REVIEW ARTICLES
Challenges for Health and Tourism in Jamaica
David V.M.Ashley,† Georgiana Gordon-Strachan,
Mary Helen Reece, and Deanna E.C.Ashley
Country Profile
Jamaica is an island nation located almost at the
center of the Caribbean Sea, approximately 150 km
south of Cuba and 160 km west of Haiti, its two near-
est neighboring countries. It is the third largest island of
the Caribbean and the largest of the English-speaking
ones. Its surface area is 11,424 km2,1 and it has a popu-
lation of approximately 2.7 million. It is dependent on
tourism, which contributes 45% of its foreign exchange
earnings and 23.5% of gross domestic product annually.2
This article discusses health risks facing visitors to
Jamaica and the challenges posed through tourism growth.
Health Indices
Jamaica has a strong public health tradition with well-
trained professionals. Government expenditure on health
is approximately 4% of the gross domestic product, and
the per capita expenditure on health in 2000 was $45
(US).2 Using the strategy of primary care, Jamaica has
been able to provide a comprehensive health care ser-
vice. Given the generally good health indices for the rel-
atively limited expenditure, Jamaica has provided good
health at low cost.1,3
There have been many significant achievements in
health in Jamaica during the past 50 years. Life expectancy
†
David V.M. Ashley, PhD, deceased July 31, 2004: formerly
Ministry of Health, Kingston, Jamaica; Georgiana Gordon-
Strachan, PhD: Epidemiological Research and Data Analysis,
Ministry of Health, Kingston, Jamaica; Mary Helen Reece,
MSc:Tourism Product Development Company Ltd., Kingston,
Jamaica; Deanna E.C. Ashley, DM: Health Promotion and
Protection Division, Ministry of Health, Kingston, Jamaica.
The authors have no financial or other conflicts of interest to
disclose.
Reprint requests: Deanna E.C. Ashley, DM, Health Promotion
and Protection, Ministry of Health, 4th Floor, 2-4 King Street,
Kingston, Jamaica.
J Travel Med 2004; 11:370–373.
370
at birth is 74 years, with females living longer than males.
The infant mortality rate in 1998 was estimated to be
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20 deaths per 1,000 live births.1,4 The major causes of
death and disability in Jamaica have changed from com-
municable and infectious diseases to the chronic disease
conditions. In 1945 the leading cause of death was
tuberculosis. Seven of the 10 leading causes of death were
infectious diseases. Since 1982 the leading causes of
death have been chronic diseases. In children under 5
years of age, the leading causes of death are respiratory
distress of the newborn, disorders of fetal growth, and
problems associated with childbirth.4
The main use of hospital care (excluding obstetric
uses) is for unintentional injuries owing to motor vehi-
cle accidents and intentional causes associated with vio-
lence. Jamaica has a high rate of crime and violence,
despite its decline in recent years.Violence is heavily con-
centrated in poor inner-city communities, mainly as a
result of interpersonal conflicts and gang feuds.5 Acts of
violence and aggression against tourists are infrequent and
represent approximately 1% of the cases of illness seen
in the sector.6 Trauma from accidents, however, accounts
for 45% of cases requiring medical interventions in
tourists. Motor vehicle and water sport accidents account
for approximately 50% of the cases seen.6 Construction
of the coastal highway, which began in 2000, has already
contributed to safer road conditions for tourists. Road
signage improvements and training and certification of
taxi and tour operators are part of the ongoing mission
of the Tourism Product Development Company Lim-
ited (TPDCo. Ltd.) to reduce motor vehicle accidents.
In addition, legislation has been enacted for the use of
seat belts by drivers and passengers and the wearing of
helmets by motorcyclists (legislated in 2000).The Min-
istry of Health focuses on improving medical emer-
gency services in tourist areas.To reduce accidents from
water sports,TPDCo. Ltd. conducts safety training and
certification programs for water sports operators.
