The following is the first part of an extract from a presentation made in June last year by Dr John Hall, consultant neurologist and past president of the Medical Association of Jamaica (MAJ) at an MAJ Symposium.

Health, wealth and development are inextricably linked as conjoint concepts of the new millennium. This thread of concepts is being embraced by developed and developing countries, in the old world and the new. In our own hemisphere, there are the Canadian model, the American model, and the Cuban model. Jamaica is also fashioning its own paradigm, some 46 years after the advent of political independence, and the end of colonial rule.

It might be salutary to recall that the tide of history has taken Jamaica through three significant stages: the plantation period, the post-Emancipation era of British colonial rule up to 1962, and the momentous post-Independence period. These stages are not that clear-cut. Into the turbulence of that progression must be thrown the watershed event of West Indian Federation (1958-1962), which came to an abrupt, abortive end, following the Jamaica Referendum in 1961 and Eric Williams' famous dictum "one from 10 leaves nought." Historically, the West Indies Federation (WIF) is the political grandfather of what has now been mutated into what is called the CARICOM Single Market and Economy.

a fine product

Some 50 years ago, the WIF was born, a fine product of the Colonial Office in Whitehall, London, and of British post-war socialism. This was a well-timed gesture of an empire in economic decline and distress, after the horrors and costliness in life and resources of World War II. The colonial ex-servicemen, who had fought for freedom and democracy, bought into the concept.

The unprecedented large body of West Indian students in the British Isles after World War II, with the scales of the colonial mind set removed from their eyes, also bought into the concept. They saw on the horizon the beckoning light of a common historical, cultural bond and the prospect of political independence. The political leaders of the day also bought into the concept. They visualised an expansion in terms of geography, cultural diversity, economic opportunities, and political potential. The event was unprecedented in the history of the British West Indies.

Today, the British empire has been transformed into the Commonwealth; the Cold War has ended; and with the long-gone collapse of the WIF there are new realities. The varying political and economic fortunes of these island states have been well documented.

The health services of Jamaica, as well as the other island states of the CSME (including Guyana) have been under scrutiny and been the object of much criticism. Jamaica as of April 6, 2008, abolished all user fees at its government health facilities.

Simultaneously, the health budget was cut by $5.4 billion. It is well known that 83.4 per cent of the health budget goes to pay salaries, leaving only 16.6 per cent for services, maintenance, etc, where the budget cut will clearly hit hardest. What is not so well known, or remembered, is that in this small island of 2.6 million people there are, in addition to the large cadre of ministry of health staff, four regional health authorities (RHAs) which are almost autonomous.

If the Medical Association of Jamaica is to be believed, and the long litany of complaints from doctors in the health service given any credence, these RHAs have been distinguished for their dysfunctionality and ineptitude, as well as for the costliness to the taxpayer of their ballooning bureaucracy. Taxpayers still have a sizeable bill for essential drugs and special laboratory facilities not yet available in the government service.

imbalances

The health inequalities in Jamaica and the CSME are not solely an issue of funding, in my view. More significant are the imbalances and maldistribution of skills - inter-territorially and intra-territorially. The physician/population ratio, as gleaned from WHO statistics 2005, show a significant deviation from metropolitan norms. Using Canada as the gold standard, only The Bahamas and Barbados are at acceptable levels.

The nurse/population ratio is similarly unsatisfactory. Only Barbados, St Kitts and Dominica (1999) show any semblance of acceptable figures. As for Jamaica, the shortage reflects the health-care skills drain. Notably, 83 per cent of all registered nurses (RNs) from the region work in the USA and Canada (PAHO basic indicators 2005). Every year in recent times, recruiters come to Jamaica at least twice per year.

With lucrative salary packages and fringe benefits, they induce (or capture) our most skilled nurses from key areas: intensive care, operating theatre, paediatrics, neonatology, renal dialysis and other specialised areas, for work in the metropolis. Essentially, this is a replay of historic, imperial, attitudes of yesteryear - removing resources, human or otherwise, to facilitate a superior lifestyle in the 'Mother Country' and developed world.

