This keynote address was presented at the opening ceremony of the Public Health and Society in Latin America and The Caribbean History Conference hosted by The Department of History, Faculty of Humanities and Education, The University of The West Indies, St. Augustine.
First, let me congratulate the organizers of this conference and thank them for the invitation to speak. Six years ago I spoke here on the challenges of Caribbean public health and presented data on the epidemiological picture, the transitions that are occurring and the specific disease problems which needed to be addressed. But I do not think such an approach is appropriate for this conference. It is a pleasure to see the Department of History of the University of the West Indies collaborating with institutions the distinction of whose academic credentials is unparalleled to present a conference in which history is linked with public health and society. The link between society and the public’s health is strong and binding but to my knowledge has not really caught the fancy of the professional historian. I welcome this linkage and hope that this is the start of an initiative which will fill a gap in the Academy and our society.
In general, I am not enamored of historical determinism, and I am constantly bothered by the obvious inability to prove the counterfactual. But I have come to accept that the functioning of peoples and societies of past generations presents us with a laboratory for some analysis of the present. Given the centrality of health both at the individual and population level to the vitality and functioning of any society, it is crucial that there be a historical lens on our health. I am rather chagrined that there is not a rich literature on the history of Caribbean public health. There are factual accounts of the health events in the Caribbean, but there is not a literature of their analysis in the context of the ideologies and mythologies that are peculiar to this region. I would venture to say that the linkages that bring current practitioners of public health a sense of their past are yet to be fully developed. I hope that conferences such as this may give a spark to development in this field.
There are many definitions of public health some of which are long and some of which are short. It has been variously defined as:
“The science of protecting and improving the health of families and communities through promotion of healthy lifestyles, research for disease and injury prevention and detection and control of infectious diseases. Overall, public health is concerned with protecting the health of entire populations”
or as
“It promotes and protects the health of people and the communities where they live, learn, work and play”
But the one which I have always favored is that it is
“The science and art of preventing disease, prolonging life and promoting health through the organized efforts of society”
You will note that it does not say health of or for whom. It is implied that it is for the body public – all the people. You will also note the centrality of society to public health and you will also perceive that there is no limitation on the efforts to be applied, as we recognise now that caring for the public’s health involves and harnesses to the task all the available scientific, educational, technological and social skills and knowledge of society. There is an indissoluble link between society and public health that trends in both directions. Society as a whole has an obvious impact on public health, as it is its efforts that are organised to care for the people’s health and conversely public health influences tremendously how society functions in its various roles. The health of the people represents one of the critical inputs into that social area or dimension that is fundamental to human development.
Even before entering medicine, I was fascinated by the development of thinking in medicine and health in general and I do believe it is salutary to look at the paths that have been trod to bring us to this point. It is not only in the sense of learning from one or other specific episode or figure. from the past because much of what we learn is through a successive accretion of knowledge, but it does give me a sense of appreciation, admiration and often humility at what was done and the extent to which much of the present represents the utopias of those who went before us. I will try to relate some of this particularly to the Caribbean.
Health has been a concern of civilizations from time immemorial and there are numerous ancient writings on the state of individual health and the measures taken to identify and treat disease. The history of medicine is filled with great names. There is the great polyvalent Egyptian physician Imhotep who was also an architect of one of the Pyramids. Individual medicine flourished in the ancient Egyptian courts and we read of physicians who were for example keepers of the king’s right eye and another who was keeper of the king’s rectum. I wonder how he discharged that duty. But my favorite is the great Hammurabi, King of Babylon whose code still makes fascinating reading almost as a primer for a managed care system. He laid down the scale of fees to be charged and the penalties, often severe, for incompetence or negligence.
The Greeks built on Babylonian, Chinese, Indian and Egyptian lore and practice but developed a more scientific approach to diagnosis and treatment. We read of Aesculapius the God of medicine who had two sons who were surgeons and two daughters Panacea and Hygeia. It is said that personal-care physicians worship the former and those in public health the latter. Aesculapius was so successful even in raising the dead that Pluto, king of the underworld was concerned about the fall in his population, so he complained to Jupiter who smote Aesculapius with a thunderbolt, killed him and then took him to mount Olympus. The work of Hippocrates of Cos is very much still with us in several forms. His legendary oath still represents much of medicine’s ethical standards and his perception of the external influences on health and disease resonate even today. Roman medicine extended the Greek practice and much is made of the aqueducts and sewers of ancient Rome which demonstrated some appreciation for the virtues of environmental sanitation. But in the post-Roman age of darkness medicine descended again into mysticism and magic until the Renaissance saw a renewed attention to science such as it was.
