Unit 3

Health and Disease in the Caribbean

INTRODUCTION

Good health is central to a good quality of life for all of us. It is also
essential for the economic and social stability of a country or nation
as ill health on a large scale reduces productivity and increases the
cost of health care.

According to certain statistics, health in the Caribbean has improved

in recent decades. Life expectancy has increased. More people are
living longer, shifting the balance in the distribution of age groups in
the population. The proportion of the population over 60 years is
increasing while the proportion under 15 years is declining as the
birth rate decreases (CAREC, 2001). This sounds good but it raises a
serious issue; in years to come there will be fewer people of working
age to support increasing numbers of elderly citizens. Many debili-
tating diseases in the elderly result from years of poor eating habits
and lifestyle choices. The importance of maintaining a healthy life
style while we are young cannot be over emphasized.

Another improvement is the reduced incidence of many communi-

cable diseases, but the increasingly rapid rate of the spread of
HIV/AIDS infection is of grave concern. Added to this is the fact
that chronic nutrition-related diseases are increasing as our life
styles change. Diseases like heart disease, diabetes, and hypertension

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 are now the leading causes of death in the region. We hope that
after completing this Unit you will have a better understanding of
these health issues and a new awareness of what is required of us to
improve and maintain the health of the region. Good health
concerns us all.

OVERVIEW

There are three sessions in this Unit. After introducing the concepts
of health and disease we begin with a brief review of some of the
common diseases of the region. These include non-communicable
disorders associated with poor nutrition and/or life styles and
communicable diseases, the ones we “catch”. Particular attention is
paid to AIDS because of its increasing incidence in the region. This
session also includes a short discussion on substance abuse, because
of its association with sexually transmitted infections and other
causes of ill health.

In the second we consider the changing patterns of nutrition in the

Caribbean and some of the attendant problems, including obesity.

The final session of the unit begins with a brief review of the
genetic basis of inheritance then describes three inherited disorders.
Biotechnology and gene therapy are mentioned only briefly as they
are covered in more detail in Unit 4.

LEARNING OBJECTIVES

After completing this unit, you should be able to:

1. Identify the main diseases prevalent in the Caribbean

2. Explain the importance and difficulties of controlling HIV/AIDS

in the Caribbean

3. Outline nutrition trends in the Caribbean and discuss their

implications

4. Analyse the links between diet, lifestyle, and the pattern of

chronic diseases prevalent in the region

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 5. Comment on substance abuse and its implications for regional
health and productivity

6. Describe the causes of some genetic diseases

7. Discuss the possible implications of disease for regional health

and productivity

8. Discuss the importance of understanding the causes of disease as

exemplified by the diseases included in this Unit

9. Discuss the importance of reasoned behavioural lifestyle choices,

which will promote good health

FOR THE STUDENT

You should focus on the ways in which knowledge of a disease

affects the ability to prevent or treat the disease rather than details
of the disease itself. Consult the learning objectives for guidance as
you go through the Unit.

READINGS

• Bajaj, Jasbir S. Emerging epidemic of diabetes mellitus. West

Indian Medical Journal, 50 (Suppl. 1): 15–16, 2001.

• Caribbean Epidemiology Centre (CAREC). Overview of health in

the region. 2001. http://www.carec.org/overview_health.htm.

• Douglas, Ken-Garfield. Drugs among our children. The Gleaner, p.

B6, September 19, 2001.

• Figueroa, J. Peter. World Aids Day Press Conference. The Gleaner,

p. A1, November 25, 2000.

• HIV/AIDS in Africa. UNAIDS Fact Sheet. December 2000.

• Introduction and General Considerations. Recommended dietary

allowances for the Caribbean. Kingston, Jamaica: Caribbean Food
and Nutrition Institute Mona, 1994.

• Mackoon, Lindsay. 360,000 living with AIDS in the Caribbean.

The Gleaner, p. A1, November 1, 2001.

• Novel Gene Therapy Approach for Cystic Fibrosis in First

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 Human Trials. ScienceDaily Magazine. Source: University
Hospitals of Cleveland, 2002.

• Roberts, Michael, Michael Reiss, and Grace Monger. Cancers in

Biology. Thomas Nelson and Sons Ltd., pp 564–566.

• Terms of reference of expert group on Caribbean food and

nutrition surveillance system. Recommended dietary allowances for
the Caribbean. Kingston, Jamaica: Caribbean Food and Nutrition
Institute Mona, 1994.

• The editorial. Cajanus, 33(1): 1–3, 2000.

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 Session 3.1
Some Diseases Common
in the Region

Introduction

How do we know when we are sick or well? The concepts of health

and disease are not as easy to define as they appear to be. According
to the World Health Organisation (WHO) health is “a state of
complete physical, mental and social well-being not merely the
absence of disease or infirmity”. To be healthy a person must feel
well in body and mind and all our organs and systems must be func-
tioning efficiently. Given this definition, are you sure you are
healthy? Disease is even more difficult to define as there are a
number of serious conditions that cannot really be called “diseases”,
for example, broken bones. However, a good working description
might be “any disorder of any bodily or mental function”.

Disease can be broadly categorised into two groups. Communicable

diseases include all diseases caused by other living organisms. These
organisms may be transmitted from one person to another either
directly or indirectly, causing them to spread. In our first session we
will look briefly at a few examples of communicable diseases,
including AIDS, in some detail. This will be followed by a discussion
of some non-communicable diseases. Non-communicable diseases
cannot be “caught” from the external environment. They have their
origins within us. We cover diabetes, hypertension, heart disease,
and cancer, at present the four most important “killers” in the
Caribbean. They are of interest not only because of their heavy
social cost but because they are largely preventable or controllable.
Substance abuse is also included here because of its connection to
AIDS, other STDs and other conditions of ill health.

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 Communicable diseases
A brief look at incidence in the region

The incidence of many communicable diseases in the region has

been reduced. With few exceptions, those that have the potential to
be fatal are on the wane. This can be credited to the health services
of the region and a reasonable basic standard of living compared to
many other developing countries. A few countries are free of
malaria. Nevertheless, we remain vigilant as travel to sources of
infection can cause its return. Cholera, yellow fever, and typhoid are
mostly confined to specific areas.

Successful vaccination campaigns have eliminated many vaccine-

preventable diseases. Smallpox and poliomyelitis have been eradi-
cated, and we are the first region in the world to have got rid of
indigenous measles (CAREC, 2001). High rates of childhood vaccina-
tion, higher than in the United States, have been responsible for
this. Vaccinations against diptheria, whooping cough, tetanus and
polio are required for acceptance into public schools in some territo-
ries.

Dengue fever remains a problem. Outbreaks of this mosquito borne

viral disease have increased in frequency and intensity over the past
ten years. The mosquito that spreads the disease, the Aedes aegypti,
is present throughout the region. In 1998, there was an outbreak in
Jamaica, and in the following year, Trinidad and Tobago had its first
major outbreak of dengue haemorrhagic fever which is potentially
fatal.

Tuberculosis is also of concern. After years of decline, the incidence

level began to increase in the early 1990s. Figures of 37.5, 25.4, and
22.7 per 100,000 in the population are estimated for Guyana,
Bahamas, and Trinidad and Tobago, respectively. In Haiti and the
Dominican Republic, the figures are much higher. Some of this
increase is no doubt associated with the increasing incidence of
HIV/AIDS. But in addition to this is a weakening of the infrastruc-
ture to deal with the disease. There has been a reduction of funding
and trained staff because it was felt that tuberculosis was no longer
a cause for concern in the English speaking region.

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 ACTIVITY

How would you describe the health status of the Caribbean

with respect to communicable diseases, excepting STDs?

(Hint: Comment on the overall picture for the region. Mention

exceptions by disease and country and in concluding briefly
touch on prospects for the future.)

Sexually transmitted diseases (STDs)

Many of the traditional sexually transmitted diseases (STDs) have

declined in recent years. These include the bacterial diseases syphilis
and gonorrhoea and the viral disease Herpes genitalis (Herpes simplex
virus 2 or HSV2) which causes genital sores. However, about 10 to
15% of sexually active women have been shown to have the bacter-
ial infection Chlamydia (CAREC, 2001). The rate of infection with
these diseases is important, since their presence in individuals may
make infection with the AIDS virus easier.

Acquired Immune Deficiency Syndrome (AIDS)

AIDS is caused by infection with the human immunodeficiency

virus, HIV-1. The time between infection and the appearance of
symptoms varies, and may sometimes be years.

Incidence in the Caribbean

In terms of the percentage of Table 3.1

the population infected with
% Population with HIV
HIV-1, the Caribbean now ranks
second only to sub-Saharan
Africa. The following table Haiti 5.17
Guyana 2.13
shows the percentages of the Cuba 0.02
population in the 15–49 years Barbados 2.89
old age group infected with Dominican Republic 1.89
HIV-1 in the Caribbean, as of Belize 1.89
December 1997. Jamaica 0.99
Bahamas 3.77
Trinidad & Tobago 0.94
On the surface these figures
may not seem alarming (UNAIDS Report 1998, cited in World
compared to the figures for Bank Study 2001)

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 some of the African countries which run as high as 35.8% in
Botswana and 20% in South Africa. The important point is that
they are increasing, not decreasing, as they should. More AIDS cases
were reported in the Caribbean in the three years between 1995 and
1998, than in the 15 years since the beginning of the epidemic in the
1980s. A 1999 estimate put the number of people living with HIV or
AIDS in the region at 360,000. Some 85% of these cases are in Haiti
and the Dominican Republic. Cuba has relatively few cases.

The infection is now moving into the younger age groups. The
majority of diagnosed cases are between the ages of 25 and 34. This
means that the infection probably occurred between the ages 15 and
24, if time is allowed for the infection with the virus to develop into
AIDS (the incubation period). The increase in this particular age
group is a major concern as they represent our future labour force
and their health will impact significantly on our social and
economic well being in years to come.

