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Islands, health and development
He&
Pergamon
& Place, Vol. 1, No. 4, pp. 195-197, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 135>8292/95 $9.50 + 0.00
1353-8292(95)00028-3
Editorial
Islands, health and development David R. Phillips Department of Geography,
University of Nottingham, University Park, Nottingham NG72RD,
In few environments are people, economy and location as closely tied as in island settings, especially in small islands. In many ways this makes islands ideal for the study of health and place. However, as this special issue of Health & Place illustrates, islands come in many shapes and sizes with varying economic development and potential, and differences in health status and health care. It was this feature that encouraged the IGU Commission on Health, Environment and Development to convene a conference on health and islands in Mauritius in 1994. Papers presented at that meeting form the basis for most of this issue. Two papers, by Andrew Cliff and Peter Haggett and Nancy Davis-Lewis and Moshe Rapaport, were invited to provide overviews of epidemiological significance of islands and the variety of epidemiological experience exhibited in the Pacific islands. Many islands have remarkably good health status given their levels of economic development and resources for health care. It has been suggested that there is a type of small island demography, in which relatively low fertility, low mortality and high rates of emigration are to be seen (Jones, 1993). Certainly, for many reasons, the epidemiological (health) transitions of many islands have been very impressive, often considerably ahead of non-island states in the same areas of the world. Many have populations which are ageing and experiencing ever-increasing life expectancy, with associated health and social care requirements (Kinsella, 1992; Bartlett and Phillips, 1995). By their bounded nature, islands are often clear entities for health care research and, with a few exceptions, inhabitants are restricted to local services. This leads to problems and some opportunities. Islands are often isolated and there are potential problems of communication but this isolation can provide protection from some types of diseases. However, the same isolation may
UK
lead to susceptibility to infectious diseases owing to low immunity. Occasionally, low pools of genetic diversity can lead potentially to genetic disorders. As Cliff and Haggett’s paper discusses, islands can have a special epidemiological significance and can allow population thresholds for infectious disease transmission in particular to become evident. In service terms, small populations may not reach critical thresholds to enable certain types of health and social services to be provided, although in larger islands this is usually less of a problem. There may also be difficulties of recruitment of highly trained staff and professional isolation may occur. Balanced against this is the advantage some professionals perceive of working alone or in small teams, often in pleasant environments. A review by Hotchkiss (1994) notes a number of these features and also points out that many islands have desirable features such as an orientation to primary care; easy access to whatever local services are provided; care by generalists; respect for local practices; and recognition of the need to establish links with larger centres for both service provision and professional development. Epidemiological transition and the wider concept health transition is now well recognized (Caldwell et al., 1990; Chen et al., 1992; Caldwell, 1993; Phillips, 1994). The concepts feature prominently in many papers in this issue. Some island epidemiological problems, such as the rapid emergence of non-communicable diseases noted by Nancy Lewis and Rapaport, Kalla, Wanasinghe and Bartlett, are in many ways a reflection of socio-economic and health care success. However, this type of success brings its own problems, particularly when resources are limited and other epidemiological needs from infections and nutritional problems continue. Today, many islands seem to have epidemiological profiles that reflect all types of medical and social needs: infectious 195
Islands, health and development:
D. R. Phillips
and parasitic conditions; chronic and degenerative diseases; psychological and psychiatric morbidity; and the social care needs of very young and very old people. The prevalence of these various sources of morbidity and mortality and the ways in which incidence changes over time have great practical and economic significance for the planning and provision of health and other human services. However, news is not universally good about islands and health. For example, there is evidence of social problems and emergence of industrial and road accidents at high levels in some places. Many islands do have low incomes and poverty can be widespread, albeit in attractive settings. Steven Royle’s paper focusing on the British islands in the South Atlantic illustrates the difficulties of service provision for small populations and the possibility of aid dependence. Remoteness, small scale and populations mean that the economic opportunities and the health care facilities of these islands are limited and that inhabitants may have to make do with restricted emergency health care even if health appears remarkably good in the circumstances. The same is to be seen in some larger islands; for example, wealthy residents in some West