How Barbados is transforming its health environment

Covid-19 has highlighted the importance of preventing non-communicable diseases

But it has set back some on-the-ground health advocacy work

The Healthy Caribbean Coalition aims to reduce the impact of the next pandemic.

The Covid-19 pandemic has highlighted the burden of non-communicable diseases (NCDs) on health services all over the world, and how important it is to arrest recent increases in the prevalence of those diseases. For example, the Caribbean has some of the highest rates of obesity in the world, and those rates have increased significantly within the past 30 years. On average, one in two Caribbean children are now living with obesity or are medically overweight, with rates as high as 60% in Dominica. Those figures might have increased four times in the past two decades.

“We know that obesity in childhood is a marker of potential early-onset of NCDs,” says Maisha Hutton, executive director of the Healthy Caribbean Coalition, who represent over 100 organisations across the region. “NCDs such as diabetes, cancers and heart disease (including high blood pressure) are a major challenge in the Caribbean. We have the greatest burden of NCDs in the Americas, with 78% of all deaths and 76% of premature deaths among persons aged 30-69 years attributable to NCDs.”

Although the pandemic has set back the work of on-the-ground public health advocates in the Caribbean, who have been trying to improve the lives of people with NCDs and those at high risk of developing NCDs, it has also highlighted the effect that NCDs have on increasing the risks of other diseases and death. Now, cardiovascular, respiratory health and obesity are top of the agenda, but health advocates have had to adapt to the pandemic, which means more work is being done online.

NCD awareness is essential to reduce the impact of future public health crises – particularly promoting healthy diets and addressing childhood obesity, says Hutton. Young people are key to achieving this in the Caribbean.

The risk factors for developing some NCDs include tobacco use, harmful use of alcohol, unhealthy diets, physical activity and pollution. All of which, Hutton says, have contributed to problems in the Caribbean. But Hutton singles out poor diets as critically important and particularly worrying among children and young people, where one in three is overweight or obese.

“In the Caribbean, we have for some time been experiencing a nutritional transition from locally-grown fruits and vegetables, real food, in essence, to ultra-processed foods, which are high in sugars, fats and salts,” says Hutton.

Hutton and Pierre Cooke Jnr, a Youth Voices technical advisor to the HCC and an NCD advocate, say children are exposed to unhealthy food products in their environments including their neighbourhoods and schools. In an effort to address this, the HCC worked with regional public health agencies, and over 50 regional organisations and 350 public health professionals including academics across the Caribbean on a digital campaign to raise awareness around food labelling.

The campaign was supported with academic research that showed that the introduction of clearer food labels can lead to customers making better informed decisions about their health. For example, a study of 1,206 adult shoppers at popular supermarkets across Jamaica compared three front-of-packet labeling schemes. The first was an octagonal warning label stating the product is high-in salt, sugar and fat, the second was a single magnifying-glass containing a warning, and finally the traffic light labeling model commonly used in the UK.

The octagonal warning labels resulted in customers correctly identifying the least harmful product 2.1 times more frequently, intending to purchase the least harmful product 1.9 times more frequently and correctly understanding the nutritional content of a product nine times more frequently.

“Front-of-package warning labels assist consumers in improving their diets and hopefully, ultimately preventing obesity and NCDs and it helps those living with NCDs to better manage their conditions by avoiding certain foods,” says Hutton.

The HCC developed a “roadmap” for improving health outcomes across the Caribbean, with a number of areas that Hutton sees room for improvement. “The first is this idea that people living with NCDs need to be at the centre of making decisions,” says Hutton. She compares NCDs to other movements with good public participation, like climate change and social justice. Hutton sees less public engagement on matters of health compared to those issues. The second area is working to prevent NCDs in the first place.

“The other piece is around rights and equity, and this idea that people have a right to access health, they have a right to healthy environments,” Hutton says. She cites the number of opportunities a child has to buy unhealthy foods on their way to school as one way that the environment is failing them. Sweetened drinks and ultra-processed foods are easily available inside and outside of school gates.

Another key approach is involving people living with NCDs and young people. “We really want to create a healthy generation of individuals who can contribute and be productive to local economies,” says Hutton. “If we do not do that, we run the risk of creating an unhealthy generation, unhealthier than the current one, that's a drain on economies – a risk we just cannot afford to take in our highly vulnerable small developing state settings.”

The HCC is trying to educate a new generation about preventing the main risk factors that can lead to NCDs. The organisation is starting conversations about healthy environments and accessing healthy food as a way to address childhood obesity in the Caribbean and prevent diet-related NCDs.

Part of HCC's work to address childhood obesity and NCD prevention during the pandemic, has been supported by NCD Alliance's Civil Society Solidarity Fund on NCDs and COVID-19; an initiative that is helping groups like the HCC remain resilient during the pandemic.

This is where young advocates like Cooke can help. Hutton says Cooke was “so confident and so approachable” when she first met him as an 18-year-old. His ability to connect with younger audiences has enabled him to speak directly to them and encourage many to become community advocates themselves. “He's passionate about ensuring that young people are part of the conversation,” she says. “And he knows that in order to do that he needs to speak their language – unpacking why these diseases are relevant for them.”

Cooke says that young people are sometimes unaware of the dangers of processed foods. Cooke says where he grew up in rural Guyana was very different to urban life; fruits and vegetables grew in abundance around his house and he regularly ate them as part of a balanced diet. On moving to the city and seeing the availability of ultra-processed foods, he knew that the balance was off. Drawing on his own experiences of having access to fresh foods as well as knowledge about how to make healthy choices, Cooke was able to act as an advocate for young people in the Caribbean.

 “I say, ‘you have a right to education, you have a right to health, you have a right to a safe and healthy environment, you have a right to be protected from people using you in a type of way that exploits your health’,” says Cooke, adding that it is key this message comes from someone his age, who shares the lived experience with his audience.

Hutton says that the pandemic has made the public more aware of the importance of protecting their health, and of the dangers of unhealthy choices that lead to NCDs and obesity. This has created a greater interest in home-grown foods, she says, and led to a variety of initiatives to encourage household food security such as projects where people living with NCDs were supported with backyard gardens and families were given fruit trees.

“[Covid-19 has] really has been a wake up call for us as a community, I think as a collective, that we've not done enough to prevent NCDs,” says Hutton. “We know those who are suffering from NCDs or obesity are more likely to have severe Covid-19 and higher mortality rates.”

“If we don't take action now and really shift our thinking, and our approach to NCD prevention and control, we're going to be in trouble,” she concludes. “When the next pandemic rolls around, we simply won't have the capacity, especially if [it] is worse than Covid.”

This work has been made possible thanks to NCD Alliance's Civil Society Solidarity Fund on NCDs and COVID-19 and to the financial contributions of NCD Alliance’s supporters: The Leona M and Harry B Helmsley Charitable Trust, Access Accelerated, AstraZeneca, ECOBANK Foundation and Viatris.