HIV transmission in the Caribbean

The predominant mode of transmission in the region is by hetero-

sexual intercourse (60%). As a result of this, the number of women
with the disease is rising and with that the possibility for infection
of children before or at birth, or through breast-feeding. Infection
through blood products is less than 3%, but this is not good enough.
We must improve the safety of our supplies still further throughout
the region. Sharing needles by substance abusers is not a common
source of infection but high crack-cocaine use seems to be associated
with high risk of HIV, as shown in the Bahamas, Trinidad and
Tobago and Jamaica (CAREC, 1999). This association may result
from impaired decision making, as in the case of alcohol and mari-
juana users. For example, it is highly likely that persons under the
influence of a drug will have unprotected or indiscriminate sex,
sometimes to support their habit.

Populations at high risk provide a pool of infection for further trans-

mission of the virus. In addition to substance abusers, other high-
risk groups include:

• young people (they may be unprotected by condom use,

especially as sexual activity tends to begin early)

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 • male homosexuals
• newborns of HIV-positive mothers
• pregnant women (Cuba has no sign in this group)
• commercial sex workers
• persons with a history of STDs. (As at 2000, some 39% of AIDS
cases in Jamaica had a history of other STDs (Figueroa, 2001).)

Treating AIDS

In the English-speaking Caribbean, AIDS is the largest cause of

death in the 15–44 year group (63% in 1996). The high rate is due to
many factors, including lack of access to drugs to treat HIV, and to
medicines to deal with the secondary infections, like tuberculosis.
The absence of strategies to prevent mother to child transmission
(vertical transmission) is another factor. Both of these are linked
with the inability of governments and/or people to afford the
required drugs.

n Anti-HIV drugs are A programme to help prevent vertical transmission is now in place
especially expensive.
Zidovudine (AZT) in Jamaica where one in 100 pregnant women are HIV infected, and
costs US$3,000 per one child so infected is born every week. There is free voluntary
year per case. Newer
treatments are even testing of pregnant women. Women found positive are given two
more expensive at tablets of Nevirapine at the onset of labour, and the child a single
US$1,000 per month
per patient. dose of the drug within the first 72 hours of its life. Breast-feeding is
Nevirapine discouraged in these mothers, since the virus may be passed on in
(Viramune) may be
as good as AZT in this way, and mothers are provided with a substitute formula. The
reducing vertical programme started in four parishes and is being extended to cover
transmission, and is
fortunately cheaper the entire island. Vertical transmission has been reduced consider-
at about US$4.00 per ably in the industrialized countries by providing drug assistance for
child.
the mothers. We can do the same.

The social cost

One enormous challenge associated with the AIDS epidemic is the

plight of children of parents with the disease, whether or not the
parents are alive or the children are left as orphans. A second is our
economic inability to treat and care for patients properly. A third is
the adverse effect the epidemic is having on our economy from three
angles:

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 • The enforced reduction of our labour force leading to decreased
productivity.

• The burden it creates on our health systems: UWI/CAREC

estimates are that some 3.5% of our gross national product could
be spent on AIDS over the next 20 years, and we still shall not
have spent enough.

• The effect it will have on our tourism and foreign investment:

We are perhaps the most tourist-dependent region in the world,
and tourism is very sensitive to disease.

Preventing AIDS – what needs to be done

The emphasis has to be on preventing the disease. Public understand-

ing of the disease and how it is spread is not good enough at pres-
ent. As with the nutrition-related diseases, the situation calls for
aggressive educational programmes. These need to be geared to
reach all ages and levels, but especially the young. In the Caribbean,
sexual activity sometimes starts at the ages of 10 and 11 so school
populations below and above these ages need to be targeted. School
dropouts and street children must also be reached.

Further research is also needed, but this is not likely to be very

successful if cases are not reported. HIV/AIDS, by law, is a notifi-
able disease only in Jamaica, St Lucia, and Belize. Perhaps this
should be standard throughout the region. Should there be manda-
tory testing of rapists as happens in the Bahamas and Bermuda?
These are issues that must be addressed at the level of the policy-
makers. The presence of a CARICOM-led task force on HIV/AIDS
which has developed a Caribbean Regional Strategic Plan of Action
for HIV/AIDS, 1999–2004 is evidence of some recognition at the
policy level of the seriousness of the situation.

As the director of the Medical Research Foundation in Trinidad is

reported to have pointed out very recently, the HIV virus is the
cause of AIDS, but is not the cause of the pandemic. It has spread
rapidly because of certain contributing factors (Mackoon, 2001). We
need to publicise and eliminate these factors if we are to succeed in
stemming the spread of the disease.

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 ACTIVITY

Self-check: Answer the following questions to find out how

much you remember. Find the answers for those you have
forgotten in the passage you have just read.

1. What causes AIDS?

2. What are the main ways in which it is transmitted?

3. Which country in the Caribbean has the lowest incidence of

AIDS?

4. Which countries have the highest incidence in the English-

speaking Caribbean?

5. Which age group is now at greatest risk of becoming

infected and why is this cause for concern?

6. What is vertical transmission and how can it be reduced?

7. What is the most important reason for our inability to treat

and care for those with AIDS?

8. What measures should form part of an HIV/AIDS preven-

tion plan?

CRITICAL THINKING ACTIVITY

The incidence of many communicable diseases, including other

STDs, has been reduced. Why do you think HIV/AIDS has
remained a serious problem for such a long time?

Non-communicable diseases

Non-communicable diseases include a wide range of disorders. They

include the so called “human-induced” or self-inflicted diseases such
as lung cancer and alcoholism, inherited diseases, mental illness,
nutritional disorders, and metabolic disorders, some of which are
also linked to nutrition. There are no rigid boundaries between the
different groups. Non-communicable, nutrition-related diseases such
as diabetes, heart disease, and hypertension along with cancer, now
rank as the leading cause of death in the region. Between 1984 and

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 1989, 24–57% of all deaths in the region were due to these diseases.
Malnutrition and infectious diseases accounted for only 2% to 7% of
deaths over the same period.

Some of these nutrition-related diseases are influenced by hereditary

factors. They seem to “run in families” (see Session 3.2, The Basis of
Inheritance), although the disease itself is not inherited. The precise
genetic linkages are not known but such families seem to be pre-
disposed to developing the disease. Diabetes, hypertension, and heart
disease all fall into this group. What they also share in common is
that they can be prevented, delayed or controlled by changes in
lifestyle such as diet, exercise, and stress relief and abstention from
smoking and excessive use of alcohol. It is important to note that
changing lifestyle after being diagnosed with any of these diseases is
not nearly as effective as taking preventive measures. (As they say in
one of our islands, “You better take in front before in front take
you”!)

Diabetes mellitus

In diabetes mellitus, blood levels of glucose (the simple sugar that

our bodies use as a source of energy) are higher than normal, because
the body either does not produce, or does not use insulin efficiently.
Insulin is a hormone (secretion of a gland that goes directly into the
blood stream) produced by special cells in the pancreas. Insulin
promotes the uptake of glucose from the blood into cells for use or
storage, thereby lowering blood sugar. Blood sugar levels between 70
and 110 milligrams per decilitre are considered normal. In most
persons the level rises after a meal, but goes back to normal after
about two hours. This does not happen naturally in diabetics. Excess
stays in the blood, unavailable to the cells that need it, and is
excreted in the urine.

In persons with Type I (insulin dependent diabetes mellitus (IDDM))

the insulin-producing cells in the pancreas have been destroyed.
These diabetics develop the disease at an early age, usually before 30.
To survive, they must take insulin injections. Not many people have
this type of diabetes.

Most diabetics have Type II (non-insulin dependent diabetes mellitus

(NIDDM)). In these diabetics, normal levels of insulin may be

170 FD12A
 secreted but the cells that should, do not respond to it. Some young
people have this type of diabetes but it tends to develop in older age
groups. Type II diabetes may be controlled by a diet and exercise
regimen, or by using oral drugs along with this. In some cases, it
may become necessary to use insulin.

Diabetes may cause several long-term complications. Heart attacks

and strokes are more common. Damage to the blood vessels of the
eye can cause poor vision. Poor blood supply to, and damage to the
nerves of the skin reduce sensitivity, making injuries more likely,
and wounds heal slowly. More women than men have diabetes.
This may be linked with the fact that more women than men are
obese, obesity being an important risk factor.

The high rates of diabetes and its complications exert a heavy toll
on hospital services in the Caribbean. The estimated cost of medica-
tion, treatment in hospital for amputations of infected limbs, eye
disease, and other related services for diabetics is in excess of US$30
million annually. A study recently co-ordinated by the
Commonwealth Caribbean Medical Research Council (CCMRC)
showed that in Trinidad’s Port-of-Spain General Hospital, diabetic
patients occupied approximately 26,659 bed days per year. This cost
the hospital over US$1.8 million.
n Think about it: In
how many different In Trinidad and Tobago, the average cost of one diabetic admission
ways might having a
family member with
was calculated as approximately US$516. This sum would cover the
severe diabetes cost of treating up to nine diabetics in a government primary care
affect other family
setting for one year. We can only imagine what it will cost 10 years
members?
Given the cost to the from now if preventive action is not taken seriously. Many of these
society, should admissions would be avoided with better preventive management in
testing and
attendance at these primary health care settings (cited in Henry et al., 1997, from
primary care clinics Gulliford et al., 1995).
be made mandatory?

Hypertension
n MmHg, a unit of Hypertension (high blood pressure) is a condition in which the pres-
pressure equal to
that exerted by a sure of the blood in the arteries is persistently abnormally high.
column of mercury 1 Mostly, the cause is not known, but excess fat in the diet, long-term
millimetre high under
standard gravity. smoking, excessive alcohol intake, and obesity seem to be among the
Normal atmospheric contributory factors.
pressure is
760mmHg .