I have always noticed that the overriding noteworthy feature of the ancient medical history is the focus on the individual. I am often amazed at the accuracy of the clinical observations, but then I am reminded of the teaching of my Professor of Medicine who would tell us that the ancients exercised the same five senses that we have and these must be the first instruments the good physician should use in establishing the state of health or the nature of the disease. It is hard to find in the writings and doings of the eminent physicians of history the notion that the health of the public as a collective was of prime importance. Indeed I find the Greek concern for the health and integrity of the person to border on the narcissistic.
Let us fast forward to the appearance of mercantilism, imperialism and industrialization that led to the overcrowding in the cities that became the poles of production. The annals of public health are filled with heroes such as John Snow and Edwin Chadwick and even before Louis Pasteur and Robert Koch established the germ theory of disease which led to the birth of modern public health, they would point to the need for the change in sanitary conditions to protect the public’s health. Attention often had to be focused on the epidemics of diseases such as cholera, tuberculosis and typhoid fever that were a consequence of the insanitary conditions in which people especially the poor lived and worked.
But my public health hero is the 19th century German physician Rudolf Virchow who pioneered the reform movement for public health in Germany. His report of an epidemic of typhus in Silesia blasted the government and the recommendation was that the treatment did not lie in medicine but in “prosperity, education and liberty which could only develop on the basis of complete and unrestricted democracy.” He saw clearly the relationship between the public’s health and the form of societal organization. He made the famous statement “medicine is a social science and politics nothing but medicine on a large scale”. Virchow insisted on the role of the state in making the necessary changes in the sanitary conditions to protect the public’s health.
 In his essay on Public Health Services he wrote the following:
“The premises for well-being, however, are health and education, and it is hence the duty of the state to provide the means for the maintenance and improvement of health and education to the greatest possible extent by public health and public education facilities. It is thus not enough for the government to safeguard the major means of existence of its citizens, i.e., to assist everyone whose working capacity is not sufficient to make a living. The state must do more. It must help everyone to live a healthy life. This simply follows from the conception of the state as the moral unity of all individuals composing it and from the obligation of universal solidarity.”
In his last editorial in which he comments on the decline of the health movement, he emphasized the need for popular involvement and pointed out that “the task was to educate the people concerning the problems of health and to assist them toward winning the final victory by continuously providing for them new teachers”. There is a role for the people in seeking and obtaining the public’s health and it is the notion of responsibility of the people to which I will return as being fundamental in the quest for the public’s health.
His take on the role of the community resonates with me even now. He wrote:
“As regards the scope of public health care, it is the community that has the obligation to safeguard the right of each individual to exist, i.e. to exist in health. It is however clear that a grouping of single individuals can neither guarantee existence nor health just as it cannot abolish either death or disease”.
I have referred to the public and the poor almost as if it was a homogeneous whole. Virchow’s focus was primarily on improving the health of the poor and disadvantaged through state action but it is clear that he saw public health as we now conceive it as the health of the whole population as something which should concern us all.
Let me now turn to the Caribbean initially with regard to who or what is the public about whose health we should be concerned. It would be fatuous to regard the Caribbean public of the 18th and 19th centuries as homogeneous. There would have been the public of the slaves and the public of the others and although environmental conditions for obvious geographical reasons would apply to both, they bore differentially on the two groups.
We know a great deal about the health of the slaves and I have described elsewhere three periods in which slave health was treated differently. There is the period from the middle of the 17th century to the beginning of the 18th century in which the economy at least in Jamaica, was dominated by small holdings with small numbers of slaves. The concern for health was with regard to preserving the reproductive capacity. But with the growth of the sugar industry and the explosion of the slave trade, the situation changed dramatically. Since it was relatively easy to replenish the stock, slaves were worked as hard as possible under conditions that were not conducive to health. The sanitary and nutritional conditions were grim and infant and adult mortality were as a consequence high. With the abolition of the slave trade in 1807 and the scarcity of supply, we find efforts to improve health care and efforts to increase fertility. One thing that is certain is that the slaves themselves had little or rather no say in the establishment of the sanitary conditions in which they lived and worked. Thus one of the basic tenets of the people having input into how and what sanitary conditions were organized could clearly not have been met.
