Winston Davidson, Contributor

THE CONTRIBUTION of 50 years of Independence to the health conditions of the Jamaican people will be understood with greater clarity if the analysis is located against the background of the pre-Independence period.

The most important index of the health conditions in any community is the infant mortality rate. The mortality data indicate that at least one to two in every 10 infants died before the age of one year in the colonial territories of the British West Indies. The majority of these children died from nutritional, diarrhoeal, and respiratory diseases. Poverty was the primary cause. Jamaica ranked second when compared to the rest of the British West Indies territories in 1937.

Public-health Legacy

After emancipation in 1838, as the plantations closed down, worsening social conditions led to massive epidemiological crises in Jamaica. The ex-slaves built their shacks on marginal hillside lands characterised by improper disposal of human and solid waste, the absence of pit latrines, the absence of potable water supply, and the presence of faecal contamination in bushes, rivers, and streams from which they collected water for domestic supply.

The inevitable consequences were outbreaks of cholera in 1850, which caused 32,000 deaths; a smallpox epidemic in 1852; and epidemics of typhoid fever and cholera, again in 1853, resulting in deaths of a quarter of the population of Kingston. By 1865, conditions were so poor that it led to the Morant Bay Rebellion, the recall of the governor, and the institution of a Royal Commission.

Strategic response

The response of the colonial government to address the health situation was the promulgation of the 1867 Public Health Law, the introduction of the Local Parish Board of Health, and an expanded district public-health system which is part of our legacy to this day. The building of the Bellevue Hospital for the custodial care of the mentally ill roaming the streets in every parish was the expected outcome of an emancipated people burnt out by decades of poverty, hunger, and a sense of hopelessness.

Greater emphasis on public health, better roads, safer water supplies, the enactment of quarantine measures, and the provision of dispensaries occurred throughout Jamaica. People, irrespective of income, were able to obtain drugs and medical supplies. The Kingston Dispensary was opened in 1870. By 1874, the 14 parishes were divided into 40 medical districts and 35 district medical officers were allocated to 14 parishes. A number of sugar estate hospitals, closed prior to emancipation, were reopened and placed under the administration of the district medical officers.

Although this health response by the colonial government was a strategic necessity and was in keeping with the current epidemiological trends, the measures were not sufficient to address the root causes giving rise to the worst health conditions of the time.

Riots, rebellion, and healthcare in the watershed of 1938

The restlessness of the populace as a result of the poor social and economic conditions led to riots, rebellions, and social instability throughout the British West Indies. The popular uprisings were so serious as to demand the intervention by the Crown of another Royal Commission - the Moyne Commission - in 1938. This commission arrived at a number of conclusions:

1. Housing accommodation for the poorer people in the West Indies is generally deplorable and general sanitation is primitive.

2. Much ill-health arises from poverty - poverty of the individual, of the medical departments, and of governments.

3. Much ill-health is of a preventable nature and much arises from ignorance.

4. The high rate of illegitimacy combined with large families and a lack of parental responsibility are serious factors in health.

5. The cure of disease has received much more attention than its prevention.

6. Little improvement in the health of the people is expected no matter how extensive the hospital facilities are. This will continue until such defects are remedied.

7. Relatively too large a proportion of the available funds and medical efforts is expended on curative medicine and too little on prevention.

8. There is neglect of rural districts in favour of the urban areas.

9. The creation of at least one school of hygiene with the training of auxiliary medical personnel is recommended.

10. The centralisation of medical institutions for the training of all classes of medical personnel is recommended.

11. The reorganisation of the medical services for the better balance between preventive and curative medicine is recommended.

12. A minimum of 10 per cent of the national Budget should be spent on health-care services.

Proud but incomplete legacy of achievements

Housing - (See Lord Moyne's Conclusions #1 and #2)

All governments in independent Jamaica have worked very hard to correct the colonial legacy of squatting. With limited resources, the housing stock for Jamaicans, including the poor, has moved from less than 4,000 houses in 112 years (1838-1962), to approximately 200,000 houses in 50 years, or approximately 20 times more houses in half the period of time when compared with the legacy period of colonial governance in Jamaica.

Squatting is a deterrent to building a stable and secure family and to enabling responsible parenting. Affordable housing is the best way to build healthy families, develop a sense of personal pride, a culture of responsible parenting, and healthy lifestyles in communities. This is one of the most important conditions for addressing Jamaica's present epidemic of non-communicable diseases.

Population Control 1962 to 1972 - (See Lord Moyne's Conclusion #1)

In 1966, when the population grew at unprecedented non-sustainable rates, family planning measures were introduced by the Government of the day to decrease the rates of population increase to levels that would not compromise Jamaica's ability for sustainable economic growth. This was done in concert with family planning pioneer Dr Lenworth Jacobs and evolved into the National Family Planning Board. All governments have continued this policy in collaboration with the University of the West Indies and non-governmental organisations.

At present, Jamaica boasts state-of-the art reproductive-health services at the University Hospital of the West Indies and in the public and private sectors. A number of these services have been assessed to be globally competitive in both cost and quality. The rate of population increase in Jamaica has been reduced to acceptable levels as a result of this very important programme. When these advances are coupled with continued advances in the reproductive rights of women, the future looks very bright for Jamaica over the next 50 years.