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 When we check our blood pressure, we measure the pressure of the
blood against the walls of a large artery. Two figures are recorded.
The higher is taken when the heart contracts (systole) and the other
when it relaxes between beats (diastole). For example, a reading of
120/80 (mmHg) means that the systolic pressure is 120, and the
diastolic 80 mmHg. Blood pressure differs with age, activity and
time of day. Normal figures for an adult range between about
120/80 mmHg and 130/85 mmHg, but the characteristic is very
individual. Persistently higher readings may suggest to the doctor a
need for monitoring, depending on the individual and other factors.

A diet with severely reduced salt intake is believed to improve the

condition, as does exercise and measures to relieve stress. A low-fat
diet is often recommended as well. Various kinds of drugs are used
to control blood pressure; some are expensive and others have
unpleasant side effects in some people.

Studies on Caribbean populations show that on average, 30% of

adults have hypertension, compared to 12–15% of adults over 35
years, who have diabetes mellitus. In the Bahamas the prevalence of
hypertension in males increased from 8.6% in the 20–40 year old
group, to 23.1% in the 40–60 age group, and 32.7% in the 60+ age
group. The trend in females was similar. So the disease, whilst most
common in the elderly, is not limited to this group.

Heart disease

Hypertension and heart disease are on the increase in the Caribbean.

This increase parallels, as it does in other parts of the world, an
increase in the quantity of fast foods, junk foods and other lifestyle
changes regarded as modern. The glamorous but stressful lifestyle of
the busy executive who attends numerous cocktail parties and does
not get enough sleep or exercise is a recipe for developing hyperten-
sion and heart disease. At equal risk is the underpaid night watch-
man who eats starchy foods with lots of greasy gravies or the
stressed out, overworked, overweight housewife who snacks all day.
A recent report (CAREC, 2001) puts heart disease first in a list of
leading causes of death in the region (strokes, diabetes, cancer and
injuries are the others in that list).

High levels of fat in the diet are known to contribute to heart

172 FD12A
 disease. Fatty deposits in the coronary artery which supplies the
heart muscle with oxygen and food, can obstruct the flow of blood
to the muscle. With exertion, or when the artery becomes
completely blocked, the blood supply may become insufficient, caus-
ing weakening or death of the heart muscle from lack of oxygen.
This is accompanied by intense pain and the weakened heart muscle
may fail to pump adequate amounts of blood either to itself or to
the brain and other tissues. It may then cease to function altogether.
This is what has happened when someone is said to have had a
massive heart attack. When small branches of the coronary artery
are blocked only a part of the heart muscle is affected and a person
may experience pain for a short time and have a mild heart attack.
This warning is sometimes ignored. There is little data on blood
cholesterol levels in the Caribbean population.

In order to prevent these nutrition-related chronic diseases, healthy

lifestyles should be acquired early in life. As a region, this depends
on education campaigns based on the most recent scientific
evidence. The success of these educational efforts will depend on the
entire population, that is, on each one of us.

CRITICAL THINKING ACTIVITY

1. Think carefully. How much of the foregoing information

have you heard before? List what you knew.

2. Have you ever given serious consideration to changing any

aspects of your lifestyle as a consequence of what you knew
before? Would you consider it now?

3. Do you think that governments should have a specific policy

in place to help prevent these diseases or should it be left to
personal choice?

4. What other methods, besides education, might be effective?

Cancer

There are probably few people in the Caribbean who have not lost a
relative or friend to cancer. Although much more is known about
the disease than was known 20 years ago it is still in many ways a

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 mystery. There are many different kinds of cancer. What they have
in common is that they are all uncontrolled growths that if left
untreated invade normal tissues to their detriment.

The relationship between nutrition and cancer is a complex one.

The most obvious link is perhaps the occurrence of carcinogens
(cancer-promoting agents) in some foods. However, these various
carcinogens may only form a small part of the link between diet and
cancer. Besides, not all persons exposed to them develop cancers.
Research in this area is continuing but it seems likely that dietary
components such as fibre, fresh fruits and vegetables, and foods
such as garlic and onions, may play a protective role against the
development of some cancers. Other dietary factors seem to have a
negative impact. These include high intake of fat (especially satu-
rated fat) and cured or smoked foods such as ham, bacon, pig tails,
smoked herring and so on.

A comparison of the mortality rates for malignant neoplasm in the

Caribbean with the rates in Canada and the USA shows that the
rates in some of the countries of the sub-region are almost as high as
the rates for North America (World Health Organization, 2000) (see
Figure 3.1).

Figure 3.1 All cancer mortality by country – 2000

140

120

100

80
Deaths / 100,000

60

40

20

0
ca s lize ad e
ados Jamai ahama Be Trinid urinam Guyan
a n USA anada
rb bbea C
Ba B S Cari

174 FD12A
 The problem has increased over the years. Between the 1960s and
1990s the increase in mortality from nutrition-related cancer among
the countries of the region ranged from a low of 1.3% in Belize to
12.9% in St Vincent, with the figure in Jamaica showing an increase
of 5.7%. Cancer was the third leading cause of death in Jamaica
(82.2/100,000 population in 1990). The increase coincides with the
change in dietary patterns over the same period.

CRITICAL THINKING ACTIVITY

Chronic nutrition-related diseases are more prevalent in the

elderly. With increasing life expectancy, the proportion of this
group in the population is growing.

1. What are the implications of these facts for family life and
the health services in your territory?

2. Can our resources stretch to adequately provide treatment,

prevention, and care, for all age groups?

3. Should preference be given to any particular age group if

there is not enough to go around?

Substance abuse

Substance abuse and its related health problems fall into the cate-
gory of self-inflicted diseases. Despite this, they include effects that
are caused by changes in the functioning of the nervous system
making them very difficult for the affected individual to control.
The social and economic effects of substance abuse go far beyond
those of most other diseases, for example, an increase in crime. One
of their many health-related effects is their association with the
spread of HIV/AIDS and other STDs.

Many of those admitted to our psychiatric institutions are

substance abusers. In addition risk-taking behaviours, motor vehicle
accidents, homicides and suicides are linked to substance abuse. The
most frequently abused substances in the region, in descending
order of frequency are alcohol, tobacco, marijuana, cocaine, and
some psychotropic drugs. The habits begin young – at school.

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 Alcohol and tobacco are socially acceptable, and this makes the
temptation to use them much harder to resist. Alcohol abuse has
been associated with road fatalities, violence, family disputes, sexual
abuse, and poor job performance. Long term use causes liver damage
that may be eventually fatal. Smoking tobacco is associated with
lung cancer, heart disease, bronchitis, and emphysema. Emphysema
is caused by the gradual breakdown of the thin walls of the tiny air
sacs in the lungs. Eventually this results in decreased surface for
gaseous exchange. People affected with emphysema show severe
breathlessness and in later stages have an uncontrollable racking
cough. It has also been shown that children living in homes where
parents smoke have a higher incidence of diseases such as sinusitis,
tonsillitis, and other bronchial diseases.

Marijuana (ganja, “herb”) is used in most Caribbean countries and

has been for a long time. Its use has been associated with deteriora-
tion in mental function and with behavioural disorders (Mahy and
Barnett, 1997). Smoking ganja also affects the lungs just as smoking
tobacco does. However, marijuana has been shown to be of thera-
peutic use in some areas. One use that is well recognized is the
reduction of the pressure within the eye. The extract Canasol, devel-
oped by Caribbean researchers, Manley West and Albert Lockhart, is
registered and used in the treatment of glaucoma (National
Commission on Ganja, Jamaica 2001).

Many of our young people experiment with alcohol, tobacco, and

marijuana, according to surveys done among them in Jamaica,
Trinidad, and Belize. According to Garfield Douglas (2001) very few
people begin to use alcohol and tobacco as adults – first use has
occurred usually by the end of high school. He also suggests, that
cigarettes, alcohol, and marijuana are likely to act as “gateways” to
using other drugs like cocaine. Clearly, prevention of the larger use
of drugs should focus on the young, to delay the onset of tobacco
and alcohol use.

176 FD12A
 CRITICAL THINKING ACTIVITY

1. What do you think should be done about decriminalizing

marijuana?

2. Does the scientific evidence help you to make up your mind?

3. What are the arguments for and against such a step in the
Caribbean?

The debate on whether the use of ganja should be decriminalized

continues. Sympathisers point to the easing of restrictions in several
European countries. Others feel it is no more dangerous than alcohol.
Some fear the repercussions on trade with the United States, which
is openly against the idea.

The use of cocaine and crack-cocaine is also growing among adoles-

cents (Mahy et al., 1997). Unfortunately, Caribbean countries are
increasingly being used as transshipment points for drugs, increasing
the likelihood of greater substance abuse in the region.

QUICK REVIEW
Some important points to remember

l Non-communicable disease – breakdown in the functioning

of the body, cannot be transmitted from person to person.

l Types of non-communicable diseases – human induced,

mental, metabolic, nutritional, and genetic disorders.

l Leading causes of disease related deaths in the region –

hypertension, heart disease, diabetes, and cancer.

l Incidence of hypertension and heart disease reduced by a

low fat diet, increased exercise, limiting alcohol intake and
smoking, and reducing stress.

l Cost of treating results of hypertension, heart disease, and

diabetes is very high. Primary preventive care costs compara-
tively little.

l A key factor in preventive management of nutrition-related

disease is education.

FD12A 177
 l Causes of cancer still not well understood. High intake of
saturated fats and cured/smoked foods suspected. Some
foods may contain carcinogens, others appear to be protective.

l Throughout the region (and worldwide) increased incidence

of these diseases coincides with changes in eating habits
away from the traditional diets.

l Substance abuse associated with increases in HIV/AIDS and

other diseases.

l Substance abuse has many social effects, including destruc-

tion of family life, crime, abuse, and poor job performance.

l In all cases prevention is cheaper and more effective than

attempts at cures and treating the effects.

CRITICAL THINKING ACTIVITY

1. Substance abuse is associated with unemployment, loss of

productivity, upsetting family life and other personal rela-
tionships, and with the spread of HIV/AIDS.
(a) What measures do you think would most effectively help
to curb it, especially in our young people?
(b) Can science and medicine help? How?

