Think about a vacation in the Caribbean and what comes to your mind? Clean air, superb scenery, relaxation, reinvigoration, and renewal? Unfortunately, this is not the reality for many residents of the poorer Caribbean islands. In several Caribbean countries, from 15 percent to 30 percent of the population live below the poverty line. The region's infant mortality rates vary from 10–12 per 1,000 live births in Barbados and St. Lucia to 24 in Jamaica and 52 in Guyana. Meanwhile, HIV/AIDS has taken a particularly heavy toll on the Caribbean, with prevalence rates that are second only to those of sub-Saharan Africa.
In the wake of the United Nations Millennium Summit, prime ministers of the Caribbean Community (CARICOM) met in Nassau in 2001 to review the region's health priorities and declared their conviction that "The health of the Nation is the wealth of the Nation." Inspired by this—and by the spirit of the Millennium Development Goals—Caribbean governments have developed new strategic plans for health. How realistic are their goals in the current economic and political climate? How likely are these strategies to succeed in improving quality of life for the Caribbean poor?Epidemiologic transition
The last century witnessed dramatic changes in health status across the Caribbean region. The appalling conditions existing at the emancipation of slaves in 1838 remained essentially unchanged for a hundred years—what might be called the "dark century" of Caribbean underdevelopment. During this period, Barbados, for example, had infant mortality of higher than 300 per 1,000 live births. It was not until 1937, when civil disturbances broke out across the region, that Caribbean governments finally instituted long overdue social and governmental reforms.
Many years passed, however, before the region's health indicators showed substantial change. This happened in the 1960s, following the development of the first modern public health services in the region, led by Sir Maurice Byer. Byer's work emphasized maternal and child health through the development of public health clinics staffed largely by public health inspectors and nurses—efforts that had an impact throughout the region. By the 1970s, such emblems of underdevelopment as infant malnutrition had been all but eliminated (Haiti being the exception), while most severe infectious diseases—such as tetanus, diphtheria, whooping cough, typhoid, syphilis, streptococcal pneumonia, and scarlet fever—had all but disappeared. These developments were accompanied by equally dramatic changes in demographics. With improved economic opportunities, improved health care and improved nutrition, life expectancy increased across the region, accompanied by an increase in chronic, noncommunicable diseases associated with an aging population.
Political and economic changes were important too. As Caribbean countries gained their independence from Britain during the 1960s, economic development accelerated. The tourist industry exploded, employment shifted from low-income manual work to higher-income service jobs and light industry, and Caribbean culture was transformed.
Among the lifestyle effects was a shift from low calorie intake and high activity levels to high food intake and low activity, a pattern that can now be seen in every Caribbean capital city. Indeed, the majority of Caribbean women today are overweight, and a third are obese. Several epidemiologic studies find that the Caribbean has among the highest rates of hypertension, diabetes, and their complications. Diabetes and vascular disease are now among the region's top causes of illness and death.
During the latter part of this epidemiologic transition—which took place over 30 to 40 years—the scourge of HIV/AIDS has emerged as the number-one killer of young Caribbean adults. The increased threat of AIDS, together with the huge and growing burden of chronic noncommunicable diseases, constitutes a "double whammy" for the region's countries. Yet the economic and political realities are such that major aid goes only to the very poor, and never in adequate quantities to build capacity or significantly alter the status quo.
Most Caribbean countries have concentrated their financial resources on infrastructure development and education (at the primary and secondary levels) and are simply unprepared to deal with the massive new burdens of both chronic diseases and HIV/AIDS. While some countries have healthier economies (Trinidad and Tobago and the Bahamas, for example) and others have a stronger educational base (for example, Barbados), no Caribbean country is free of poverty, and none has adequate human resources in health care. In fact, some countries, such as Guyana, must deal not only with HIV/AIDS and chronic diseases but also malaria and other infectious diseases, while grossly handicapped by a crippled economy. While the region's leaders have finally recognized the importance of a healthy population for national development, this belated recognition may still not be sufficient to translate goals into outcomes.
The Millennium Development Goals emphasize broad issues such as environmental sustainability and global cooperation in aid, trade, and debt relief. In these areas, the Caribbean countries sometimes seem to be pawns in a larger game. Their small, paradisiacal islands provide a playground for North American and European tourists (particularly cruise passengers, who now outnumber land-based visitors in many of these tourist destinations). The native population bears the brunt of the resulting environmental pollution, destruction of coral reefs, overdevelopment of some islands, and unfair trading conditions—all of which threaten the sustainability of tourism-based economies.