There are also several accounts of the health of the free population in the region and the diseases that affected them. I cannot find much in the way of evidence of the government either locally or in colonial Britain concerning itself with the kinds of measures that would lead to improvement of the overall health of the population. In part this may have been due to ignorance and in part to the laissez-faire approach to imperial governance in the Caribbean at that time. The concern for health post emancipation declined dramatically all over the Caribbean. There was less pecuniary interest in maintaining the health of the ex-slave population. The local or imperial authorities would not invest in the basic sanitary measures to prevent disease or promote health thus the health conditions deteriorated. The best description of these conditions is found in the reports of the various commissions sent to the Caribbean to investigate the causes of the riots which rocked the region in the 30s as a result of the deteriorating social conditions. The health situation was abominable.
Birth rates were much higher than in Europe but the most unsatisfactory feature was the high rate of infant mortality in all the colonies. Although the general mortality rates were not very high yet there was much chronic sickness and hookworm infestation was very prevalent. There was abundant evidence of childhood malnutrition and unsatisfactory housing of many of the poor people which together were some of the main causes of ill health. One striking feature was that not only was expenditure on health low, but the percentage spent on preventive medicine or public health was abysmal. For example in Barbados only 8% of health expenditure went to preventive measures. The Moyne Commission recommended a school of hygiene which eventually became the West Indies School of Public Health which was responsible for training many of the public health nurses and sanitarians who formed the backbone of the region’s public health services for many years.
As a result, in large part because of the implementation of the recommendations made by these various commissions, the improvements over the second half of the last century were spectacular. We find maternal and infant mortality falling, life expectancy increasing, and the installation of preventive services throughout the Caribbean. These changes in the public’s health have been attributed to several factors. First is the political change throughout the region. When one looks at the decline of infant mortality as a measure of public health activity in many countries, it is clear that the decrease began or the rate of the decrease increased coincidentally with political progress. It cannot be proven, but it is tempting to speculate that the popular voices heard in the new democracies were factors which contributed to increased state attention to health as Virchow had counseled.
Another factor is the institutions which were created and had impact on health and I believe there were at least three that are of prime importance. There is the University of the West Indies which was started in 1948 with the medical school as it was recognized that there was an urgent need to train doctors for practice in the West Indies. Its main contribution has been through the production of the human resources which administer the health systems and the research it has carried out. It has been pointed out at least in Jamaica again that the marked change in health status came at about the same time that doctors trained at the University of the West Indies were entering into practice. The research that has been of value has not only been biological research or research into the basic nature of disease processes but also research into the social factors that are critical determinants of health. As an example, the research into the metabolic as well as the social aspect of childhood malnutrition has led to advances in the understanding and treatment of this condition all over the world and a reduction in mortality.
Another key institution has been the Pan-American Health Organization (PAHO). This is the oldest existing international or intergovernmental health organization in the world. The Caribbean countries became members as they became independent and the relationship with the Organization has led to the technical cooperation especially with ministries of health which has strengthened their health programs. PAHO was responsible for two centers in the Caribbean – the Caribbean Food and Nutrition Institute (CFNI) and the Caribbean Epidemiology Center (CAREC) which provided invaluable contributions in nutrition and in epidemiology as their names indicate. Many of the functions of those two centers were incorporated into the new Caribbean Public Health Agency (CARPHA).
The third institution is the Caribbean Community-CARICOM which was established by the Treaty of Chaguaramas, came into being in 1973 and has been the agency with the convening power to stimulate collective action in health in the region. It has been responsible for convening the meetings of ministers of health and placing health issues before the Heads of Government. Its leadership in stimulating cooperation in health has been outstanding.
Another important feature of the development of public health in the Caribbean has been the influence of leaders- men and women of vision who saw the need and filled it. It is invidious to select names, but no pantheon of public health leadership would be complete without the names of Philip Boyd, Kenneth Standard, Morris Byer, Luther Wynter, Ossie Siung, Christine Moody and many others whose names space does not permit me to include
What is the current state of the public’s health and are there any concerns? If one examines standard epidemiological data, there would be cause for much satisfaction. The life expectancy at birth is 73 years, infant mortality rate is 16.5 per thousand live births and the dreaded childhood infections are now a thing of the past. Young doctors no longer see measles, poliomyelitis or whooping cough. There are now well-established health institutions and even although there are limitations, every country can claim a network of primary care centers. There has been steady progress against HIV and the Caribbean is on track to eliminate mother to child transmission of the virus.
