...half of all deaths in The Bahamas are attributed to diseases that are caused by poor lifestyle choices

Historical Perspective on Bahamian Healthcare
by Larry Smith
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Experts say that to address the skyrocketing costs of modern medicine, we have to rely more on preventive and primary care rather than costly hospital treatment.

According to Health Minister Dr Hubert Minnis, about two thirds of public spending on healthcare goes to treat diseases that are caused by poor lifestyle choices. And half of all deaths in the Bahamas are attributed to these same illnesses.

For example, there are tens of thousands of diabetics in the Bahamas, and complications from the disease include kidney failure, heart disease and blindness. It costs taxpayers $60,000 a year to treat each of the more than 200 people with kidney failure who are currently undergoing dialysis at the Princess Margaret Hospital.

Bahamians spend about half a billion dollars on public and private healthcare today (some 7 per cent of GDP). This represents an incredible transformation from the early years of the 20th century, and it is interesting to take a historical view of this subject.

Back then, there were only three doctors outside of Nassau - at Inagua, Harbour Island and Green Turtle Cay - to serve 42,000 people living in the widely scattered out islands. According to Dr Harold Munnings in his 2005 history of the Princess Margaret Hospital, out islanders "obtained what care they could from untrained midwives, clergymen and herbalists".

The PMH began life as a poorhouse in 1809 and entered the 20th century as a place of last resort for those in need of medical care. According to a 1905 account It had four sections - for the sick, indigent, lepers and insane. Treatment was free, but patients were referred to as "inmates", and those who could afford it arranged for medical care at home - quite the opposite to current practice.

In 1925 several American visitors contracted typhoid fever in Nassau - a killer disease transmitted by dirty food and water, so the British authorities dispatched a senior public health expert to investigate.

He deplored the filth of heavily populated communities not included in the city's new water-works and sewerage system, then under construction. He also noted the prevalence of tuberculosis, venereal disease, gastroenteritis and tetanus, and strongly criticised public indifference to Nassau's dreadful sanitary and housing conditions.

Unfortunately, these conditions did not begin to change until the middle of the century, when a British official was still able to write that "Behind Nassau's picturesque old-world streets and the princely mansions along the East and West shores are slums as bad as any West Indian Colony, and far worse than anything Bermuda can show."

In 1953, two thirds of the homes on New Providence still had no running water. And preventable diseases were due mostly to overcrowding, ignorance, poor nutrition, and lack of public hygiene.

An unpublished medical memoir written by Dr Malcolm Hale about a year before his death in 2003 at the age of 77 offers a useful perspective on this period of modern history. Hale arrived in Nassau in 1954 on a three-year contract as a medical officer for the new Bahamas General Hospital (which was renamed after a visit by Princess Margaret in 1955), and stayed on in private practice.

"I arrived by boat from England on December 16," he recalled. "We anchored outside the bar and a tender came out to carry us in. On it was a reporter from the Guardian to interview the new doctor, and a photographer to take his picture...the effort hinted at the state of medical needs of the community."

He identified the new Emerald Beach Hotel on Cable Beach, the redeveloped Bahamas General Hospital and the first City Market food store as emblems of changing times for Bahamians. They represented a dramatic break with the economy of the past, he said, and were a sign that prosperity was beginning to trickle into the general population.

Shortly after his arrival Dr Hale was put in charge of the TB and geriatric wards at the Prospect Hospital, as well as the Lazaretto off Carmichael Road, which was no more than a narrow dirt track. This was in addition to his out-patient and casualty duties, as well as occasional out island clinics.

Prospect Hospital was a collection of wooden buildings on Prospect Ridge built for the American and British air forces who trained in the Bahamas during the Second World War. Like Windsor airfield it was handed over to the Bahamian government in 1945.

"The general health of the population was poor," Dr Hale recalled. "Tuberculosis was rife; new cases were discovered almost daily, many from out island settlements, some of which like Rolleville (Exuma) and Moores Island (Abaco), were heavily infected. Fortunately, my entry to the medical profession coincided with the discovery and availability of a whole range of effective medications...Now patients came to be cured, not to die."

