 8-10 years and causes outbreaks which extend over a 2-3 years period.

Thus we were able to predict with accuracy the switch to type-2 outbreaks which began in 1997 and which were worse in 1998. Type-4 outbreaks in 1999/2000 can also be predicted. A new factor is the emergence of dengue virus type-3 from the region in the last 20 years, the possibility of explosive outbreaks has increased. Ideally, we need a vaccine while we continue with the efforts to involve communities in vector control and source reduction.

Finally several outbreaks of food and water-borne disease in major hotels and some outbreaks in the community in recent years, have resulted in some destinations experiencing cancellations of visitors arrivals, demonstrating the clear link between health and sustainable tourism. We have also seen an emergence of a new strain of Salmonella, S. Enteritidis, in the past few years, that is associated with eggs. This is now the subject of a special research study with UWI.

This brief overview indicates that the health status of the Caribbean today, at the turn of the millennium, is that of a complex mosaic. Chronic diseases and injuries co-exist with communicable diseases and social pathologies such as substance abuse and violence, while new emerging and re-emerging infectious diseases threaten us, linked to ever-increasing travel in and out of the region.

Underlying this are fundamental socio-economic and behavioural determinants.

The analysis strongly suggests that the best way to improve health of the population is to invest in health promotion, and in comprehensive disease prevention programs.

Health promotion includes healthy public policy such as education for all, and measures to combat poverty; genuine inter-sectoral collaboration and alliances; developing and fostering sound personal health skills and behaviours; re-orientation of health services; empowering communities; and creating supportive environments. Health promotion requires that we all become better at advocacy and learn to talk the language of the economic decision-makers.

How do we choose on which health problems to focus, particularly in the context of the new community arrangements and the advent of the Council for Human and Social Development? The criteria for choosing priorities include human and economic impact; international implications, e.g., political, trade, tourism; public health; the availability of proven interventions; the condition or factor being a basic determinant affecting several outcomes, e.g., literacy, diet; a likely positive benefit: cost ratio; the need for a health promotion approach; and the opportunity for synergy between sectors in country and between the regional health institutions.

From such an analysis the following priorities emerge:

Policy implications

Health is broad based and necessary for social and economic development. While the region has made health gains, much avoidable ill health and death persists.

A major impact is possible by acting on key determinants. This would unleash intellectual and economic productivity in our populations and decrease health service costs. Because the fundamental determinants of health span many sectors, the use of a health promotion approach is essential in furthering Caribbean Cooperation in Health.

[ Annual Report 2000 ] [ 25th Anniversary Celebrations ] [ World AIDS Week ] [ Overview of Health in the Region ] [ Caribbean Health Trends ] [ Surveillance Report ] [ About Us ] [ Data/Statistics Archives ] [ Travel Health ] [ Vacancies ] [ Programmes ] [ Publications ] [ Case Investigation Forms ] [ Links ] [ Upcoming Events ] [ Disclaimer ] [ CHealthNetwork ]

Caribbean Epidemiology Centre
16-18 Jamaica Boulevard, Federation Park
P.O. Box 164, Port of Spain
Republic of Trinidad and Tobago
Tel: (868) 622-4261, Fax: (868) 622-2792
E-mail: postmaster@carec.paho.org

Page last modified 04 July, 2001