2. We are the most tourist-dependent region in the world

(CAREC, 2001).
(a) What effects do you think (a) the communicable diseases
and (b) substance abuse in the region are having on our
tourism industry?
(b) To what extent might these conditions be the result of
our extensive tourist industry?
(c) What suggestions do you have for dealing with any
adverse effects you see?

178 FD12A
 Session 3.2
Nutrition and Associated Problems

Introduction

Over the past four decades or so, nutrition in the Caribbean region
has undergone a major transformation. Traditional diets tended to
be low in animal protein, high in complex carbohydrates (e.g. yam
and sweet potato) and fibre, with “reasonable” amounts of fat. The
more modern diet that has come with urbanization and so-called
development is high in animal protein and fat, processed refined
carbohydrates, and little fibre. The fast food culture has not helped.
Salt preserved foods, such as salted codfish, have always formed part
of the Caribbean diet. These are still commonly used in addition to
the new sources of salt: fast and junk foods. This transformation in
our diet has lessened some old problems but brought new ones
which are proving more difficult to deal with.

What we eat is our choice. However that choice can be skilfully

manipulated by marketing specialists. Glossy photographs of
chicken and chips look much more inviting than a dead fish in a
glass case which you will have to go home and prepare yourself.
Similarly, canned foods are advertised as “full of goodness” that
cannot be compared to the vitamins and minerals available in fresh
fruits and vegetables.

In this section, we shall look briefly at the nutritional status of the

region, considering food consumption trends, and food availability
and accessibility. After this session we hope you will make better
decisions about what to eat and be able to contribute to the debate
on policies that encourage importation and consumption of large
quantities of foreign foods to the detriment of local agriculture and
our health.

FD12A 179
 Food consumption trends

For many years, the most important nutritional concern for the
region was energy-protein malnutrition. Many children were getting
neither the total calories, nor the protein supply they needed to
develop properly, both before and after birth. So we focused our
efforts on increasing the overall calorie and protein supply available
to our country’s populations.

Recent reports on food availability in the region suggest that we

now have a sufficiency, or over-supply, of energy and nutrients to
meet the nutritional needs of the population. On average, all coun-
tries in the region have available more than the 2,250 calories and 43
g protein requirement per person suggested by the Caribbean Food
and Nutrition Institute (CFNI) (Figure 3.2.a).

We achieved this increased supply largely through enhancing the

availability of foods from animals, fats and oils and refined sugar.
Over the past 40 years, for example, average fat availability in the
region has moved from 50 g to 80 g per person per day. Caribbean
populations consume far more fat than recommended by CFNI
(Figure 3.2.b).

Figure 3.2
(a) Energy availability in the Caribbean: (b) Fat availability in the Caribbean:
Calories/person/day 1961–1994 Grams/person/day 1961–1994

(Heavy horizontal lines indicate recommended daily allowance, RDA, levels. Courtesy of
Dr. Fitzroy Reid, Caribbean Food & Nutrition Institute, CFNI)

But while we met calorie and protein needs, we ate fewer cereals,
fruits, vegetables, legumes, roots, and tubers. As a result, what we
now have is a very significant decline in under-nutrition rates, but

180 FD12A
 an enormous increase in the incidence of chronic diseases that might
more properly be thought of as related to a kind of “over-nutrition”.
These diseases include diabetes, hypertension and heart disease, and
some nutrition-related cancers. At the same time, iron deficiency
anaemia remains a problem, especially in pregnant women and pre-
school children (Cajanus, 2000).

We now face a very complex challenge. We must maintain the over-

all gains in nutrition levels, but make our populations more aware of
how to select their diets in order to avoid or delay the chronic
diseases mentioned above. To meet this challenge, we need to collect
information in each territory on the factors that determine what
people choose to eat. This includes availability of foods from each
food group, access, patterns of consumption in different communi-
ties, and existing beliefs about food. With these findings in hand we
would be able to make informed decisions and develop appropriate
policies and plans to improve our nutrition status.

Based on a diet supplying 2,250 calories per person per day, CFNI
has recommended that staples (cereals, roots, and tubers) should
supply 45% of that energy; legumes, nuts, fruits, and vegetables
25%; food from animals 15%; fats and oils 10%, and refined sugar
only 5%. In order to stay healthy we should:

• aim to meet those nutrient goals

• decrease our dependency on imported foods
• discourage the growing popularity of those fast foods that are
high in fat, animal protein, and refined carbohydrates

This requires early and continuing education of a quality that can

successfully counteract the effects of the marketing techniques that
target our populations. Collaboration at the regional level is essen-
tial, since Caribbean countries are similar in many ways. But our
ethnic and economic differences demand that each country must
work out its own specific solutions.

FD12A 181
 ACTIVITY

1. Summarise the main trends in nutrition in the Caribbean at

present under the following heads: overall calorie and
protein availability, types of foods consumed, and specific
problems. (You may check the upcoming section titled
“Nutrition problems” for additional information.)

2. Outline the activities required to improve the eating

patterns of our citizens.

Food supply

We need to ensure that food is not only available to all the people all
the time, but that such food provides the nutrients needed for
people’s full development, both physical and intellectual. Further,
we should be able to do this on an on-going basis. What we do now
should not put in jeopardy the natural resources needed to ensure
future generations the same advantage. In other words, the food
supply must be sustainable (available over time).

The two most important factors that determine whether or not

people do get the food they need are availability and accessibility.
We noted earlier in the section that adequate calories and protein are
available in the region. Whether adequate supplies of the right foods
are accessible to all is another matter. The fact that some under-
nutrition exists side by side with obesity in the region suggests that
the distribution of available food supplies needs to be examined.

182 FD12A
 Although living conditions have improved greatly in most
Caribbean countries, poverty still persists throughout the region.
Food may be available but not affordable for those people living
below the poverty line. In 1995 it was estimated that 38% of the
total population was living in poverty. Levels varied throughout the
region – ranging from 65% in Haiti to 5% in the Bahamas.

The following data show differences in access to food for those who
earn the least in our society. Minimum wage earners in Barbados,
Belize, Montserrat, and St Kitts and Nevis in 1993–1994 needed to
use between 15% and 28% of their earnings to have a well-balanced
2400 kilocalorie per day diet. In Grenada, this figure was between
43% and 34%, while in Guyana costs went from 80% in 1993 to
63% in 1994. Figures varied widely in Jamaica for the period. In
December 2000 the cost of feeding a family of five adequately for
one week was estimated at J$1,828 (US$40). The present minimum
wage in Jamaica is only J$1800 per week.

We also need to consider a third factor with regard to food supply.

Even if food is available and accessible, is it being assimilated so that
the body can use it effectively? Infestation by worms may prevent
absorption or badly prepared food may inhibit the absorption of
certain nutrients. If minerals that are needed in very small quanti-
ties are not being assimilated for any reason, deficiencies will
continue even though enough food is being eaten.

ACTIVITY
1. Distinguish between the terms “available” and “accessible” as
applied to food supply.

2. What other factor determines whether citizens receive an

adequate supply of food?

FD12A 183
 Nutrition problems
Deficiency problems

Problems with deficiency diseases seem, for the most part, to be

localized. In Jamaica, for example, high prevalence of marginal vita-
min A deficiency, wasting, and anaemia varied in different regions
(CFNI, 1998). Data from nutrition risk mapping, also in Jamaica,
suggest that rapid urbanization and the consequent stress on infra-
structure, together with poverty, are associated with the presence of
some pockets of persistent malnutrition. In countries with indige-
nous populations, there is some evidence of greater prevalence of
nutrition deficiency among those groups.

Energy-protein malnutrition (EPM)

The term energy-protein malnutrition means just what it says – a
deficiency in the diet of the calories and protein needed for good
health. Children are particularly prone to this type of malnutrition,
as Dr. Cicely Williams of Westmoreland, Jamaica, discovered. Dr.
Williams, who qualified in 1923 with the first group of women
admitted to Oxford University Medical School, found in her work
in Ghana (then the Gold Coast), West Africa, that many children
had symptoms she had noticed in Jamaican children while she was
growing up. They had swollen bellies, diarrhoea, fever, and were
very weak and listless. She discovered that giving children a diet rich
in protein and calories could reverse the condition.

Figure 3.3 (left) Child suffering from

kwashiorkor. The child’s legs show oedema
(accumulation of fluid), healing of infected
lesions, and “crazy pigment skin”
characteristic of zinc deficiency. The child is
apathetic when undisturbed and irritable
when touched.

Figure 3.4 (right) Child suffering from

marasmus, characterised by no oedema,
severely reduced muscle mass and marked
irritibality. The child is receiving an
intravenous drip for severe dehydration and
has a nasogastric tube inserted. Hands are
taped to prevent removal of the tubes.
(Both photographs courtesy of Professor Terrence Forrester, Tropical Metabolism
Research Institute, UWI.)

184 FD12A
 She therefore called the condition protein-energy malnutrition
(PEM), and the disease it produced kwashiorkor, the term used in
West Africa (meaning the disease the old baby gets when the new
one comes – in other words when the baby is weaned). In the
Caribbean, we also see “mirasmi” babies – babies with marasmus,
which is another way in which this type of malnutrition shows
itself.

Much research into this type of malnutrition has taken place since
Dr. Williams’ original discovery. Whereas the original emphasis in
treatment was on the protein in the diet, more emphasis is now
being placed on the energy aspect. So the term now used is energy-
protein malnutrition (EPM).

Throughout the region, the incidence of EPM has declined signifi-

cantly over the past 25 years. Since the late 1980s and early 1990s,
levels of undernutrition in pre-school children have declined to less
than 5% in nine countries. Rates between 5 and 10% have been
reported in six others, and only one country had a level higher than
10% (cited in Henry et al., 1997, p.192: original source Sinha D.
1995). Severe forms of EPM like kwashiorkor and marasmus are no
longer a problem, but chronic low level EPM remains. It shows up
as stunting, the child’s height being below the average for healthy
children of the same age.