The English-speaking countries of CARICOM have a long tradition of cooperation in health planning, with support and technical cooperation from the Pan American Health Organization (PAHO). Regional and national strategic health plans now all place top priority on the major health issue of the millennium goals: stopping and reversing the spread of HIV/AIDS. But they must also tackle the region's ever-growing burden of chronic noncommunicable diseases and also address other key areas, including the environment, nutrition and human resources.
To date, only the Bahamas and Barbados have been able to mount a sufficiently strong response to HIV/AIDS, one that appears to have slowed the epidemic. Barbados has succeeded in reducing mother-to-child transmission dramatically, and both Barbados and the Bahamas provide antiretroviral treatment to nearly all those who need it. But for most AIDS sufferers elsewhere in the Caribbean, both antiretroviral drugs and the technical and medical support required to manage their use remain largely out of reach. National HIV/AIDS committees or commissions have been formed throughout the region, but vary in strength and effectiveness.
International aid has helped increase human resource capacity in the region's health sector. (The University of the West Indies, with support from the European Union, has been at the forefront of the region's fight against HIV/AIDS.) At a scientific conference, "HIV/AIDS: Research Partnerships for Action," hosted by the University of the West Indies HIV/AIDS Response Program in June, key players in this area met to share advances in research and management programs, and to chart future strategies. These include overcoming the stigma of AIDS; translating knowledge into behavior change; improving screening, monitoring, and evaluation; and strengthening partnerships. The conference also brought to light an important cultural aspect of the Caribbean's vulnerability to AIDS: liberal attitudes toward sexual relationships, on which tourism sex often becomes superimposed.Chronic diseases
While HIV/AIDS has followed an alarming course, with dramatic consequences that evoke intense emotions, chronic noncommunicable diseases are, like the poor, always with us. They have a significant impact on employment, poverty, productivity and national resources in the Caribbean. Hypertension, the so-called "silent killer," affects nearly half of Caribbeans over 40, and diabetes afflicts more than 20 percent of the same age group. Ironically, this prevalence has led to a level of tolerance and acceptance that itself poses a barrier to aggressive intervention. There are many other such barriers. Efforts during the last part of the 20th century were focused on improving health care, with only token nods to health promotion. Although Caribbean governments now recognize that "an ounce of prevention is worth a pound of cure," both the resources and the infrastructure needed for effective prevention remain lacking.
PAHO and the Caribbean Health Research Council have developed collaborative regional programs to deal with such major Caribbean health problems as diabetes and hypertension. But the poor economies of most Caribbean countries work against a serious and effective assault on the problem. Today there are still too few personnel skilled in health promotion; only a limited number of physiotherapists, nutritionists and physical education teachers; too few and often inadequately trained fitness instructors; poor facilities for exercise in urban areas; and inadequate agricultural policies for promoting lowcost, healthy diets. The situation is compounded by crime in urban areas, dangerous roads for cyclists, and many other administrative, environmental, and societal obstacles.
There are success stories in Caribbean health, however. The progress against HIV/AIDS in Barbados and the Bahamas is instructive. These programs owe their success largely to the strong commitment at the level of the prime minister and permanent secretary, with "focal points" in relevant ministries and with dedicated budgeting. Following a similar model, Barbados' Ministry of Health recently appointed a task force to develop a framework for a Chronic Disease Commission. Only such a body, with a clear mandate and funding, can hope to mount a comprehensive, intersectoral effort to prevent and control these diseases. Health economists also will have a critical role in evaluating the cost effectiveness of preventive strategies.
To tackle the big health picture through a pan-Caribbean effort, the governments of CARICOM have appointed a Regional Task Force on Health and Development, chaired by Sir George Alleyne, past director of PAHO and now chancellor of the University of the West Indies. The commission is charged with reviewing the major health priorities and developing a strategic plan with a strong emphasis on economic realities. It is expected to issue a report within the next few months, and its findings should have a major impact on the region's approach to health and development. The evidence presented should empower national and regional programs and help cement partnerships and financing that are needed to create effective programs.
The Caribbean is perceived across the world as a tropical paradise for the pursuit of healthy (and some "not-so-healthy") pleasures. It is time for the great majority of the region's own people to reap the true benefits of that paradise and begin to live much healthier lives. While many of the Millennium Development Goals are likely to be achieved in the region's more developed countries, others still have a long way to go in such key areas as HIV/AIDS, aid and trade, and environmental sustainability. The Caribbean is both vulnerable and important to its larger neighbors, and progress during the next few years will be crucial to our ultimate development.
Henry Fraser is dean of the School of Clinical Medicine and Research and director of the Chronic Disease Research Centre, Tropical Medicine Research Institute, at the University of the West Indies, Cave Hill Campus, in Bridgetown, Barbados.