He described the geriatric wards as pathological museums. "Especially impressive were cases of elephantiasis and the whole spectrum of tertiary syphilis. The leprosarium was a collection of small wooden cottages (with) about 20 patients when I took over, most in advanced stages of disfigurement, especially of hands and face.

"The few new cases I admitted were diagnosed in the early stages and so far as I know all were cured and returned undisfigured to society. The old cases stayed at the Lazaretto and died off over a period of several years. Most of the cases were white."

In the out-patient clinics, Dr Hale treated many malnourished children with intestines bloated with Ascaris worms. Vermicide was probably the most heavily prescribed drug at the time, and he credited it with making the greatest single contribution (except for penicillin) to the health of the community.

Dysentery was also common, as were sexually transmitted diseases like gonorrhea and syphilis. But the popular remedy for VD at the time, Dr Hale noted, was to have sex with female infants. "It took a major educational effort by the profession to disabuse the population of this idea, and I wonder today if we fully succeeded."

Although HIV-AIDS was unknown at the time, Hale suspected that "the occasional cases of multipathology which responded to no treatment, and which were unsolved diagnostic puzzles, and invariably fatal, may have been AIDS. Interestingly, as AIDS increased, the other STD’s declined and have become rare."

Epidemics of whooping cough were devastating, Hale said. "I remember Kenneth Eardley, an older private physician, telling me he had signed two or three hundred death certificates due to this illness in one outbreak just a few years previously. And how many times have I heard older women say 'I born 13 but I bring up three'?"

In the 1950s there was relatively little obesity and much less diabetes than now, Dr Hale reported. But one serious health condition has remained constant. High blood pressure was, and is, a common problem amongst Bahamians of all ages, together with its deadly complications of stroke and heart disease.

in fact, while he was a resident at the PMH, Dr Hale and others contributed data to a US hypertension study. In their 1958 report, the American researchers noted that:

"Almost everyone on the Islands has a relative that has 'the high blood,' died of hypertension, or has had a stroke...An analysis of the water supply in Nassau and several of the outer island groups revealed that the well water was significantly high in sodium content."

The study reported salt levels of less than a milligram per millilitre in the drinking water of major US cities, whereas drinking water at the PMH contained 129 milligrams and on Eleuthera 210 milligrams. This meant that Bahamians were ingesting up to 10 grams of salt per day from water alone. And that was in addition to the sodium found naturally in foods, or added in cooking. Nor did it account for the fact that salt pork was a common ingredient in most dishes at the time.

Currently, the American Heart Association recommends an intake of less than 2.5 grams of salt per day for the general population - that's about a teaspoon - and even less for high-risk individuals. I can testify from personal experience that this guideline is as difficult to achieve in today's fast food-dominated diet as it was back in the 1950s when we all drank salt water.

Hale was one of a growing band of doctors who participated in the vast expansion of medical skills and services in the Bahamas over the past half century. His assessment of how things had changed over that time?

"Today the general health of the population is excellent," he wrote in 2002. "except for self-inflicted conditions, principally obesity (and its complications), HIV-AIDS, and gunshot wounds."

In fact, the current level of violent crime is straining our healthcare system. There were 51 cases of knife and gun attacks treated by the PMH in October alone, and ER doctors treated more than 160 other assault cases, as well as 94 traffic accident victims last month.

Apart from these walking wounded, most of the patients who crowd the PMH emergency room don't need to be there - they just don't know any better. Preventive medicine and affordable drugs are important, but public education to improve compliance or avoid problems in the first place is just as critical.

There is a growing awareness in government that we will never have enough money to solve our healthcare challenges using costly tertiary care approaches. Cancer, AIDS, diabetes, hypertension and stroke, heart attack and kidney failure top the list of modern medical problems in the Bahama - and they all are preventable with education, diet and drugs.

For the time being plans have been shelved for a new $600 million public hospital, which surveyors were staking out only months ago on acres of prime forested land at Prospect Ridge. The enormous investment that would be required to build a new hospital has led successive governments to content themselves with redeveloping the PMH at its present site.

"I would love to work in a new, state-of-the-art hospital," Dr Munnings told me recently, "but a properly funded programme to prevent chronic disease has to be the priority."

November 17, 2010

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