Food and nutrition surveys show this decline in EPM. In Grenada,

surveys conducted by the Food and Nutrition Council showed a
decline in undernutrition in children 3–5 years old, from 39.6% in
1985 to 8% in 1990. Hospital data from Jamaica, 1994, showed that
2.3 % of the 0-59 month old admissions were diagnosed with EPM,
as compared to 5% in 1993. (National Survey by the Planning
Institute of Jamaica).

The survey also showed that the 0–5 months and 6–11 months age
groups had the largest proportion of admissions for malnutrition –
38.8% and 50.8% respectively. This is surprising since EPM levels
tend to increase with age between ages 0 to 5 years. The feeling is
that, as the Ghanians observed, this is associated with poor weaning
practices. The figures suggest a need to re-emphasise the importance
of breastfeeding.

FD12A 185
 Iron deficiency

Iron deficiency anaemia affects between 6 and 65 % of pregnant

women throughout the countries. The Turks and Caicos Islands
(65%), Guyana and Belize (52%) and Jamaica (51%) register the
highest proportions of pregnant women so affected. National
surveys carried out in five countries by CFNI, indicate that among
children under 5 years old, between 34 and 57 of every hundred
have this type of anaemia. Among adults (15–60 years) in Guyana,
42% were anaemic. Among this group, females were more than
twice as likely to be affected as males.

These deficiency levels are believed to result from insufficient iron

in the diet and inability to use what is taken in. To reduce these
deficiencies four strategies have been adopted: iron supplementa-
tion, dietary modification, iron fortification, and the control of
intestinal parasites. In Jamaica, for example, since 1984 flour forti-
fied with iron has been available. Barbados, Belize, Grenada,
Guyana, and St Vincent and the Grenadines also currently have iron
fortification programmes.

All English-speaking Caribbean countries have in place iron supple-

mentation programmes aimed primarily at pregnant women and
infants. Their impact is not yet clear. Infrequent and delayed (late in
pregnancy) attendance at clinics and unwillingness to follow the
programme have been problematic.

Vitamin A deficiency

CFNI surveys over the period 1996–1998 have identified vitamin A

deficiency in small sections of the population in Antigua, Dominica,
Guyana, Jamaica, and St Vincent. Severe deficiency was identified in
less than 1.3% of the population. Marginal deficiency was, however,
identified in 1.1% – 10.6% of preschoolers, school children, and preg-
nant women. The picture in Jamaica was noticeably different, with
58.1% of children 1–4 years old, 18.8% of school children, and 33.6%
of pregnant women recorded as marginally deficient in this vitamin
(CFNI, 1997a, b; 1998).

Iodine deficiency

Iodine deficiency is not generally regarded as a problem in the

Caribbean. However a study done in Guyana identified levels of

186 FD12A
 42.8% in pregnant women and 27.6% of female children, and 26.1%
of male children 5–14 years old. In 3.9% of the female and 2.5 % of
male children, the deficiency was regarded as severe (CFNI, 1997b).
Iodine can be supplied as iodized salt. The latter is available in most
countries.

CRITICAL THINKING ACTIVITY

1. The data on deficiency diseases presented in this section

makes comparisons difficult. Why is this so?

2. Select any one country mentioned above and write a short

paragraph on some aspects of the deficiency problems of
that country.

3. What aspect of malnutrition do you think requires the most

urgent attention in the region? Explain why you hold this
opinion.

Problems of nutrient over-intake and choice

Obesity

We have already noted that there is more than enough food calories
available in the region to satisfy our nutritional needs. We now need
to be concerned, not by undernutrition but overnutrition. The real
cause for concern is no longer how much we eat but what we eat,
that is, the type of nutrients consumed. The trend towards more
animal, fatty, and refined foods, including sugar-based types, is not
good. In addition, as the region “develops”, we have adopted a more
sedentary lifestyle. These are important contributors to obesity.

Even casual observation suggests that much obesity is present in the

n Body mass index
is calculated as
Caribbean. Recent studies of obesity among adults of 20+ years
weight in kilograms suggest that some 30–32% are overweight, and 19–21% are obese
divided by height
squared, in metres
(CFNI unpublished data). When does overweight become obesity?
(kg/m2). Early World Health Organization (WHO) standards categorize persons
studies used different with Body Mass Indices (BMI) of 25 and over as overweight. Among
measures e.g. weight
for height charts, these, persons with a BMI 25 to 29 are regarded as pre-obese and
making comparison persons with BMI 30 and over are regarded as obese. Within coun-
difficult. WHO
recommends the use tries, geography, level of education, and gender seem to be associated
of BMI. with differences in obesity. Females consistently show higher

FD12A 187
 proportions of obesity than males as shown by studies done in
Dominica, Guyana, Trinidad, and Jamaica. Among Jamaicans, over-
weight is more frequently associated with lower education levels.
More rural residents than urban are pre-obese but there seem to be
no urban/rural differences at higher levels of BMI. In Trinidad,
however, more rural residents are obese, compared with residents in
the city or towns.

Several studies worldwide have suggested that obesity is the major

link to the development of nutrition-related chronic diseases which
now rank as the leading cause of death in the region. Refer to
Session 1 of this Unit where the link between nutrition and these
diseases was discussed in more detail.

Dealing with the problem

Any effective strategy for dealing with the nutrition problems of the
Caribbean must take into account

l the need for an effective public health campaign,

l training health professionals to use a more client-oriented
approach to the care and education of their clients, and
l enlightened regional and national health care policies based on
up-to-date research

Public education

The following comment was made about Jamaica, but it could well
be said of the whole Caribbean region:

Many of the risk factors affecting the health of Jamaicans are

either not perceived by the population as such or they are only
superficially understood. These include obesity/overweight,
cigarette and/or marijuana smoking, heavy alcohol intake, a
fatty, high salt diet with lots of refined sugars, sedentary
lifestyle, failure to adequately treat hypertension and diabetes,
multiple sex partners and poor health-seeking behaviour.
(Figueroa 2001)

Only education can improve this superficial understanding. People

must be taught how lifestyle factors affect health, and what steps
should be taken to preserve health and well-being. Early in life, we

188 FD12A
 should encourage careful attention to diet and involvement in regu-
lar physical activity. We should try to ensure that citizens with
family histories of nutrition-related diseases have regular medical
checks, hopefully delaying or avoiding altogether the onset of these
diseases. Smoking and substance abuse should be discouraged.

To be effective, however, the educational process must be interactive

and participatory. As Garcia (1999) points out in addressing the
problem of diabetes education in Cuba, conventional health care and
education focuses on the illness rather than the individual. “It is
assumed that doctors and nurses know everything while people with
diabetes know nothing.” Patients are mere objects when this is the
approach. Education has to move away from just giving information
to providing positive support, based on patients’ own life experiences.

ACTIVITY

1. Do you agree with the statements above about the way

many health care professionals view their patients?
(Consider experiences that you have had with health care
professionals that made you feel ignorant and undereducated
in health matters or guilty).

2. Write out a short “conversation” between a public health

nurse and a group of patients to show what you consider to
be a more productive approach to dealing with people.
(Select as your topic information from one of the diseases
covered in this session.)
You might like to consider including the following:
l A suitable greeting
l A period for allowing patients to get to know each other
or talk about themselves
l Allowing patients to share experiences with each other
and ask questions as you talk

Health-care policies

Some important gains have been made with respect to health-care

policies. Regional governments and policymakers are conscious of
the role of food and nutrition in the achievement and maintenance

FD12A 189
 of good health. This issue was a key component of the Caribbean
Co-operation in Health (CCH) initiative, launched by the CARI-
COM Ministers Responsible for Health as far back as 1986. The
overall goal was to “prevent malnutrition in all its forms and
prevent and control those diseases conditioned by nutrition practice
and behaviour”. CARICOM Ministers at a 1991 meeting, approved
the goals and targets of the CCH. Targets set for CARICOM coun-
tries to develop were:

1. National food and nutrition policies

2. Food and nutrition strategies

3. Nutritional surveillance systems

4. Programmes and activities for preventing the most prevalent

nutritional disorders

5. Nutrition component to health education programmes

6. Regional policy for training in nutrition

7. Reduced health risks from food contamination

A report to the 1992 meeting of the CARICOM Ministers

Responsible for Health, indicated that all countries had by then
developed some form of nutritional surveillance system. Satisfactory
progress was also being made in several countries in developing
national food and nutrition policies, strategies, and preventive activ-
ities in relation to anaemia, EPM and obesity, as well as in the devel-
opment of educational materials for use by teachers (Henry et al.,
1997). Later reports out of PAHO/WHO show that this trend has
continued (PAHO/WHO, 1998).

CRITICAL THINKING ACTIVITY

1. How can we improve our food production and distribution

systems to ensure that the poorest among us can obtain the
needed nutrients, without either encouraging a culture of
“hand-outs” or suppressing human dignity?

2. Can genetically manipulated (GM) foods help? (See Unit 4.)

190 FD12A
 But national plans for health care are enormously affected by
economic constraints. Treatment and care costs are high, and for
each individual who has a chronic disease (diabetes, hypertension or
heart disease), a lifetime of such costs is often involved. Therefore,
the best approach is an integrated one that emphasizes preventive
and health promotion measures, while supporting treatment and
care. All programmes and plans should reflect these two considera-
tions. The aim is to cover all stages of life – pregnancy, early infancy,
childhood, adolescence, and adulthood.

For example, care and nutrition in pregnancy need special attention.

These are crucial stages of growth and development. Research has
shown that nutrient deficiencies during pregnancy affect the foetus
and may have detrimental effects that last a lifetime. Breastfeeding
needs to be actively encouraged and child growth monitored contin-
uously even in countries where malnutrition is reduced. This will
lead to early identification of those with deficiencies and those most
likely to develop nutrition-related diseases (high risk). These individ-
uals can then be targeted for treatment when it will be most effec-
tive.

The preventive and monitoring activities suggested above should be

given priority in health-care budgets. Together they cost much less
per person than treating those who are already ill. We need to
support policies that advocate these measures so that we can reduce
expenditure on expensive equipment that can care for only a few
persons at a time, after they have fallen into crisis.