Legislative Watersheds During the 1970s - (See Lord Moyne's Conclusion # 4)

The 1970s enabled the most far-reaching legislation affecting the mother and child, which created rights for the illegitimate child who was the victim of social discrimination and alienation as a result of the Bastardy Law which victimised an estimated 75 - 80 per cent of children born out of wedlock in Jamaica. The new law negated the notion of illegitimacy and gave legitimacy to the child born out of wedlock; the right of inheritance and, therefore, a legal right of attachment to his family; and a sense of identity and inheritance.

There was other fundamental legislation which laid the foundation for women's rights and the status of not only women, but also children in Jamaica today:

Equal pay for equal work of women, increasing the possibility of the child receiving an improved nutritional status.

Maternity leave with pay enabled women to retain their job while breastfeeding. The pregnant woman was viewed by industry as a liability in the working environment. The risk of malnutrition in children was mitigated both by the reality of greater job security of the mother and the provision of breastfeeding.

Primary Health-care Revolution of the 1970s - (See Lord Moyne's Conclusions # 2, #3, #5, #6, #7, #9)

The introduction of the primary health-care programme created greater access for the poor to basic health services with the introduction of 375 health centres delivering basic preventive health services in the vast majority of communities in Jamaica. The services included:

Mass nutrition education emphasising breastfeeding.

Community health education.

Complete immunisation of infants and children from communicable diseases.

Fluoridation programme for the prevention of dental caries in children.

Mother and child antenatal and postnatal programmes.

Community participation through the development of community health committees.

The foundations of universal access to free basic health care to all the population at the community level in Jamaica.

The foundation for the eradication of preventable communicable diseases in Jamaica.

Mass breastfeeding and mother-and-child nutrition programmes.

Primary health care was the platform for building the national preventive health strategy.

The training of several new categories of health workers facilitated the rapid expansion of primary health care to the rural parishes.

Rapid expansion of mother and child antenatal and postnatal clinics had a profound effect on the infant mortality rate.

The value of communities being allowed to participate in community health action was demonstrated in the mass aedes egypti control programme in the epidemic of dengue fever in 1978. The epidemic was controlled in six weeks, a record for control programmes at the time.

The primary health-care programme has been in existence for over 30 years and has made a profound impact on the control of immunisable diseases, doubling the rates of immunisation between 1977 and 1979. It did so by introducing a policy of beginning immunisation at six weeks rather than three months.

This set the stage for introducing compulsory immunisation as a prerequisite for entering primary school. Communicable diseases such as measles, mumps, rubella, polio myelitis, tetanus, small pox, tuberculosis in children and the seasonal outbreaks of gastroenteritis have been relegated to becoming diseases of the past in Jamaica. This is one of Jamaica's proudest legacies of Independence.

Birth of Community Mental Health

The colonial government had a policy of custodial care for psychiatric patients at the Bellevue Hospital . There were over 3,500 mentally ill patients who were locked down in the institution, existing under inhumane conditions.

The results of a peer review study by Dr Wendel Abel et al in 2008 revealed: "Despite limited resources, Jamaica was able to shift from institutional care to community care by implementing the appropriate policy framework, building on primary care services, providing mental health beds at the community level, the training of specialised community mental health nurses (mental health officers) and improving access to psychotropic drugs. As a result, the country has developed a more accessible mental health service; the number of patients treated in the community has doubled over the past decade, and 67 per cent of inpatients are now treated outside of the mental hospital; and there has been a reduction in the population of the mental hospital". At present, Bellevue Hospital's population is 800 patients.

The contribution of the Cuban Government to the development of Jamaica's health service for over 40 years has resulted in hundreds of Jamaicans trained in medical, dental, nursing and allied health professions.

Governments since Independence have displayed a remarkable sense of unity of purpose in the management of the health sector by their consistency and continuity of health programmes and policies of their predecessors. This is a very important pre-condition for sustainability and successful health outcomes.

Any growth in the economy over the next 50 years can only be sustained if the inter-connected triad of human health, environmental and climate-change impact, and natural-disaster prevention and management is taken into account.

Policymakers at all levels of Government, as well as the private sector, continue to ignore this fundamental developmental triad at their peril. The relationship between the pride of home ownership, marriage, nuclear-family development, responsible parenting, and enabling healthy lifestyles in all its forms, was never a core value in pre-Independent Jamaica. This relationship, more than any other, represents the essence of present and future attempts at developing a culture of healthy lifestyles, which is the defining culture for nation building and sustainable growth and development in a brutally competitive globalised world.

Winston Davidson is head, School of Public Health and Health Technology, University of Technology. Send feedback to editor@gleanerjm.com.

Jamaica continues to celebrate 50 years of Independence. We have achieved a lot. However, there is much work left to be done if we are to progress as a country. We must begin to tackle Jamaica's chronic problems in a targeted and sustained way, to make this country a better place to live, work and grow families. The Next 50 Years, a special Gleaner series, will spotlight some of the challenges we must fix in the coming years. We want to hear from you. Email us at editor@gleanerjm.com and join the debate.