Health Care and Services
Public health services to the tourism industry are pro-
vided on a cost-recovery basis through fees applied for
A s h l e y e t a l , H e a l t h a n d To u r i s m i n J a m a i c a
health certification of hotels and restaurants and for the
training and certification of food handlers.Clinical services
for the tourist industry are, to a large extent, provided
through a network of hotel nurses and private practitioners
on call,supported by the emergency medical and specialist
services provided at government hospitals.6
Emerging and Reemerging Diseases
Eosinophilic Meningitis
Infection with Angiostrongylus cantonensis, the most
common cause of eosinophilic meningitis, was previously
unknown in Jamaica, but larvae may have been introduced
with imported food commodities or other goods, or in
rats infesting the hulls of boats docking at Jamaican
shores. A report of eosinophilic meningitis in an adult
Jamaican who had never traveled outside the country
raised the question of the endemicity of A. cantonensis in
Jamaica.7 Its endemicity was confirmed through an out-
break in 2000 of 11 cases among tourists,apparently result-
ing from ingestion of contaminated vegetables from a
tourist establishment and subsequent identification of the
parasite in local rats and land snails.8
Legionnaires’ Disease
There have been no known cases of legionnaires’
disease reported in travelers returning from Jamaica.9
Entrance of the Legionella bacteria to domestic water
systems is the most common method of transmission of
legionnaires’ disease.10 Routine monitoring of the national
water supply ensures its quality and safety in Jamaica. Stan-
dards for control of water quality and safety in hotels and
other tourist establishments have been implemented in
hotels as preventive measures for legionnaires’ disease since
1996, and they were reinforced in the Public Health Reg-
ulations governing tourist establishments, promulgated
in August 2000.11
Communicable Diseases
Communicable diseases such as cholera, yellow
fever, yaws, and the plague commonly associated with
developing countries have not been reported in Jamaica
for several decades. Malaria was eradicated in 1954, and
there have been no indigenous cases reported since,
although 6 to 10 imported cases are reported annually.
The influx of visitors from neighboring Caribbean and
Central American destinations puts Jamaica at risk of rein-
troduction of malaria and cholera. Relevant surveillance
strategies have been put in place to monitor travelers from
high-risk destinations and the occurrence of suspected
cases in the local population.4
Typhoid fever is now far less common than it once
was , with fewer than 20 cases reported annually over the
371
past 5 years. Dengue fever is endemic with periodic
outbreaks, notably in 1977 and most recently in 1998.
Other diseases typically associated with travel to tropi-
cal countries are not reported in Jamaica.4
Vaccine-Preventable Diseases
In Jamaica poliomyelitis was eradicated in 1982,12
as was measles in 1992.The last case of diphtheria was
reported in 1994, and only two cases of neonatal
tetanus have been reported since. Several cases of
pertussis-like syndrome are reported annually. In recent
years there has been a campaign to eliminate rubella
and congenital rubella syndrome.There was only one
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case of rubella reported in 2000. Approximately 120
cases of tuberculosis were reported annually over the
past two decades.The incidence rate for tuberculosis
of 4.9 per 100,000 is among the lowest in the world.
With an increase in tourist arrivals, the possible reemer-
gence of tuberculosis, especially resistant strains, poses
a major threat to the local population.This is especially
so because of its association with human immuno-
deficiency virus (HIV) infections. To date, resistant
strains of tuberculosis have not been detected in
Jamaica.4
Traveler’s Diarrhea
Until the early 1990s, traveler’s diarrhea was prob-
ably the illness of greatest concern to the visitor to
Jamaica. A survey by Steffen and colleagues of 29,532
tourists over 16 years old who were departing from the
Donald Sangster International Airport, Montego Bay,
reported that during the 12-month period between
March 1996 and February 1997, 23.6% of tourists suf-
fered from traveler’s diarrhea during their stay.13 Bacte-
rial infection with Escherichia coli was the most common
cause of traveler’s diarrhea.14–17
In 1996 the Ministry of Health initiated a program
to reduce traveler’s diarrhea by 50% over a 5-year period
by improving environmental health and food safety
standards of hotels.A surveillance system to monitor ill-
nesses in tourists resident at sentinel hotels was imple-
mented, and a major program of awareness-building,
education, and training was developed for the person-
nel in the industry. By the end of 1998, a repeat airport
survey showed that traveler’s diarrhea attack rates had
fallen from 23.6 to 18.7%, a reduction of 20.8%. The
mean incidence rate of cases reported from sentinel
hotels across Jamaica fell from 14.72 cases per 10,000
guests in 1996 to 4.82 cases per 10,000 guests at the end
of 2001, a reduction of 67.2% (Figure 1). For the first
5 months of 2002, the incidence rate for traveler’s diar-
rhea was 4.31 cases per 10,000 guests (D.V.M. Ashley,
personal knowledge, 2002).