This brief treatment of the status of nutrition in the Caribbean and

its associated problems raises a number of questions. Some of these
are suggested below. You may think of others. They need to be
considered carefully if we are to reach our goal of adequate nutrients
for all and a healthy society.

In this context, it is important to note the enormous contributions

of the Caribbean Food and Nutrition Institute and the Tropical
Metabolism Research Unit of the UWI to research and understand-
ing of nutrition and its problems, and to public education in the
region.

FD12A 191
 ?
? CRITICAL THINKING

1. Fast foods are popular because they are convenient and

satisfying.

(a) Are they better or worse than our traditional foods?

(b) Suggest how we might change the character of the
present fast food offerings to make them more nutritious
but still tasty?

2. To move from our present focus on treatment of disease, we

need to actively promote health. Should governments assist
this effort by placing some restrictions on the types of foods
sold in certain places e.g. schools, government canteens etc.?

(a) Would you consider this encroaching on your individual

freedom?
(b) What other measures can we use to effectively educate
the most needy sections of our populations?

3. As we seek to satisfy our own food needs, what steps should

we take to conserve the natural resources that future genera-
tions will need to help feed themselves?

Will GM foods provide a solution or hinder this cause? (See

Unit 4 for more on GM foods.)

192 FD12A
 Session 3.3
Genetic Diseases

Introduction

Sometimes persons are born with an illness or a disability and there

is nothing we can do about it. In some cases, it is in their genes. In
the same way that they inherit a dimple from a father, an unusual
hairline from a mother, hair texture from both of them and a
crooked first finger from a grandfather, they have inherited the
disorder from one parent or both or perhaps a grandmother. Other
nutrition-related or lifestyle disorders seem to depend on genetic
factors to a certain extent. There is little we can do about genetic
diseases at present but genetic engineering offers some hope for the
future and in some cases the symptoms and signs can be treated
successfully.

Despite our inability to cure genetic diseases, understanding how

they are inherited is important. People can make informed choices if
they can find out whether or not they carry the genes for certain
diseases and what the chances are of passing them on to their chil-
dren. Couples may opt not to have children, but if they do choose
to have children, they will be better prepared to deal with any
disabilities caused by a genetic disease.

A number of ethical issues surround inheritance and the more we

know the better we will be able to contribute meaningfully to
debate on these issues. As a society, we should support parents in
their efforts to obtain improved benefits and facilities for the treat-
ment or training of affected children so that as adults they are less
dependent on the state. A better understanding of these disorders
should also reduce the prevailing prejudice and fear of accepting
persons with genetic disabilities as legitimate members of our
society.

FD12A 193
 OVERVIEW

Before we consider genetic disorders or diseases, we need to under-

stand how we inherit our characteristics from our parents.
Understanding this is also important for dealing with some aspects
of the unit on biotechnology that follows this one. In the first
section of this session we shall deal with the basis of inheritance.
The way genes store information and control the functioning of our
cells and our bodies and how they pass on that information is dealt
with in some detail. We then look at two examples of inherited
disorders that are common in the region; sickle cell anaemia and
Down’s syndrome. Two other inherited disorders are treated briefly
before the final section on biotechnology and genetic diseases.

FOR THE STUDENT

It is not intended that you learn to describe the detailed structure

of DNA but you do need to take some time to understand it so that
the rest of the section makes sense. Similarly, understanding of how
different diseases are inherited is important but you need not learn
how to replicate the genetic diagrams included.

194 FD12A
 The basis of inheritance

Each cell of an organism carries within it a full set of the genetic

instructions that define its characteristics. These instructions (or as
they are commonly called, genes) are carried on structures called
chromosomes within the nucleus of each of the estimated 50 tril-
lion cells in your body. A chromosome is a long, spiral strand of a
material called deoxyribose nucleic acid (DNA). We will deal with
this in an upcomig section of this session. This intricately and
precisely folded molecule, carries on it all the information required
to make your body and control its every function. Chromosomes
also have segments that regulate the activities of the chromosomes
themselves.

Figure 3.5 Chromosomes from a human male cell stained to show

certain characteristics more clearly.

Source: W. Ganong, 1997. Review of Medical Physiology, Appleton & Lange,

Connecticut, USA.

For each kind of organism, there is a specific number of chromo-

somes. In humans this number is 46, made up of 23 pairs (see
Figure 3.5). Human chromosome pairs are numbered 1 to 23 accord-
ing to their length, shape and banding pattern as revealed by
specific stains. The 23rd pair (XY) determines the sex of the individ-
ual. Note that this “pair” does not really match. Can you see the
difference? The dark bands are characteristic segments of the DNA,
not genes.

Chromosomes pass on instructions for development, growth, and

general functioning, from generation to generation by means of

FD12A 195
 special reproductive cells called gametes, for example, sperms and
eggs. Most organisms have male and female gametes. How are the
instructions passed on? This is done in two ways. The astonishing
thing is that the basic mechanism is the same in all organisms.

Cell division for growth (mitosis)

For growth to take place, one cell divides into two, two into four,
and so on. The new cells increase to the size of the one from which
they came, before they themselves split into two again. Each new
cell has the same number of chromosomes and the exact number of
genes in the same order on the chromosomes as the cell from which
it came (the parent cell). This number is the number for the species.
This is the way cell division takes place in almost every part of your
body (with one exception). It is termed mitosis (Figure 3.6).

Figure 3.6 Mitosis – cell division for growth

Parent cell – 4 chromosomes

present in pairs (in this case, F M
M F
2 pairs): one of each pair from
father (F); one from mother (M)

Each chromosome replicates to

FM
form two identical strands of
M F
DNA (chromatids) in prepar-
ation for division.

Cell divides into two:

one strand from each
chromosome goes to
each daughter cell

The cells grow, but the

DNA strand in each
chromosome will not
replicate into two
strands unless the cell
is going to divide

If the cell is dividing over and over how does the number of chromo-
somes remain exactly the same? Before mitosis each chromosome
makes an exact copy of itself to form a chromosome with two
strands held together at a single point. Each strand in the double-
stranded chromosome is called a chromatid.

196 FD12A
 Cell division for gamete formation (meiosis)

In mitosis you get back exactly what you start with! A cell divides
to form two exact copies of itself. Cell division for gamete forma-
tion is somewhat different, (the exception mentioned above).
Gametes are reproductive structures, in our case, the male sperms
and the female eggs. Remember that our body cells have 46 chromo-
somes. Sperms and eggs have only 23 chromosomes i.e. half the
number found in body cells. There is a very practical reason for that
which should be fairly obvious if you think about it. Cells with the
capacity to produce gametes divide in a two-step process.

Figure 3.8 Meiosis – reduction division

Step 1: One cell becomes two, but each daughter cell gets one of
each chromosome pair, and so has 23 unpaired chromosomes. Note
that one will get the X and the other the Y chromosome (see
above). This step is called a reduction division because of the halv-
ing of the chromosome number.

Step 2: These two cells divide to become four, each with 23 chromo-
somes. In a male, these four cells become the gametes (sperms), half

FD12A 197
 having X chromosomes and half Y.

The process is called meiosis (see Figure 3.7). By convention, we

represent this half or haploid number as n, and the full diploid
number in the body cells as 2n. The haploid number of humans is 23
and the diploid number is 46, thus we have n chromosomes in our
gametes and 2n in all our other body cells.

Interestingly, in females Step 1 in meiosis starts in the ovaries of the

foetus i.e. before birth, then stops. About 1 million of these “pre-
eggs” survive until after birth, remaining dormant until puberty
when the process restarts. Then one is selected for release at ovula-
tion each month. In her lifetime a woman will release only some
400–500 eggs. The rest degenerate.

Passing on the instructions to the next generation

What happens to the chromosomes after fertilization?

When a new individual is formed, there is fusion of the male and

female gametes. We say that the sperm fertilizes the egg. At fertil-
ization both gametes join together to form a zygote with 46 chro-
mosomes. Of this number, 23 are paternal chromosomes from the
sperm and 23 are maternal chromosomes from the egg. The process
of meiosis ensures that the diploid number of chromosomes (2n)
remains constant from one generation to the next.

Also important is the fact that sperms may have either an X or a Y

chromosome. All eggs have X chromosomes. After fertilization, if
the sperm had an X the child would be female. If it had a Y chromo-
some the child would be male. Can you complete the diagram in
Figure 3.8 to show how sex is inherited?

The zygote divides repeatedly by mitosis to become multicellular.

We refer to it as an embryo, and later, once recognizable organs
begin to form, as a foetus.

198 FD12A
 Figure 3.8 The inheritance of sex

Male Cell Female C ell

XY XX
MEIOSIS

X GAMETES
X

FERTILIZATION

XY

How do chromosomes carry instructions?

Chromosomes contain DNA (deoxyribose nucleic acid). DNA carries

the instructions for proteins to be made by the cell (cells are mostly
protein). In 1952, Cambridge University scientists James Watson
and Francis Crick, proposed that the DNA molecule is shaped like a
double helix. The molecule is double stranded, and the two strands
are twisted on each other into a spiral or helix (see Figure 3.9a, next
page). Each strand is made up of alternating phosphate and sugar
(deoxyribose) units. The two strands are linked together by pairs of
bases, adenine (A), thymine (T), cytosine (C), and guanine (G).
There are differences in the size and shape of the bases, such that
adenine is always linked to thymine, and cytosine to guanine
(Figure 3.9b).

FD12A 199
 Figure 3.9

(a) The DNA double helix with two “backbones” of sugar-phosphate

linkages – see (b). Each sugar has an organic “base” attached (A, T, G
or C). (b) The two “backbones” are held together loosely by linkages
between complementary bases, so that two identical replicas of the
original (old) molecule are produced, with a matching sequence of base
pairs. This sequence determines the sequence of amino acids in the
proteins coded for by the particular DNA sequence – successive triplets
of base-pairs code for particular amino acids.

