In His Own Words: The Caribbean Community Uses Evidence to Influence Policy

In His Own Words: The Caribbean Community Uses Evidence to Influence Policy

By George Alleyne

Sir George Alleyne , OCC, M.D., F.R.C.P., F.A.C.P. (Hon), D.Sc. (Hon), is director emeritus of the Pan American Health Organization (PAHO) where he served as director from 1995 to 2003. A native of Barbados, and graduate of the University of the West Indies (UWI) in Medicine, he served nearly 20 years in academic medicine at UWI. Dr. Alleyne entered PAHO in 1981.

During his term as director he dealt with and published on issues such as equity in health, health and development, and the basis for international cooperation in health. He has also addressed several aspects of Caribbean health and the problems the region faces. Dr. Alleyne has received numerous awards for his work. 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 honor that can be conferred on a Caribbean national.

One of the basic propositions of the Disease Control Priorities Project (DCPP) is that the articulation of evidence from its major products—including Disease Control Priorities in Developing Countries, 2d edition (DCP2) and Global Burden of Disease and Risk Factors—can influence policymakers to make the correct decisions. The experience of some of DCP2’s editors in the Caribbean in this regard may be of interest.

When 15 heads of state of the countries that form the Caribbean Community (CARICOM) met in Nassau in 2001, they made a Delphic pronouncement: “The Health of the Region is the Wealth of the Region.” The Caribbean Community is the regional grouping of Caribbean countries, established by a formal treaty to further regional action in all areas that contribute to regional development. In order to make this statement or aspiration a reality, they established the “Caribbean Commission on Health and Development”, chaired by me, one of the editors of DCP2. The commission was composed of economists and health professionals to collect the necessary data and present the evidence, as they said, “to propel health to the center of the development agenda.” Dean Jamison, another DCP2 editor, also participated in this exercise. The Commission was also seen and funded as a local follow-up to the Sachs Commission on Macroeconomics and Health of the World Health Organization.

The commission produced its report in 2005 and presented to the heads of state the health panorama and attendant problems for the Caribbean. The report emphasized that the three critical health problems were noncommunicable diseases (NCDs), HIV/AIDS and the sequelae of injuries and violence. In addition, the weaknesses of health management systems were emphasized. Because of the favorable climate for further Caribbean integration, the commission recommended the establishment of a Caribbean-wide health insurance program. If there was to be free movement of persons throughout the region, such a program would be critical. Acceptance of the commission’s report was facilitated by the fact that the chair and other members of the commission presented the data to every one of the 15 heads of state and their cabinets in their own countries.

In a second presentation to the heads of state in 2006, the commission decided to focus on NCDs, given that the issue of HIV/AIDS already had the attention of the policymakers and Caribbean-wide plans and programs had been put in place. The data showing that the age-adjusted mortality rates for the major cardiovascular diseases and diabetes were several times higher in the Caribbean than in North America, coupled with the fact that life expectancy was increasing as infant and child mortality fell, made a tremendous impact. In addition, evidence of the significant economic burden of noncommunicable diseases undoubtedly caught their attention. The magnitude of the burden of NCDs was presented not only in terms of the mortality and the number of DALYs (disability-adjusted life years) lost, but emphasis was placed on the possibility of addressing the modifiable risk factors, which in general were obesity, tobacco, alcohol, and diet.

The Prime Minister of Trinidad and Tobago was so impressed with the data which, among other things, showed that his country had higher age-adjusted mortality rates for cardiovascular diseases than the other large Caribbean countries, that he asked that two steps be taken: first, that there be a “National Consultation” in his country as a matter of urgency and before he presented his budget to Parliament; and second, that there be a regional summit of the heads of state to discuss NCDs exclusively. He wished to be apprised of the effectiveness and the cost-effectiveness of the various interventions that could address the modifiable risk factors in his country.

A National Consultation in Port-of-Spain, Trinidad and Tobago, on September 15, 2006, drew a large audience representing a wide cross-section of the public, including the media, the academic and public health community, the Minister of Health of Barbados, as well as interested members of the general public. It was structured along the following lines:

• Political statements by the Prime Minister, the Minister of Health, and the Secretary General of CARICOM, who is the highest ranking public official in the region;
• Presentation of the magnitude of the burden of disease;
• Interventions that would be most applicable to modifying risk factors were described by international experts:
  • Prabhat Jha, another DCP2 editor, described the international and local situation with respect to tobacco, drawing from material in DCPP. Tobacco-related deaths in Trinidad and Tobago were 30 percent of all deaths in males and 15 percent in females. The experts recommended measures the government should take, including a tripling of excise taxes on cigarettes which would drop consumption and raise income by TT$30 million and save 25,000 to 50,000 lives over the next 15 years.
  • Shiriki Kumanyika, professor of epidemiology in the University of Pennsylvania, made a similar presentation with respect to diet and the possibility of reducing obesity.
• An analysis of the trade barriers that must be overcome for the Caribbean to adjust its dietary intake by reducing the importation of obesogenic foods, or those that promote obesity, and stimulating the local production of fruits and vegetables.

The consultation made the following recommendations to the prime minister to be acted upon in the short- and medium-term:

• Increase the taxes on tobacco;
• Strengthen the warning on cigarette packages;
• Ban smoking in public places;
• Establish registers for the NCDs;
• Make physical education mandatory in schools;
• Regulate food advertising to children; and
• Guarantee availability of medicines for NCDs.

Two weeks after receiving the recommendations, the prime minister took action. In his budget presentation, he raised the tax on cigarettes by 16 percent and also increased the tax on alcohol. Legislation is being prepared to ban smoking in public places, and we understand that the Ministry of Health is working toward making the messages on cigarette packages much more forthright in explaining, in graphic form, the effect of smoking. Physical education is already mandatory in primary schools.

The heads of government have now decided to meet in a regional summit in September 2007 to address the problem of NCDs. An approach similar to the one used in the national consultation will be used. If this summit takes place, it will be the first time to my knowledge that a collection of 15 heads of state dedicate specific attention to noncommunicable diseases and the possibility of preventing or controlling them.