But the infections have not disappeared. The recent epidemics of Chikungunya, the persistence of dengue and the appearance of Zika are all sources of concern. However, the Caribbean must guard against organizing its public health programs on the basis of episodic public hysteria caused by epidemics of infectious disease. 112 years ago Samuel Adams pointed out that public panic and hysteria were often the driving forces for public health programs. He wrote:
“Because the public, led astray by the fear of a word, misbelieves or disbelieves the true danger, we must, perforce, waste strength in fighting shadows, while the real enemy exacts its ceaseless toll of life, all but unchecked.”
One writer in commenting on the dreaded Black Death which killed almost a quarter of Europe’s population pointed out that it was not plague itself but it was fear of the plague that was devastating. The control of epidemics is important especially in the region that depends on tourism but it must not be forgotten that it is the NCDs that constitute the main burden of morbidity and mortality in the region. The prevalence of hypertension in some countries is over 25%, diabetes mellitus is a major problem and obesity as one of the risk factors for NCDs is increasing at an alarming rate. It is not only obesity in adults that is problematic but Caribbean children are becoming increasingly fatter. I have seen data from Barbados which show that whereas in 1981 the prevalence of overweight and obesity in school children was 8.52% in 2010 it had increased to 32.5%. My observation tells me that this is a Caribbean wide phenomenon.
Recently however there has been a call for the Caribbean to be concerned about population health. It has been pointed out that some of the gains at least in adult mortality are not being sustained. A comparison of adult mortality between persons of African descent in the Caribbean and a similar group in North America showed a reduction in mortality between 2000 and 2009 in both groups but the Caribbean men fell short of the levels achieved by their counterparts in North America.
How does one maintain interest in the public’s health? I revert to my hero Virchow. His modern day devotees would contend that the public’s health is a matter of social justice which should preoccupy the population as a whole. They would posit that adequate care and protection of the health of all people represents an age old challenge of convincing those who make decisions especially political decisions that health is so important, so fundamental to our humanity, that it is unjust for there to be an unequal distribution of it. This state of the public’s health depends on the social risk factors that cause ill health. These factors are themselves not all distributed equally and some of the most important ones such as wealth or material resources or the capacity for self-determination and empowerment are distributed along a gradient. There is clear evidence that health is distributed along these gradients and there are hierarchies of health. The rich are healthier; those who have more power over their lives and are more satisfied with what they do are healthier.
The thorniest problem of public health which continues to occupy us now is how to influence this gradient. It is clear that we can affect the public’s health by the application of new technologies and we should be very happy indeed with the availability of such technologies which have led to a general improvement in the public’s health. I contend that we must continue to search for and apply these technologies. We must engage in the research which will explain the best method of having these technologies penetrate those sectors which are often resistant to new behaviors and new forms of practice. However, it is argued that this is not enough and technology is only a small part of the answer. The answer lies in the unequal distribution of power and resources and a great part of the burden of death and ill health will be reduced only if as a matter of social justice we engage in a new discourse on the means for reducing that hierarchical gradient.
Virchow recommended that the people should be vocal about the need to protect their health. In our traditional democracies the people speak most loudly through the ballot box, but I believe that this must be supplemented by the voices of civil society. There has been one development of this nature with regard to NCDs in the figure of the Healthy Caribbean Coalition but there are no major civic organizations clamoring loudly in between epidemics for attention to promoting the public’s health.
Perhaps the historians will help in that their research will uncover examples of societies in which the powerful minority accepted what is almost contrary to human nature and are prepared or convinced to lose resources and privileges which maintain that hierarchy to which I referred. They may discover the models of social justice which will be valuable in our quest for the public’s health. And to those who will say quite appropriately that we have done well so far, I will do no more than quote Charles Dickens’ Oliver Twist as he held out his empty bowl; “Please sir I want some more” and I trust I will avoid the wrath of the modern day Bumbles.
I thank you and I wish your conference well.
Sir George Alleyne, Chancellor of The UWI was born in Barbados and graduated from the then University College of the West Indies as the gold medalist with the degree of bachelor of medicine and surgery (MB.BS) in 1957, he obtained his M.D from the University of London in 1965. He entered academic medicine at The UWI in 1962, and his career included research at the Tropical Metabolism Research Unit for his doctorate in medicine. He was appointed Professor of Medicine at The UWI in 1972, and four years later became Chairman of the Department of Medicine. He is an emeritus professor of the UWI and was appointed Chancellor of the UWI in 2003. Sir George has received numerous awards in recognition of his work, including prestigious decorations and national honours from many countries of the Americas. In 1990, he was made Knight Bachelor by Her Majesty Queen Elizabeth II for his services to medicine. In 2001, he was awarded the Order of the Caribbean Community, the highest honour that can be conferred on a Caribbean national. |