Source: (a) from: J.D. Watson, 1968, The Double Helix. The New American Library, Inc.,
USA.)

Here is the key to the mystery of how these chemicals are able to
carry so much information. The sequence of the bases on each DNA
strand forms a code that directs the production of specific proteins.
Each DNA strand is therefore a list of different instructions for
making different proteins that the cell needs to carry out its specific
functions. To understand this fully, we must first describe the struc-
ture of proteins. Proteins make up most of the cell structures, and
enzymes that control what each cell does are also made of protein.

Each protein is made of hundreds or thousands of smaller molecules

called amino acids, arranged in a particular way. A succession of
three bases on the DNA strand codes for one amino acid. The
sequence of these triplets, as they are called, gives the sequence for
linking specific amino acids together to make a particular protein.
Proteins are not made inside the cell nucleus but outside in the cyto-
plasm. DNA does not leave the nucleus so a messenger molecule,
mRNA, copies the code from the DNA and takes it from the nucleus
into the cytoplasm. Structures in the cytoplasm called ribosomes

200 FD12A
 then follow the instructions and assemble the protein. A length of
DNA that codes for one protein is called a gene. Genes give us our
characteristics.

How we inherit our characteristics

Genes are carried from parent to offspring in the gametes. So each

of our body cells has two genes for each character – one gene
coming from the male parent, and the other from the female parent.
We can look at the inheritance of sickle cell anaemia to see how the
process works. Haemoglobin is a complex protein molecule found in
red blood cells. It gives the blood its red colour but more impor-
tantly, it carries oxygen around the body so cells can use glucose for
energy.

A segment of the DNA at a particular point along chromosome

No. 11 of both parents codes for (determines the sequence of amino
acids in) one chain of the haemoglobin molecule (it has four) (see
Figure 3.10). This is the gene for the haemoglobin A protein chain
(HbA).

Figure 3.10 Simple diagram of the structure of haemoglobin

In most people both of the genes for HbA in the maternal and
paternal chromosome 11 will be identical. In the Caribbean and else-
where, some people have a different haemoglobin. A single base pair
in the entire sequence coding for HbA is different. Thus, a different
amino acid is substituted into the haemoglobin chain. This slightly
different haemoglobin is termed haemoglobin S (HbS), and behaves
differently from normal HbA, causing sickle cell anaemia. We will
explain this further in a later section of this session.

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 Each variant of a gene is called an allele; HbA and HbS are alleles of
the Hb gene. Let us take this single characteristic – the haemoglobin
molecule, and work out the possibilities for the offspring from
parents with different alleles for this gene. To do this, we need to
understand the terms dominant and recessive as they apply to
alleles. Sometimes one allele of a gene compensates for and masks
the effects of the other allele when they are present together. In this
case the allele A (coding for HbA), will mask the effect of the allele
S (coding for HbS), preventing its effects from showing up in a
person. When this is so, we say the allele A is the dominant allele,
and S the recessive allele. We call the alleles (variants of genes) in
the cells, the genotype for the characteristic.

In this case the possible combinations of genotypes for haemoglobin

are AA, AS and SS. What shows up on the outside, that is, whether
the person has the symptoms of sickle cell anaemia or not, is termed
the phenotype. Figures 3.11 and 3.12 show how you can work out
the probable phenotypes for children born to parents with certain
genotypes.

Figure 3.11

n Can you explain

why all the children
of this couple are
normal although
there are two
different genotypes
shown?

Probable phenotypes of children of a father with sickle cell “trait” (see

the section on biotechnology and genetic diseases) and a mother with
normal genotype. Note that the diagram also shows that fertilization
takes place randomly; any sperm has an equal chance of fusing with any
egg. So we look at both possibilities.

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 Figure 3.12 Probable phenotypes of children of a father and mother,
both with sickle cell “trait” (AS genotype).

n How many ways

are there to get
children carrying the
alleles for sickle cell
anaemia?
If you were
counselling these
parents, what would
you tell them about
their chances of
having a normal
child?

The inheritance of sickle cell anaemia represents the simplest situa-

tion. Sometimes more than two alleles (variants) for one characteris-
tic may exist in a population. Each gamete will still have only one
allele and each body cell two. For example, there are three alleles for
human blood groups, A, B and O, but A and B are both dominant to
O, so there are four possible blood groups (phenotypes); Group A,
Group B, Group O and Group AB. How many different genotypes
are possible? Some characteristics are determined by the interaction
of several genes as with skin colour or height, but that is a very
complex matter.

Some genetic “accidents” and the conditions they cause

Genetic “accidents” are mutations

Normally in nature, the DNA instructions are passed on accurately.

Sometimes, however, there is an accident or mutation. For example,
in meiosis the separation of the paired chromosomes may not be
perfect. If for example, one pair does not separate, some of the
resulting gametes will have 24 chromosomes instead of 23 and
others only 22. At other times, the number of chromosomes may be
right, but the molecule of DNA itself is affected. Bases may be left
out, or the sequence may be changed, so that proteins with altered
characteristics are formed, as in the case of HbS above.

Any gene can undergo a mutation, and there are about 30,000 genes
in humans. So, theoretically, thousands of genetic diseases are possi-
ble. But many embryos formed from gametes with genetic defects

FD12A 203
 die, either before birth (in a miscarriage) or shortly after. Others live
with the conditions or diseases caused by the mistakes. These condi-
tions may show varying degrees of severity. We look briefly at four
of these conditions. One of these, Down’s syndrome, involves a
whole chromosome. The other three involve single genes.

Down’s syndrome

The condition is named after the English physician who first

described it just over 130 years ago. The cause, however, was not
known until the microscope and staining technology became avail-
able. In 1959, a French physician Lejeune, showed that individuals
with Down’s syndrome had three copies of chromosome 21, not
two as is normal.

In Down’s syndrome, one gamete, usually the egg, has 24 chromo-

somes, because during meiosis, instead of separating into different
daughter cells, both maternal and paternal copies of chromosome 21
go into one daughter cell. The matching cell with 22 chromosomes
has no copy. When a sperm with 23 chromosomes fertilizes the egg,
the child formed has 47 chromosomes instead of 46, three copies of
chromosome 21 instead of two. Embryos formed with fewer chro-
mosomes than normal usually die.

Individuals with Down’s syndrome show abnormalities of the face,

eyelids, hands, and other body parts. Typically they are short, with
relatively small skulls, and a flat, rounded face. They are mentally
retarded, sometimes severely. They also tend to be susceptible to
infections, especially of the respiratory tract and ears. The incidence
of Down’s syndrome increases markedly with the mother’s age.
Estimates given are of a risk of 1 in 2,000 at age 20, 1 in 900 at age
30, 1 in 100 at age 40, and at age 44, 1 in 40 (Taylor et al. 1997, p.
865).

Sickle cell anaemia

The mutation causing this condition is a recessive variant of the

gene for making haemoglobin (Hb), situated on chromosome 11.
Haemoglobin made by the allele with the mutation (HbS), differs
from normal haemoglobin (HbA) by one amino acid only.

204 FD12A
 Figure 3.13 Scanning electron
micrograph of blood from a sickle
cell patient. The blood is placed in
a low-oxygen medium to induce
sickling then quick frozen. The
normal red blood cells are disc-
shaped, sickled cells are
distorted.

(Courtesy of Professor Graham Serjeant,

Sickle Cell Trust)

Normal red blood cells with HbA are disc-shaped. In the lungs, Hb
combines with oxygen. This it gives up to cells that need it. The red
blood cells then return to the lungs where Hb picks up more
oxygen. The process is continuous. To get through very small blood
vessels, the red cells bend and flex. When there is not much oxygen
the red blood cells with HbS change shape and become fragile and
stiff. (Some of them become sickle-shaped, hence the name.) The
abnormal shape slows the flow of blood and causes blockages in
small vessels. This can cause tissue damage and severe pain, often in
the joints and stomach.

Normal red blood cells last about 120 days in the circulation. Those
with the sickle shape seem to last only about one tenth of that
time. Individuals therefore become anaemic because of the rapid and
continuous breakdown of the cells. Treatment includes pain relief
measures, drug therapy, and transfusions. Exposure to certain condi-
tions can trigger these crises. In Jamaica, cold and/or wet conditions
have been observed to do this. Where these triggers are known,
affected individuals can avoid them.

Sickle cell disease is present throughout the Caribbean region. An

estimated 10% of the population of African ancestry, are carriers.
Fortunately, the Sickle Cell Centre at the Mona campus of the
University of the West Indies has for over three decades carried out
extensive and world renowned research into the disease. There is an
on-going programme of monitoring, treatment, follow up and
education for patients. Health professionals from several other coun-
tries including the United Kingdom, Brazil, and Uganda visit to

FD12A 205
 learn from the experiences the Centre provides. Staff is actively
involved in sickle cell projects in these countries.

There is a common misconception that sickle cell occurs only in

“black” people. The mutation causing sickling seems to be present in
a large percentage of persons in populations in parts of Africa, Saudi
Arabia, Italy, Greece, Turkey, and India. It is true to say, however,
that in North and South America, Europe and the Caribbean, sickle
cell is usually found in people of African descent. The Caribbean, in
fact, has a special “connection” since the first reported case in the
West was a Grenadian, studying in Chicago between 1904 and 1907.

An interesting twist to the survival and distribution of the gene is

its association with malaria. The populations mentioned above
come from regions where there is a high incidence of malaria. People
with the normal genotype AA tended to succumb to malaria, many
of them dying. Individuals with genotype SS often died early from
the complications of sickle cell disease. Those with one allele for
HbS and one for HbA (genotype AS – carrying the “trait”) were
found to be more resistant to malaria than those with normal
haemoglobin. Persons carrying the “trait” (AS) therefore had an
advantage over those without it (AA) and were protected from the
scourge of malaria. These individuals lived longer and were more
likely to reach reproductive age than either the sicklers or those with
both normal alleles.