Indies islands may choose to receive specialist medical care in Miami rather than at home, even if their islands (such as Jamaica) have medical schools. Residents often suspect the quality of local care and those who can afford to may exercise choice by long-distance travel for care or by recourse to private practitioners where these are available (Bailey and Phillips, 1990). The development of community care facilities has been a challenge for many islands. In the poorer islands such as Sri Lanka, this presents a challenge as health needs change. In the betteroff islands such as Mauritius, a veritable ‘epidemic’ of non-communicable diseases has been identified (Chitson, 1994) and this presents problems of developing effective communitybased and primary care for chronic diseases. In the partly island territory of Hong Kong, Helen Bartlett discusses the important attempts to introduce community care into a system which is quite well provided with hospital facilities but in which primary health care is fragmented. There is a need to build a tradition of public health care (PHC) and to move from the hospital orientation of many health professionals. For elderly people and for many others, community care is being hailed as the way ahead but caring communities and a PHC referral network will take some time to establish in a mixed private-public system. Dhammika Wanasinghe illustrates the emergence, in a large island, Sri Lanka, of classical spatial imbalances of higher level health services concentrated in the urban areas. The government has tried to counter this by developing primary 196
care facilities in rural areas. As in many developing countries facing relatively rapid health transition, there is a need to provide and nurture community level and domiciliary care. Sri Lanka, too, illustrates official attempts at integration of traditional medical practitioners into the health care system and their continued use in the private sector. As well as emerging non-communicable diseases, many industrializing islands are facing new occupational and environmental challenges to health. Harry Phoolchund provides ample evidence for Mauritius as to how health is changing in the light of new occupations. That island is experiencing increasing levels of industrial and vehicular emissions which impinge on health and is striving to develop an enforceable industrial safety legislative framework. Its experience typifies that of many rapidly industrializing islands and in many ways it provides a model of what may be achieved in defining health and safety policy and standards and developing an environmental health inspectorate. It also illustrates the difficulties of achieving adequate occupational and environmental health under rapid development and the initial research and investigations may require international assistance. For many islands, it can be argued that the course and future of epidemiological transition can be clearer than in some other environments. Indeed, this theme comes across in many of the papers in this issue. The nature of epidemiological change in many islands illustrates the pressing need for strategic thinking and planning in the health sector. In many countries, this is notoriously weak. Health planners are often subject to political pressures, beset by data problems, undertake unclear analysis of health needs and situations and as a result adopt a short-term ‘fire-fighting’ approach to planning. Longer-term needs assessment for resource allocation, especially to overcome inertia, is also needed, as tomorrow’s resources are often allocated on the basis of yesterday’s or today’s patterns of supply and demand. By considering longer-term shifts in health and associated care needs based on epidemiological transition, gradual rather than radical redirections in future resource allocation may be achievable. The concept also helps to point to future education and training needs and may help shifts towards, say, primary rather than secondary care and may overcome entrenched positions among some health care professionals. Islands, with limited resources and scope for care development, may well be keen to look at their epidemiological change seriously with a view to future health care requirements. The papers in this issue illustrate many of these needs and approaches well.
Islands, health and development:
Acknowledgements The International Geographical Union Commission on Health, Environment and Development (HED) meeting was held at the Mauritius Institute of Education (MIE) in April 1994. The Commission on HED wishes to thank the MIE for organizing such a successful conference and, in particular, Cader Kalla and his colleagues who were responsible for local organization (for a report on the meeting, see Health & Place, Vol. 1, p. 66). The meeting was one of the first such geographical meetings held on Mauritius and the opening ceremony was officiated by two ministers of the Government of Mauritius. In addition, the Commission wishes to thank the European Commission for providing travel assistance for some participants from developing countries; the British Council, Mauritius, for a travel grant, and a number of local enterprises in Mauritius for generous assistance to the conference. They also thank the many participants and those who presented papers which are not included among the current selection. The Commission on HED hopes that this special issue of Health & Place will be a suitable acknowledgement and a contribution to knowledge on health and islands.
