CARPHA: Public Health on the Agenda

“A regular doctor sees an individual patient, and gives a diagnosis and a prescription. A public health specialist looks at an entire community or population to diagnose what is ailing its people, and makes a policy-level prescription to its Government or leaders.” – Dr. James Hospedales

For those who may not fully understand the term ‘public health’, Dr. James Hospedales’ remark encapsulates it well. Diagnosing, treating and follow of an individual patient typically takes a days to weeks, while the public health cycle is usually months or years, as one is trying to improve the health of thousands or millions of people.

Dr. Hospedales is the Executive Director of The Caribbean Public Health Agency (CARPHA), the single regional public health agency for the Caribbean, which was established in 2011 by an Inter-Governmental Agreement signed by Caribbean Community (CARICOM) Member States.

CARPHA is the first new international public health organization of the 21st century, and serves 24 English, French and Dutch-speaking countries in the Caribbean.

The Agency combines the functions of five former Caribbean Regional Health Institutions (RHIs):

1. The Caribbean Epidemiology Centre (CAREC)
2. The Caribbean Environmental Health Institute (CEHI)
3. The Caribbean Food and Nutrition Institute (CFNI)
4. The Caribbean Health Research Council (CHRC)
5. The Caribbean Regional Drug Testing Laboratory (CRDTL)

CARPHA brings these RHIs together as one strong force under a public health umbrella, under which issues requiring a regional response can be addressed. Such issues include:

• Emergency responses to outbreaks, epidemics and natural disasters, which challenge the health of local and tourist populations
• The prevention and control of non-communicable diseases (NDCs) such as obesity, cancer, heart disease and diabetes
• The surveillance and management of communicable diseases (CDs) such as HIV/AIDS, dengue, and emerging/re-emerging diseases including, most recently, Chikungunya and the threat of Ebola including specialised laboratory testing
• The surveillance and prevention of injuries, violence and job-related illnesses
• Contribution to global health agreements and compliance with international health regulations, usually in collaboration with the Pan American/World Health Organization
• Training and research in public health, in collaboration with academic institutions
• Environmental health and climate change
• Ensuring quality of medicines for people
• Providing timely and reliable health statistics and information for the region

“CARPHA is an expression of Caribbean cooperation in health,” explains Dr. Hospedales.

“Each Caribbean country needs all of these health measures but can’t have all that they need by themselves. By coming together, we have much greater capacity to achieve success in facing health and development challenges to the region.”

The Call of Prevention

Dr. Hospedales’ interest in public health began early in his career.

“As a medical student at UWI, I saw patients at the hospital: children with severe malnutrition or gastroenteritis, a young man who had suffered a heart attack, and carnage from vehicular accidents,” he says.

“I kept thinking: this is preventable… through education, vaccination, clean water and proper sanitation, non-smoking, healthier diets, wearing crash helmets and seat-belts, and so much more. I always felt that call of prevention.”

He decided to specialise in public health and preventative medicine, and did a Master’s degree in Community Medicine and Public Health at the London School of Hygiene and Tropical Medicine in the United Kingdom. This specialist programme focused on the research and design of policies and programmes involving the health of a whole community. He subsequently completed the Epidemic Intelligence Service Program of the US Centres for Disease Control and Prevention (CDC).

Upon his return to to the region, Dr. Hospedales worked at CAREC as an epidemiologist, and was involved in the campaign towards the elimination of measles in 1991.

As he details in a paper written for the G7 summit in June 2014, “Proactive Prevention: The Caribbean Contribution to Global Health“, the Caribbean was the first region in the world to eliminate measles. Ministries of Health, CAREC, PAHO/WHO, CDC and others worked assiduously for two years to plan the campaign.

“In May 1991 there was the ‘Big Bang’, where the campaign vaccinated 91.4% of children between the ages of 2 and 14,” explains Dr. Hospedales. “This effectively stopped the transmission of measles in the region. This model was later adapted throughout the Americas, and demonstrated the possibility of global eradication.”

Since 1991, thousands of cases of measles and hundreds of deaths have been prevented — and these benefits continue to accrue decades after the programme was executed.

It is one of many examples of how the Caribbean ‘punches above its weight class’ in terms of contributions in the field of preventative medicine.

CARPHA: a Caribbean powerhouse

A key focus of CARPHA is the building of capacity throughout the countries for the primary testing and control of diseases including dengue fever and HIV/AIDS. This involves the coordination of a network of laboratories throughout the region, and the preparation of teams to respond to outbreaks within a 24-48 hour timeframe.