If you look back at Figures 3.11 and 3.12 you should be able to see
how malaria and sickle cell worked together to develop and main-
tain a pool of individuals of the HbS genotype. This is one instance
where the mutation could be said to have had a good, as well as a
bad effect. Where malaria is no longer common, we can expect a
gradual reduction in sickle cell anaemia as persons with the AS
genotype no longer have an advantage over others although the SS
genotypes are still at a disadvantage.

Cystic fibrosis

Cystic fibrosis is the most common genetic defect of Caucasian chil-

dren. It is caused by a mutation on the recessive allele of a gene
located on chromosome 7. Individuals with cystic fibrosis carry two
recessive alleles with the mutation. If you look back at the way in

206 FD12A
 which we worked out genotypes and phenotypes, you will note that
both parents would have had one recessive allele, for their child to
have two. Each parent is said to be a carrier. In their genotype,
they have one recessive allele (which may be passed on to a child),
but they themselves do not show the disease in their phenotype.
Why not?

The gene concerned in cystic fibrosis regulates the movement of

chloride ions in and out of the cells responsible for producing
mucus. When the gene does not function, the mucus formed gets
sticky. These abnormal secretions are produced especially in the
respiratory system. Because the mucus is thick and sticky, it builds
up, blocking small passages in the lungs and providing a breeding
place for bacteria. The bacteria and the poisons they produce attack
the surrounding tissues. This leads to repeated bouts of pneumonia
and other complications. Heavy secretions of mucus in the pancreas
and liver cause other problems. The pancreas develops patches of
fibrous tissue, called cysts (hence the name of the disease), and the
passage carrying bile from the liver to the gut may be blocked.
Heavy mucus in the intestines causes digestive problems and proba-
bly obstruction. In addition, the individual may be infertile, espe-
cially the males.

Treatment includes giving antibiotics to control bacterial infections,

and daily physical therapy to clear the respiratory passages.
n Find out why
some people are Treatment with an enzyme that breaks down the mucus also helps.
albinos although their Even with such treatment, sufferers tend to die young and without
parents are not.
treatment, they die in infancy. Gene therapy may provide an answer
What are the effects for the symptoms of this disease. Some interesting research is in
of albinism?
progress at this time.

Huntington’s disease

In Huntington’s disease, it is the dominant allele of chromosome

4 that bears the mutation responsible. The condition causes severe
mental and physical deterioration. There are uncontrolled muscle
spasms, personality changes, and sometimes insanity.

Every child of an affected individual has a 50% chance of being

affected and of passing on the gene to his or her offspring. There are
no carriers. Can you work out why this would be so?

FD12A 207
 The unfortunate thing is that onset of the disease takes place
between ages 35 and 50. So individuals may have had children
before knowing that they had the allele. Life expectancy from the
onset of symptoms is about 15 years, and no effective treatment is
yet known.

Biotechnology and genetic diseases

Genetic diseases are particularly distressing because we cannot cure

them. We can, so far, only relieve the symptoms. Gene therapy, in
which the abnormal gene is replaced by a normal one, offers some
hope but its practical applications have not yet been realised. In
addition, the research being done and the techniques proposed by
gene therapists make some people uncomfortable. It raises many
questions of ethics, some of which will be discussed in Unit 3 of this
Module.

One particularly contentious issue concerns efforts being made to

improve the treatment and care of persons with defective genes.
The successful treatment and survival of haemophiliacs provides a
good example of the controversy. Haemophilia, the so-called
bleeder’s disease, was very rare because the few individuals who
inherited the condition, usually died before they reached reproduc-
tive age. Nowadays, by taking injections of certain blood products,
they can live almost symptom-free lives, grow to adulthood and
reproduce. Some people question the wisdom of preserving, and
allowing the passage, through reproduction, of defective genes,
which would normally be eliminated from the gene pool.

It is possible to avoid passing on these diseases by receiving genetic

counselling. Potential parents provide counsellors with a history of
the occurrence of a particular disease in their family. Counsellors
work out the probability of their having an affected child and they
then decide whether to take the risk or not. Techniques now exist to
examine the DNA of the couples so they can be told for sure
whether they are carrying certain defects. These techniques can also
detect abnormalities in the early foetus and a decision can then be
made to terminate a pregnancy. Knowing about inheritance allows
couples to make what they feel is the best decision but presents
other ethical issues. If, in the face of the evidence, couples choose to

208 FD12A
 have a child, at least they would be better prepared to deal with the
consequences of the disorder. (For more information on gene ther-
apy and pre-natal diagnosis, see Unit 4, Session 1.)

QUICK REVIEW

1. See if you remember the meanings of the following terms

then go back and check them in the text.
Gamete Mitosis DNA
Chromosome Meiosis Mutation
Gene Zygote Genetic counselling
Allele Embryo Gene therapy

2. Use the following outline to review the information you

have covered in this Session. Check the text for further
details when necessary.

• Chromosomes are found in the nucleus of the cell. They exist

in pairs; one of each pair is from each parent.
• Genes are found on the chromosomes.
• Genes control the characteristics of all organisms.
• Genes are made of DNA.
• Genes have variants called alleles.
• Chromosomes and the genes they carry are passed from
one generation to the next, i.e., inherited from both parents.
• Sometimes chromosomes or genes have defects called
mutations.
• Mutations cause changes in the traits that the genes control.
• Some genetic disorders are caused by inherited mutations.
• Genetic diseases cannot be cured but symptoms can be
treated.
• Examples of genetic disorders include Down’s syndrome,
sickle cell anaemia, cystic fibrosis, and Huntington’s disease.

3. Discuss the following statement with a friend or prepare it

for an informal debate between members of your group.

“Since genetic disorders are considered incurable there is

little point in learning so much about them.” (You may
wish to consider genetic counselling, new advances in
gene therapy, treatment of symptoms).

FD12A 209
 4. Explain to a friend why a person may have a characteristic
which neither parent has.

SUMMARY

In Session 1 we looked at some diseases that are common in the

region, both communicable and non-communicable. Communicable
diseases are caused by living organisms. Many dangerous ones have
been eradicated from the Caribbean by vaccination campaigns or
controlled by public health measures. Dengue and tuberculosis
remain problematic. The incidence of HIV/AIDS continues to
increase mainly by heterosexual intercourse, putting many women
and children before and after birth at risk. Treatment of HIV/AIDS
is expensive; prevention is therefore very important. Substance
abuse is prevalent in the region, contributing to the incidence of
sexually transmitted diseases and other social problems such as
crime.

The non-communicable nutrition-related diseases, diabetes mellitus,

hypertension, and heart disease, as well as cancer are the leading
causes of death in the Caribbean region. There is some genetic
predisposition to these diseases; nevertheless, they can be prevented
or controlled by changes in lifestyle such as diet, exercise, stress
relief, and abstention from smoking and excessive use of alcohol.

Session 2 covered nutrition and nutritional disorders. Changing

patterns of food consumption were discussed. There is now an over
supply of energy and nutrients but these are not distributed
between the different food groups, as they should be. The trend is
towards increased consumption of fats, oils, and refined sugars and
away from cereals, fruits, vegetables, legumes, roots, and tubers that
used to constitute traditional diets. In addition, what is available is
not always accessible to all citizens on an equitable basis.
Consequently, deficiency diseases still exist in some areas in the
region, largely due to poverty.

EPM, iron, iodine, and vitamin A deficiencies were discussed.

Problems of nutrient over-intake are of greater concern because of

210 FD12A
 their links to the non-communicable diseases mentioned in Session 1.
The Caribbean Co-operation in Health (CCH), an initiative of the
CARICOM health ministers, shows an awareness of the nutritional
problems of the region and willingness to deal with them.

In Session 3, we dealt with genetic diseases. First we looked at how

genes carried information encoded as sequences of triplets of bases
on chromosomes and how these were transmitted from cell to cell
during cell division and reproduction. The processes of mitosis and
meiosis were described in outline. Mutations were introduced as
accidents involving whole chromosomes or parts of particular chro-
mosomes. Examples covered were Down’s syndrome, sickle cell
anaemia, cystic fibrosis, and Huntington’s disease, each of which
exemplified a different kind of genetic mistake. The importance of
genetic counselling and the possibilities for gene therapy were
discussed briefly.

FD12A 211
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A World Bank Country Study 2001. HIV/AIDS in the Caribbean:

Issues and options. The spread of HIV/AIDS in the Caribbean. pp.
9–21. Intensifying action against HIV/AIDS: Key challenges for
Caribbean countries. pp 23–38. Washington, DC: The World
Bank: 2001.

Bajaj, Jasbir S. Emerging epidemic of diabetes mellitus. West Indian

Medical Journal, 50 (Suppl. 1): 15–16, 2001.

Taylor D.J., N.P.O. Green and G.W. Stout. Biological Science 1 & 2.
Cambridge, Cambridge University Press. 1997.

World Health Organisation. http://www.who.int.

Caribbean Food and Nutrition Institute. Micronutrient study report –

A three-country survey. Vitamin A, E, beta-carotene, and iron status in
the Caribbean. PAHO/CFNI/97.J2; 1997.

Caribbean Food and Nutrition Institute. Micronutrient study report –

Guyana. An assessment of the vitamin A, beta-carotene, iron and
iodine status in the Caribbean. PAHO/CFNI/97.J5; 1997.

Caribbean Food and Nutrition Institute. Micronutrient Study Report –

Jamaica. An assessment of the vitamin A, E, beta-carotene, and iron
status in Jamaica. PAHO/CFNI/98.J1; 1998.

Figueroa, J. Peter. Health trends in Jamaica: significant progress and

a vision for the 20th Century. West Indian Medical Journal, 50
(Suppl. 4): 15–22, 2001.

Henry F., Morris A. and S. Anderson. Food and nutrition: Health

conditions in the Caribbean. Scientific Publication No. 561,
PAHO/WHO, 190–203, 1997.

Johnson, Anthony. Great Jamaicans. Book II – Scientists. Kingston,

Jamaica: Teejay Ltd., Kingston, 2001.

Editorial. SCN News, 22: 2, July 2001.

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