372
Figure 1 Total incidence rates (cases per 10,000 guests) for
traveler’s diarrhea in Jamaica, 1995–2002.
Sexually Transmitted Diseases and HIV/Acquired
Immunodeficiency Syndrome
Many of the traditional sexually transmitted diseases
have declined in recent years, but HIV and acquired
immunodeficiency syndrome (AIDS) are a growing prob-
lem, consistent with worldwide trends.Annually reported
cases in Jamaica continue to increase each year. In 2001
it was estimated that 1.2% of the adult population was liv-
ing with HIV/AIDS.18 Its highest rates of infection are
in urban centers around the city of Kingston and the tourist
capital of Montego Bay. Between 1982 and 2001, annual
AIDS cases were 367 and 552.6 cases per 100,000 in
Kingston and St. James.
Programs targeting hotel staff and commercial sex
workers and their customers are part of the strategy to
control HIV transmission in tourist areas; these pro-
grams include education, promotion of condom use,
voluntary counseling, and testing.
Health Challenges
The rapid expansion of the tourist industry has cre-
ated new demands for a policy and regulatory framework
focusing on health and tourism. An intersectoral com-
mittee facilitates and guides strategic planning, policy for-
mulation, analysis, and the development of standards for
the tourism sector. Quality assurance, training, evaluation,
monitoring, and auditing of the sector are the joint
responsibilities of TPDCo. Ltd. and Ministry of Health
officers in the field.
Preventative, primary health strategies in the tourism
sector impact locally on the health of the population in
tourist resorts and neighboring regions and on the envi-
ronment.For example,the risk of outbreaks of food-borne
J o u r n a l o f Tr a v e l M e d i c i n e , Vo l u m e 11 , N u m b e r 6
diseases in the tourist sector and indeed locally depends
on how food is handled within hotels and restaurants,
the health of workers and their families, workers’ knowl-
edge and practice of safe food-handling procedures, and
a responsive surveillance system to ensure early detec-
tion of problems and prompt intervention; rather than
on measures such as immunization of either the visitor
or the local population.13,19 Regulations governing envi-
ronmental health and food safety standards in hotels and
other tourist establishments were published in The Jamaica
Gazette in August 2000.11 Under these new regulations,
the health standards of hotels are subjected annually to
rigorous scrutiny. These measures have probably con-
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tributed to the decline in the incidence of traveler’s
diarrhea in tourists visiting Jamaica.
One of the greatest challenges facing the tourist sec-
tor stems from the impact of the industry’s growth on
the environment.As the demands for accommodation for
visitors have grown, the building of new hotels has pre-
ceded the development of the infrastructure for water,
sewage, and other forms of waste disposal. Planned and
unplanned urbanization and population settlement have
resulted in a loss of prime agricultural land and alteration
and destruction of coastal and marine ecosystems, jeop-
ardizing biodiversity in these areas and beyond.
In recognition of the environmental and public health
impact of this rapid expansion, the National Environ-
ment Protection Agency, in collaboration with the Min-
istry of Health,has implemented an environmental permit
system.Environmental impact–assessment studies are now
mandatory and provide the foundation for a more orderly
development of the industry and thereby minimize the neg-
ative impacts on the environment.Rehabilitation of water-
sheds has been assigned a high priority by the government
agencies responsible for the environment. Several ecosys-
tem rehabilitation projects are being undertaken to increase
the quality and quantity of water for human consumption
and disposal of wastes of all types,thus assisting in the con-
servation of Jamaica’s biodiversity and protection of coastal
regions and beaches from pollution.
Balancing the growing demands and expectations of
the local population for health care with the health
needs of visitors, especially for emergency care, will con-
tinue to pose a challenge in the delivery of equitable and
quality services with limited resources. Expansion of the
tourism sector and diversification of the tourism prod-
uct challenges the strength and quality of our surveillance
systems and our public health education programs in the
maintenance of the public health gains of recent years.
The threat of emerging diseases and reemerging diseases
is imposing new public health challenges to minimize the
risk of their spread to locals and visitors to Jamaica.
A s h l e y e t a l , H e a l t h a n d To u r i s m i n J a m a i c a
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