There is a philosophic debate about this issue of migration of nurses and other skilled professionals. It is argued that the foreign travel, exposure to another culture, educational opportunities, and remittances to the GNP of the home territory adequately compensate. Others, however, feel that the loss of irreplaceable human resources, questionably short term - in circumstances where resource shortages, human and material, are endemic - cannot be acceptable. Is there room for ambivalence about this in Jamaica and the CSME? History and the development process will be the judge.

most concerned

The Commonwealth Medical Association (CMA) continues to be most concerned about this healthcare skills-drain. In April 2005 they met with the BMA, the Canadian Medical Association, the American Medical Association, the South African Medical Association, the Medical Council of Canada, the American and Canadian Nurses Associations, and the Royal College of Nursing - all important stakeholders. The CMA consensus documented the following:

1. All countries need an adequate health-care workforce.

2. Many countries have an actual or potential shortage of health workers: e.g. by 2020 the USA has a projected shortage of 200,000 doctors and 800,000 nurses.

3. Further loss by migration, in countries already short of health workers (especially developing countries), is very likely to create undue dislocation of health services and loss of life, in the affected countries.

4. The Global Health Fund amassed to address global health problems such as HIV/AIDS, is presently and will continue to be constrained by the lack of health-care professionals.

At the May 2005 meeting of the Commonwealth Health Ministers in Geneva, the shortage of nurses was discussed. Through the initiative of the CMA, the agenda for the November 2005 meeting of the Commonwealth Health Ministers' meeting in Malta considered the following issues:

1. All countries must strive to attain self-sufficiency in their health-care workforce, without generating adverse consequences for other countries.

2. Developed countries must assist developing countries to expand their capacity to train and retain physicians and nurses, to enable them to become self-sufficient.

3. All countries must ensure the education, funding, and support of their health-care workers to meet the healthcare needs of their populations.

4. Action to combat the skills drain must balance the right to the health of populations and other individual human rights. (Universal Declaration of Human Rights, 1948, Article 25:1.)

These self-evident truths affect Jamaica and the CSME directly with regard to capacity building and institutional strengthening. There are, however, many other issues and health-related factors which could be perceived as threats to Jamaica and the CSME generally.

When the spread of HIV/AIDS first came to attention in the early 1980s, few took it seriously or felt that it could become a pandemic. The political myopia was not limited to sub-Saharan Africa, but involved the developed countries as well. In Jamaica, there have been about 6,000 deaths from AIDS and there are an estimated 22,000 HIV/ People Living with AIDS (PLWA). Worldwide, 25 million people have already died from AIDS and there are now 40 million living with HIV/AIDS.

diseases of the poor

The prospects of HIV vaccination are much talked about, but the prestigious journal Foreign Affairs tells us that the pharmaceutical industry spends little on research for what traditionally have been regarded as the diseases of poor, developing countries.

The facts speak for themselves. In 2003, the market for all pharmaceuticals was US$337.3 billion. At that time, the market for all vaccines (polio, measles, rubella, influenza, etc) was US$5.4 Billion - i.e. just two per cent of the overall demand.

Should our region, (that is to say Jamaica and the other states of the CSME) be visited by the threatening global 'flu pandemic', the ground would be there for unimaginable chaos. There would be a shortage of vaccines as the USA, for instance, makes only 185 million vaccine doses per year whereas its real needs are for 300 million doses. Flu vaccines are very difficult to produce; they cannot be stockpiled from year to year like chemical compounds; strains in fact vary from season to season. It has also been noted that Northern developed countries would realistically meet their demands first ,and upwards of five billion people in the underdeveloped world would go unvaccinated (Garnett Foreign Affairs, June - July 2005).

In such circumstances, the immuno-compromised persons living with HIV/AIDS would be prime targets for flu. Additionally, it is now recognised that there is a global upsurge of pulmonary TB piggy-backing on the immuno-compromised AIDS population.

pharmaceutical security

Another issue which could negatively impact Jamaica and the other states of the CSME is pharmaceutical security. In the week of September 18, 2005, BBC TV aired a programme about the manufacture of retroviral drugs in India. The production process was "compromised". The dosage in the capsules was "questionable". The general integrity of the production process appeared highly dubious. The demographic impact of this could be profound. It could also facilitate the emergency of Multi-Drug Resistant Tuberculosis (MDRTB). In addition, there is growing concern about the dumping of substandard pharmaceuticals - some routed through Canada and the UK - into developing countries.

The spectre of other infectious diseases, e.g. dengue, Hepatitis B and C, leptospirosis, looms large. How realistic is it to hope that the WTO will facilitate legislation allowing less affluent countries, like Jamaica and the states of the CSME, to import generic drugs under compulsory licensing, once it is established that such countries lack the facilities to manufacture such drugs?

The conclusion of this article will be published next week.

Should Jamaica and the rest of the region be hit by a flu pandemic, there is not enough vaccine available from developed countries to deal with the problem.