Forty years. An introduction to the development of a Caribbean public health

The development of public health and primary care in Jamaica is examined with particular reference to the historical events which paved the way for their development: notably, the collaborative work undertaken by the Rockefeller Foundation (Commissions on hookworm, tuberculosis, malaria, yaws); recommendations of the Moyne Commission (leading to the establishment of the West Indies School of Public Health); and the Irvine Commission which recommended the establishment of the University College of the West Indies. A confluence of political, social and international activity in the 1970s proved catalytic in the development of the current ethos of primary health care, and the Department of Social and Preventive Medicine was instrumental in the training of the most innovative addition to the primary care health team, the community health aide. Undergraduate and postgraduate training programmes of the Department are highlighted as it celebrates its fortieth anniversary.

Forty years. An introduction to the development of a Caribbean public health.

The development of public health and primary care in Jamaica is examined with particular reference to the historical events which paved the way for their development: notably, the collaborative work undertaken by the Rockefeller Foundation (Commissions on hookworm, tuberculosis, malaria, yaws); recommendations of the Moyne Commission (leading to the establishment of the West Indies School of Public Health); and the Irvine Commission which recommended the establishment of the University College of the West Indies. A confluence of political, social and international activity in the 1970s proved catalytic in the development of the current ethos of primary health care, and the Department of Social and Preventive Medicine was instrumental in the training of the most innovative addition to the primary care health team, the community health aide. Undergraduate and postgraduate training programmes of the Department are highlighted as it celebrates its fortieth anniversary.

Public health training programs at the University of the West Indies.

The Department of Preventive Medicine of the University of the West Indies was established in 1957 with the idea of improving undergraduate teaching facilities to enable medical students to study patients in their homes and social environment. The authors describe the two public health diploma programs available at the University and cite pertinent enrollment and geographic distribution statistics. Candidates for the Diploma in Public Health are registered medical practitioners who take a series of compulsory and elective subjects and have a period of supervised field training and research during the 12-month course. The Diploma in Community Health trains students in the health and diseases of man in his total environment. Students choose among three program options: the general program, specialization in health education, or specialization in health services administration/hospital administration. The general program is the most popular because it gives the student a rounded education suitable to the needs of small states. The 12-month diploma course features the interdisciplinary approach where students from various fields discuss important issues in community health. Comprehensive courses in these areas include health services administration, social sciences, environmental health, epidemiology and biostatistics, family health, communication science, and community mental health. The authors state that the candidate for the Diploma in Community Health is assessed on the basis of course and field work, a special project report, and a final written and oral examination.

Approaches to primary health care in the Commonwealth Caribbean.

In this article, the authors present a brief review of the health problems of the Commonwealth Caribbean and of the primary care activities being implemented to solve them. Special attention is given to programs which develop new categories of health workers and direct health manpower toward learning a technology appropriate to the conditions in which they work. These programs enable the health worker and allied health personnel to adapt their roles and functions accordingly and thus provide quality health care within limited resources. The main programs are: development of new categories of health workers such as the community health aide and the nurse practitioner; education and training of allied health personnel; the training of primary health care physicians. An account is also given of primary health care in Jamaica and in the smaller territories of the Caribbean.

PIP: The authors review some of the health problems of the Commonwealth Caribbean countries and describe primary care activities that are being implemented to solve tham. Some of the most important health problems are poor environmental sanitation, sexually transmitted diseases, diabetes, hypertension, mental illness, and dental disease. Although the infant mortality rates have been reduced over time, the life expectancy of the population of these countries is considerably lower than in North America, ranging from 52 in Montserrat to 69 in Barbados, with an average of 61 years. Expenditure for health care is low in comparison to that of the US, and human resources are not available in sufficient numbers to serve the population. Programs have been developed to attain the World Health Organization's objective "Health for All by the Year 2000." The programs include 1) new categories of health care workers, such as the community health aide (CHA) and nurse practitioner, 2) education and training of allied health personnel, and 3) development of primary health care physicians. CHAs assist the trained nurses, learn to recognize important signs and symptoms of disease, and act as a link with the community and health department. Nurse practitioner training programs and special medical education programs have been established to produce nurses and physicians committed to providing health care for the Commonwealth Caribbean people. Management capabilities for primary care are developed on an in-sevice basis. With the consolidated efforts of the projects and programs, health workers learn to adapt their roles and functions according to existing conditions and thus to provide quality care with limited resources. A description is given of primary health care in Jamaica and in the smaller territories of the Caribbean.