References Bailey, W. and Phillips, D. R. (1990) ‘Spatial patterns of use of health services in the Kingston Metropolitan Area, Jamaica’, Social Science & Medicine, 30, pp. 1-12.
D. R. Phillips
Bartlett, H. P. and Phillips, D. R. (1995) ‘Aging trendsHong Kong’, Journal of Cross-cultural Gerontology, 10, pp. 257-265. Caldwell, J. C. (1993) ‘Health transition: the cultural, social and behavioural determinants of health in the Third World’. Social Science & Medicine. 36. DO. 125-135. Caldwell, J. C., Findley, S., Caldwell, P:,‘Santow, G., Cosford, W., Braid, J. and Broers-Freeman, D. (eds) (1990) What We Know About Health Transition: the Cultural, Social and Behavioural Determinants of Health, Canberra:
Australian National University Press. Chen, L. C., Kleinman, A. and Ware, N. (eds) (1992) The Health Transition, Cambridge, Massachusetts: Harvard University. Chitson, P. (1994) ‘Health care implications of noncommunicable diseases: the case of Mauritius island’, paper presented to the IGU Commission on Health, Environment and Development Meeting, Mauritius. Hotchkiss, J. (1994) Health Care on Small Islands: a Review of the Literature, Division of Strengthening of Health Services, WHO: Geneva. Jones, H. (1993) ‘The small island factor in fertility decline’, in Lockhart, D. G., Drakakis-Smith, D. and Schembri, J. (eds), The Development Process in Small Island States, London: Routledge, pp. 161-178. Kinsella, K. (1992) ‘Aging trends-Jamaica’, Journal of Cross-cultural Gerontology, 7, pp. 177-184. Phillips, D. R. (1994) ‘Epidemiological transition: implications for health and health care’, Geografiska Annaler, 76B(2), pp. 71-89.
197
Pergamon
& Place, Vol. 1, No. 4, pp. 195-197, 1995 Copyright 0 1995 Elsevier Science Ltd Printed in Great Britain. All rights reserved 135>8292/95 $9.50 + 0.00
1353-8292(95)00028-3
Editorial
Islands, health and development David R. Phillips Department of Geography,
University of Nottingham, University Park, Nottingham NG72RD,
In few environments are people, economy and location as closely tied as in island settings, especially in small islands. In many ways this makes islands ideal for the study of health and place. However, as this special issue of Health & Place illustrates, islands come in many shapes and sizes with varying economic development and potential, and differences in health status and health care. It was this feature that encouraged the IGU Commission on Health, Environment and Development to convene a conference on health and islands in Mauritius in 1994. Papers presented at that meeting form the basis for most of this issue. Two papers, by Andrew Cliff and Peter Haggett and Nancy Davis-Lewis and Moshe Rapaport, were invited to provide overviews of epidemiological significance of islands and the variety of epidemiological experience exhibited in the Pacific islands. Many islands have remarkably good health status given their levels of economic development and resources for health care. It has been suggested that there is a type of small island demography, in which relatively low fertility, low mortality and high rates of emigration are to be seen (Jones, 1993). Certainly, for many reasons, the epidemiological (health) transitions of many islands have been very impressive, often considerably ahead of non-island states in the same areas of the world. Many have populations which are ageing and experiencing ever-increasing life expectancy, with associated health and social care requirements (Kinsella, 1992; Bartlett and Phillips, 1995). By their bounded nature, islands are often clear entities for health care research and, with a few exceptions, inhabitants are restricted to local services. This leads to problems and some opportunities. Islands are often isolated and there are potential problems of communication but this isolation can provide protection from some types of diseases. However, the same isolation may
UK
lead to susceptibility to infectious diseases owing to low immunity. Occasionally, low pools of genetic diversity can lead potentially to genetic disorders. As Cliff and Haggett’s paper discusses, islands can have a special epidemiological significance and can allow population thresholds for infectious disease transmission in particular to become evident. In service terms, small populations may not reach critical thresholds to enable certain types of health and social services to be provided, although in larger islands this is usually less of a problem. There may also be difficulties of recruitment of highly trained staff and professional isolation may occur. Balanced against this is the advantage some professionals perceive of working alone or in small teams, often in pleasant environments. A review by Hotchkiss (1994) notes a number of these features and also