Mr. Chairman; Hon. Minister of Health, Dr Hamza Rafeeq; Representative of the Pan American Health Organization/WHO in Trinidad & Tobago, Dr Claudette Harry; Chairman of CAREC Council, Pro Vice Chancellor, Prof. Baldwin Mootoo; Representatives of the Inter-Religious Organization; Chief Medical Officer, Dr Rawle Edwards; Miss Denise Jones, Permanent Secretary in the Ministry of Health;

Members of the Diplomatic Corps and the Ministry of Foreign Affairs;

Representatives of partner organizations; Members of the PAHO & CAREC staff;

Distinguished guests; Ladies and Gentlemen; Members of the media.

First, let me warmly welcome you all to the Centre on this special occasion to join with us in celebrating the successes of past and imagining the possibilities for the future for further improvement in the health and development in the region and Trinidad & Tobago.

From its inception 25 years ago, the Centre has grown, from a fairly focused, specialized technical institution, with 18 countries and 40 staff, to become the Caribbean’s premier public health organization, having an evolving range of health promotion and disease prevention programs. Adding value to member countries including Trinidad and Tobago. Currently we have 21 member countries, 120 Staff, $US 5 million annual budget, and 12 major financial partners, apart from our member countries.

We have just hoisted the flag of Trinidad and Tobago, our host country, and the flags of our other member countries, in recognition and honor of them, as the most important stakeholders in the Organization. It is a time also to reflect on the power and possibilities of collective regional action to address common problems, guided by a common vision.

In my presentation, I will briefly review the Centre’s Past and Present work, and the positive impacts on health development in Caribbean. I hope to show you that time and time again, CAREC has played a valuable role as an instrument of Caribbean Cooperation in Health, contributing to improved health, lives saved, suffering avoided, health care costs averted, and intellectual and economic productivity unleashed. I then want to share with you a Public Health vision for the future, in which, through the use of the Health Promotion strategy, grounded on a strong science base and guided by quality information, our people can be Safer, Happier, Healthier and more Productive, Living in Harmony within Cleaner and Greener Environments.

And now, Ladies & Gentlemen, I want to tell you a story about the genesis of CAREC, and a conversation that occurred between Prof. Bartholomew and the then Prime Minister of T&T, Eric Williams. The story begins in the early 1970s with the spread of the 6^th global pandemic of cholera beyond the boundaries of Africa to the countries of Southern Europe and the islands of the Azores in the Atlantic, posing a heightened threat to Trinidad and Tobago, the Caribbean, and indeed the Americas. That cholera pandemic was not to reach the Americas until some 20 years later, in 1991, and it was to come from the West via the Pacific and Peru, not the East, but I am getting ahead of myself. And the occurrence of an epidemic of poliomyelitis in 1972 in Trinidad and Tobago, causing the annual Carnival to be postponed, and leading Lord Kitchener to compose his Calypso, "Mas in May". At that time, I was a teenager in St Mary’s college, and I well remember the fear my classmates and I felt when one day the teacher came into the class to announce that school was being closed early because of the polio epidemic. At this time also, T&T and the Caribbean was experiencing a widespread and severe epidemic of gastro-enteritis, which saw many hospital wards crowded with children with gastroenteritis.

Against this background, Prof. Bartholomew was invited one Sunday afternoon to the home of Dr Eric Williams, together with some other notable persons. Asked by the Prime Minister for his opinion on what could be done by the country and Caribbean to be more prepared in the face of these threats, Prof. Bartholomew replied, "Mr. Prime Minister, what you need is a CDC for the Caribbean". For those of you who may not know, "CDC" is the US Centres for Disease Control and Prevention. He then proposed the Trinidad Regional Virus Laboratory as the logical place to develop such a facility. The rest is history. Prime Minister Eric Williams very much liked the idea, which was consistent with ongoing correspondence he had been having with the then Director of TRVL, Dr Pierre Ardoin. He had the vision for a pan-Caribbean Surveillance Centre to include the French, Spanish and Dutch countries, etc., but that vision was perhaps before it its time, and the next steps took place in the context of CARICOM.