Approaches to primary health care in the Commonwealth Caribbean.

En este articulo, los autores hacen un breve analisis de los problemas de salud de la Mancomunidad del Caribe y de las actividades de atencion primaria emprendidas para resolverlos. Se concede especial atencion a los programas conducentes al establecimiento de nuevas categorias de auxiliares de salud y a la orientacion del personal en tecnicas apropiadas a las condiciones de trabajo. Esos programas permiten al auxiliar de salud y al personal homologo adaptar convenientemente sus cometidos y funciones y prestar asi una atencion de calidad con recursos escasos. Los principales programas son: formacion de nuevas categorias de auxiliares de salud, por ejemplo, ayudantes de salud de la comunidad y enfermeras auxiliares de medicina; instruccion teorica y practica de personal homologo; y adiestramiento de medicos de atencion primaria. Por ultimo, se exponen las actividades de atencion primaria de salud en Jamaica y en otros paises y territorios del Caribe

Longitudinal study of heart disease in a Jamaican rural population. I. Prevalence, with special reference to ECG findings.

A long-term epidemiological study of heart disease in a representative rural community in Jamaica was started in 1962-63 and the first follow-up survey was carried out in 1967-68. This report describes the prevalence of several cardiovascular characteristics at each survey, and their associations with other measurements. The nature of the electrocardiographic abnormalities and their relationship with symptoms of effort pain and prolonged chest pain suggests that much of the disease seen in this population is ultimately ischaemic in origin despite evidence that classical myocardial infarction and severe coronary atheroma are relatively infrequent. Nevertheless both the symptoms and the electrocardiographic abnormalities had features that were not completely typical of occlusive disease of extramural coronary arteries. These findings are discussed in terms of the four conditions-hypertension, conventional coronary heart disease, small artery disease, and cardiomyopathy-that are believed to account for most cases of heart disease in this community, and it is concluded that the overall pattern of disease cannot be explained by any single disorder of overriding importance. The evidence suggests that all may be important contributors.

Longitudinal study of heart disease in a Jamaican rural population. 2. Factors influencing mortality.

The relationship between cardiovascular characteristics and mortality was investigated in an epidemiological study of heart disease in a representative adult rural community in Jamaica. Of 449 men and 469 women followed up for 5 years, 36 men and 28 women died and the data concerning their status as regards arterial pressure, electrocardiographic abnormalities, and histories of effort pain at the intial survey have been analysed. Cardiovascular disease, and heart disease in particular, was the major cause of death in this population. Blood pressure levels exceeding 160/95 mm Hg had been recorded in about one third of the men and half the women who died and a clear trend was found between overall mortality and arterial pressure. Symptoms of effort pain and ECG abnormalities compatible with myocardial ischaemia, both of which were unexpectedly common, appeared to have independent prognostic significance. The prognosis of each was worse when associated with hypertension; hypertension unaccompanied by either effort pain or ECG "ischaemic" abnormality, on the other hand, caused no excess mortality in either sex within the period of follow-up. Although classical myocardial infarction was confirmed to be relatively infrequent, myocardial disorders with many of the features of ischaemic heart disease are an important cause of death in rural Jamaicans.

Longitudinal study of heart disease in a Jamaican rural population. 3. Factors influencing changes in serial electrocardiograms.

A longitudinal survey of heart disease in adults in a representative rural population in Jamaica provided an opportunity to study factors influencing the progression and incidence of electrocardiographic abnormalities in serial tracings taken at a 5-year interval. An analysis of changes occurring in those with ECG abnormalities compatible with ischaemia at the first survey showed that progression from a less severe to a more severe category was greater in men than in women, in hypertensive than in normotensive subjects, and, among men, in those with the amplitude criteria of left ventricular hypertrophy. The incidence of abnormal Q/QS patterns was greater in men than in women, and that of all abnormalities suggesting ischaemia was greater in hypertensive than in normotensive persons; in men, it was greater in those with high amplitude R waves. The incidence cases showed S-T and T wave abnormalities, the great majority of which were classified as showing features compatible with ischaemia rather than with strain secondary to hypertrophy. These findings, which are discussed in terms of their possible causes, seem to confirm that much of the heart disease in this Jamaican community has features of myocardial ischaemia despite other evidence that extramural coronary vessels tend to be spared from such severe occlusive atheromatous disease as is found in many other populations.