points out that many islands have desirable features such as an orientation to primary care; easy access to whatever local services are provided; care by generalists; respect for local practices; and recognition of the need to establish links with larger centres for both service provision and professional development. Epidemiological transition and the wider concept health transition is now well recognized (Caldwell et al., 1990; Chen et al., 1992; Caldwell, 1993; Phillips, 1994). The concepts feature prominently in many papers in this issue. Some island epidemiological problems, such as the rapid emergence of non-communicable diseases noted by Nancy Lewis and Rapaport, Kalla, Wanasinghe and Bartlett, are in many ways a reflection of socio-economic and health care success. However, this type of success brings its own problems, particularly when resources are limited and other epidemiological needs from infections and nutritional problems continue. Today, many islands seem to have epidemiological profiles that reflect all types of medical and social needs: infectious 195
Islands, health and development:
D. R. Phillips
and parasitic conditions; chronic and degenerative diseases; psychological and psychiatric morbidity; and the social care needs of very young and very old people. The prevalence of these various sources of morbidity and mortality and the ways in which incidence changes over time have great practical and economic significance for the planning and provision of health and other human services. However, news is not universally good about islands and health. For example, there is evidence of social problems and emergence of industrial and road accidents at high levels in some places. Many islands do have low incomes and poverty can be widespread, albeit in attractive settings. Steven Royle’s paper focusing on the British islands in the South Atlantic illustrates the difficulties of service provision for small populations and the possibility of aid dependence. Remoteness, small scale and populations mean that the economic opportunities and the health care facilities of these islands are limited and that inhabitants may have to make do with restricted emergency health care even if health appears remarkably good in the circumstances. The same is to be seen in some larger islands; for example, wealthy residents in some West Indies islands may choose to receive specialist medical care in Miami rather than at home, even if their islands (such as Jamaica) have medical schools. Residents often suspect the quality of local care and those who can afford to may exercise choice by long-distance travel for care or by recourse to private practitioners where these are available (Bailey and Phillips, 1990). The development of community care facilities has been a challenge for many islands. In the poorer islands such as Sri Lanka, this presents a challenge as health needs change. In the betteroff islands such as Mauritius, a veritable ‘epidemic’ of non-communicable diseases has been identified (Chitson, 1994) and this presents problems of developing effective communitybased and primary care for chronic diseases. In the partly island territory of Hong Kong, Helen Bartlett discusses the important attempts to introduce community care into a system which is quite well provided with hospital facilities but in which primary health care is fragmented. There is a need to build a tradition of public health care (PHC) and to move from the hospital orientation of many health professionals. For elderly people and for many others, community care is being hailed as the way ahead but caring communities and a PHC referral network will take some time to establish in a mixed private-public system. Dhammika Wanasinghe illustrates the emergence, in a large island, Sri Lanka, of classical spatial imbalances of higher level health services concentrated in the urban areas. The government has tried to counter this by developing primary 196
care facilities in rural areas. As in many developing countries facing relatively rapid health transition, there is a need to provide and nurture community level and domiciliary care. Sri Lanka, too, illustrates official attempts at integration of traditional medical practitioners into the health care system and their continued use in the private sector. As well as emerging non-communicable diseases, many industrializing islands are facing new occupational and environmental challenges to health. Harry Phoolchund provides ample evidence for Mauritius as to how health is changing in the light of new occupations. That island is experiencing increasing levels of industrial and vehicular emissions which impinge on health and is striving to develop an enforceable industrial safety legislative framework. Its