“When the Chikungunya virus entered the region in December 2013, it was tracked across the whole region, with weekly reporting from all countries,” says Dr. Hospedales.

“Doctors were trained, labs were ready, airlines were prepared to fly specimens in for testing, and information to mitigate it was prepared for the public. In this way, we have the capacity to respond before something becomes an epidemic.”

But the fact that this was a new virus to which no one was immune, and given the high levels of Aedes mosquitoes which transmit the virus, led to the disease spreading to all countries in eight (8) months.

In 2014, CARPHA was officially granted a Biosafety Level 3 (BSL-3) modular laboratory facility, the first of its kind in the region. Located in Port of Spain, Trinidad, the laboratory is an initiative of the Biological Security program of Canada’s Global Partnership Program.

The biocontainment lab has the capacity to safely identify samples suspected for a diverse range of diseases including Tuberculosis, Yellow fever, West Nile virus, Rabies, Hantavirus, Anthrax, and emerging infectious diseases with epidemic potential.

Beyond these are the simpler testing and monitoring that often go unnoticed by the public eye.

“We monitor the resistance of mosquitoes to common insecticides,” says Dr. Hospedales. “We breed mosquitoes in our insectary and test them against different types and strengths of insecticides. We can then advise national programmes on the most cost-effective approach.”

Another key concern is the issue of antibiotic resistance, which was the focus of a regional workshop in December 2014, that brought together countries, and partners like Public Health England and the Public Health Agency of Canada to take stock and plan a program of control.

“New drugs are not being developed quickly enough, and germs are becoming resistant to the existing drugs,” he says. “Resistance genes can also jump from one organism to another. More superbugs are constantly evolving, and we have to always be vigilant.”

Towards Healthier Environments: Workplaces & Schools

A core component of CARPHA’s efforts is directed towards the promotion of healthier schools and workplaces.

“Childhood obesity is a particularly insidious problem,” says Dr. Hospedales.

“Between quarter or one-third of children today are obese and tend to remain this way as they age — and are more susceptible to diabetes, cancer, heart disease, mental health issues, problems with employment and social relationships. These all point to higher lifetime health costs for a country, and we need to nip this in the bud and protect our children now.”

His team is currently preparing a policy package targeted at Trade and Economic Ministers as well as Health Ministers throughout the Caribbean. Its recommendations include:

• Mandatory nutritional labelling of locally manufactured foods
• Regulation of the school-feeding environment to remove junk food in schools
• Reduction of trans-fatty acids in foods
• Reduction of salt and sugar in foods
• Regulation of the marketing of foods high in sugar, salt and sugar
• Fiscal and trade measures to tackle the “obesogenic environments” in which we live
• Promotion of Fruit and Vegetable consumption

Beyond tackling childhood obesity is the challenge to support healthier living as a lifelong exercise that permeates through adult life at the workplace.

“While some organisations may have a gym, there needs to be a more systematic approach to healthier workplaces,” he says. “These measures include procuring healthier foods in the canteen, promoting the use of steps, putting showers in the workplace, and putting up bicycle racks. We need to change the collective mindset.”

Dr. Hospedales participated in the 2007 Summit of CARICOM Heads of Government in Port of Spain on the issue of non-communicable diseases like diabetes, cancer and heart disease.

These are caused by common risk factors like use of tobacco, unhealthy diets, physical inactivity and harmful use of alcohol. Out of this came a landmark Declaration of 27 commitments for the region that have been implementing over the past seven (7) years, including the promotion of healthier diets, increased physical activity levels and restrictions around the use of tobacco.

The CARICOM Summit on NCDs led to the United Nations Summit on NCDs in New York in September 2011 – another example of the Caribbean “punching above its weight” as it galvanised global attention to a problem which affects all countries health and economies.

He also recently participated in the launch of the Trinidad and Tobago Tobacco Free Coalition, a unified effort of several non-governmental organisations (NGOs) to evaluate lessons learnt from elsewhere to apply to the local population.

CARPHA partners actively with the Healthy Caribbean Coalition (HCC) in the promotion of health and the prevention and control of chronic diseases.

Promoting healthier populations

A key concern throughout the region is the harmful use of alcohol, where alcohol has been linked to social and economic costs including deaths and injuries through vehicular accidents, increased susceptibility to chronic diseases, sexually transmitted infections, mental health problems, healthcare concerns including liver damage and brain damage, domestic violence, suicide and many more.

“There has been a very worrying, collective mind shift from ‘going out to lime and take a drink’ to ‘going out to get drunk’, and the industry deliberately targets young people, especially girls, much more than in the past,” he notes. “As a parent, as a public health professional, as a citizen, I find it very disturbing about where we are as a country and as a region.”

He also mentions another issue faced in the region pertaining to alcohol: ‘presenteeism’.

“Workers may be at work in body but not in mind because they may be under the influence of drugs or alcohol,” he explains. “Therefore they are not productive and may even be endangering themselves and others.”

He notes that the measures to combat tobacco use and harmful use of alcohol are similar: e.g., if governments increase the price and taxation on these items, younger and less wealthy people will not be able to afford it.

“For more longer term measures, however, we need to look at improving health on the whole,” he adds. “Restricting ads for harmful substances, increasing tax on sodas and junk food, reducing tax on fruits and veggies, putting bike lanes in new developments, making gym memberships tax deductible, and so on.”

Another concern Dr. Hospedales hopes to address through CARPHA is the health and well-being of men.

“Men have shorter life spans, and are more susceptible to risks such as smoking and drinking,” he notes.

“We need more specialised health services for men. On the social front, men have fallen behind in primary and secondary education. There are also more incidents of violence. We have to train young people in conflict management. Addressing these issues will be crucial to improving the general health of the entire family and community.”

The strength of CARPHA as a unified agency is the ability to positively influence key decision makers throughout the region in a concerted effort towards the goal of improving health and wellness.

“It is in everyone’s best interest,” says Dr. Hospedales. “If you make a population healthy, you will have a more productive workforce. This will be better for government, for business and for families.”

CARPHA: Looking towards the future

January 2015 will mark only the second year since CARPHA officially began operations as a single agency, and its progress within this timeframe has been noteworthy.

As the single public health agency representing the Caribbean, CARPHA has greater leverage to gain support, funding, and key partnerships on the global scale.

Some of these global partners include Centers for Disease Control & Prevention (CDC) in the U.S.A., European Union (EU)); the German Government (GIZ); Public Health England (PHE); The Inter-American Development Bank (IDB); Pan-American Health Organization (PAHO); Pan-Caribbean Partnership Against HIV&AIDS (PANCAP); The Public Health Agency of Canada; the United Nations Environment Program (UNEP); and The World Health Organization (WHO).

Regional partners include Caribbean Agricultural Research & Development Institute (CARDI); Caribbean Disaster Emergency Management Agency (CDEMA); and The Healthy Caribbean Coalition, a 45-member NGO group; the Caribbean Tourism Organisation and the Caribbean Hotel and Tourism Association; the Caribbean Community Climate Change Center (CCCCC); the CARICOM Implementation Agency for Crime and Security (IMPACS); and the University West Indies (UWI). Regional airlines like CAL and LIAT play a key role transporting specimens for lab testing.

Dr. Hospedales indicates that CARPHA would also be interested in partnering with the private sector with the goal of working together to foster healthier communities. In particular, he can see various avenues of mutual benefit for insurance companies, financial institutions, the pharmaceutical industry, communications and technology providers, and the fitness industry. Healthy ageing is essential to avoid high health costs later in life that erode family savings and pensions.

Other challenges facing the region relate to Climate Change and Environment where the Caribbean countries, which are mainly small island states or low-lying, mainland countries are particularly vulnerable and there needs to be urgent action to mitigate and adapt to these changes.

“We need to generate this interest and investment so that we can deliver on some of the things we have earmarked for discussion and development,” he says.

“We have seen a significant amount of progress in recent years in this region, but there are still so many challenges we face to health and development, and so much potential to make a difference through public health solutions.”

Further Information

• Laboratory services provided by CARPHA include:
  • Support for surveillance and control of communicable diseases
  • Identification of vectors responsible for disease transmission
  • Micronutrient tests of foods
  • Environmental testing for:
    • Water quality testing – potable, recreational, wastewater, bottled water, coastal water
    • Heavy metal and pesticide residues (soil, water, plant/animal tissue, food products)
    • Indoor air quality
  • Quality assessment of pharmaceutical products:
    • Microbiological analysis
    • Comparative dissolution tests
    • Chemical and physicochemical analysis
    • Instrumental analysis