experience typifies that of many rapidly industrializing islands and in many ways it provides a model of what may be achieved in defining health and safety policy and standards and developing an environmental health inspectorate. It also illustrates the difficulties of achieving adequate occupational and environmental health under rapid development and the initial research and investigations may require international assistance. For many islands, it can be argued that the course and future of epidemiological transition can be clearer than in some other environments. Indeed, this theme comes across in many of the papers in this issue. The nature of epidemiological change in many islands illustrates the pressing need for strategic thinking and planning in the health sector. In many countries, this is notoriously weak. Health planners are often subject to political pressures, beset by data problems, undertake unclear analysis of health needs and situations and as a result adopt a short-term ‘fire-fighting’ approach to planning. Longer-term needs assessment for resource allocation, especially to overcome inertia, is also needed, as tomorrow’s resources are often allocated on the basis of yesterday’s or today’s patterns of supply and demand. By considering longer-term shifts in health and associated care needs based on epidemiological transition, gradual rather than radical redirections in future resource allocation may be achievable. The concept also helps to point to future education and training needs and may help shifts towards, say, primary rather than secondary care and may overcome entrenched positions among some health care professionals. Islands, with limited resources and scope for care development, may well be keen to look at their epidemiological change seriously with a view to future health care requirements. The papers in this issue illustrate many of these needs and approaches well.
Islands, health and development:
Acknowledgements The International Geographical Union Commission on Health, Environment and Development (HED) meeting was held at the Mauritius Institute of Education (MIE) in April 1994. The Commission on HED wishes to thank the MIE for organizing such a successful conference and, in particular, Cader Kalla and his colleagues who were responsible for local organization (for a report on the meeting, see Health & Place, Vol. 1, p. 66). The meeting was one of the first such geographical meetings held on Mauritius and the opening ceremony was officiated by two ministers of the Government of Mauritius. In addition, the Commission wishes to thank the European Commission for providing travel assistance for some participants from developing countries; the British Council, Mauritius, for a travel grant, and a number of local enterprises in Mauritius for generous assistance to the conference. They also thank the many participants and those who presented papers which are not included among the current selection. The Commission on HED hopes that this special issue of Health & Place will be a suitable acknowledgement and a contribution to knowledge on health and islands.
References Bailey, W. and Phillips, D. R. (1990) ‘Spatial patterns of use of health services in the Kingston Metropolitan Area, Jamaica’, Social Science & Medicine, 30, pp. 1-12.
D. R. Phillips
Bartlett, H. P. and Phillips, D. R. (1995) ‘Aging trendsHong Kong’, Journal of Cross-cultural Gerontology, 10, pp. 257-265. Caldwell, J. C. (1993) ‘Health transition: the cultural, social and behavioural determinants of health in the Third World’. Social Science & Medicine. 36. DO. 125-135. Caldwell, J. C., Findley, S., Caldwell, P:,‘Santow, G., Cosford, W., Braid, J. and Broers-Freeman, D. (eds) (1990) What We Know About Health Transition: the Cultural, Social and Behavioural Determinants of Health, Canberra:
Australian National University Press. Chen, L. C., Kleinman, A. and Ware, N. (eds) (1992) The Health Transition, Cambridge, Massachusetts: Harvard University. Chitson, P. (1994) ‘Health care implications of noncommunicable diseases: the case of Mauritius island’, paper presented to the IGU Commission on Health, Environment and Development Meeting, Mauritius. Hotchkiss, J. (1994) Health Care on Small Islands: a Review of the Literature, Division of Strengthening of Health Services, WHO: Geneva. Jones, H. (1993) ‘The small island factor in fertility decline’, in Lockhart, D. G., Drakakis-Smith, D. and Schembri, J. (eds), The Development Process in Small Island States, London: Routledge, pp. 161-178. Kinsella, K. (1992) ‘Aging trends-Jamaica’, Journal of Cross-cultural Gerontology, 7, pp. 177-184. Phillips, D. R. (1994) ‘Epidemiological transition: implications for health and health care’, Geografiska Annaler, 76B(2), pp. 71-89.
197