The CARICOM Health Ministers asked the Pan American Health Organization (PAHO) for assistance in the design and establishment of such a Caribbean Centre of Disease Surveillance and Control. A committee of five wise persons, including two still alive, Prof. Phil Brachman, now Prof. of International Health at Emory School of Public Health in Atlanta, Georgia, and Dr. Ronald St John, now Deputy Director of the Canadian Laboratory Centres for Disease Control, visited several Caribbean countries and recommended the establishment of the Caribbean Epidemiology Centre (CAREC), to be managed by PAHO, incorporating the then Trinidad Regional Virus Laboratory (TRVL).

In 1973, the Health Ministers, meeting in Dominica, approved this plan. A multi lateral agreement for the operation of CAREC was crafted and signed by governments during August to September 1974. At the same time, a bi-lateral agreement was signed with the Government of T&T to permit the operation of the Centre, in conformity with the multilateral agreement. CAREC came into being on January 1^st, 1975, transferring from UWI to PAHO administration. This was a profound transformation for the staff of TRVL. In that way, the CARICOM begat CAREC and gave it to PAHO to rear, and thus we can count CARICOM as our father and PAHO as our mother organizations!

I must here take this opportunity to pay tribute to the TRVL, the predecessor organization, which paved the way for CAREC, with excellent and ground-breaking scientific work, surveillance, training and research programs, especially in arbo-virology. Established first at Wrightson Road, POS, TRVL moved to this site in 1961. TRVL existed from 1952-1974, under Rockefeller administration until 1961, as part of a chain of international research facilities, and then under the University of the West Indies from 1961 to 1974. Many of you would not know, that the first ever isolate of dengue virus in Americas was made in 1953 in TRVL.

In 1954, Yellow Fever virus was isolated, in a patient from a Northern Range, Trinidad community. This was the first human case of the disease to be recognized since the 1913-14 outbreak in the South of the island. These findings were used to guide prevention and control activities, including vaccination campaigns, which saved many lives. Ladies & Gentlemen, lest you think this is ancient history, today, nearly 50 years later, YF is still around, with a significant resurgence in S. America and Venezuela in the last few years. In October last year, YF was the cause of death in an unvaccinated American male tourist, who visited the interior of Venezuela and then returned to California. The Government of T&T is to be congratulated on having one of the best YF vaccination programs in this part of world.

In 1954, also, new viruses, previously unknown to science, were discovered. I refer to Mayaro and Oropuche virus, named for the locations of the patients from which they were isolated, and which were later discovered to be the cause of large epidemics in South America.

In 1972, during the aforementioned mentioned epidemic of poliomyelitis, TRVL was the laboratory which isolated the virus, by young virologist, Dr. Barbara Hull, providing hard evidence of the occurrence of the virus, and stimulating prevention and vaccination campaigns, which saved many lives and prevented many people suffering from paralysis.

Building on these pioneering days, CAREC was established in 1974. During the 25 years, the Centre has been guided by five previous Directors, to whom I must also pay tribute. Dr Patrick Hamilton (UK), ‘75-82, was the first director and was noted for his parties! Dr Peter Diggory (UK) ‘82-88, who served first in T&T as a Medical Officer of health in Rio Claro, in the 50s, who was known for his down to earth nature and hard work. Dr David Bassett, (UK) – acted for 11 months as D/CAREC after Dr Diggory died on job in February 1988. Dr Frank White (Can) ‘89-95, now at the Aga Khan University in Karachi. Dr Stephen Blount (USA) ‘95-97, now Director of the office of global health at US CDC.

As the current Director, and the first Caribbean-born director, I am pleased and proud to have the opportunity to guide the Centre in facing the many challenges that exist today. In so doing, I have a great sense of pride and belief in the Center as the Caribbean’s health monitoring and disease prevention agency, and in our staff, who continue to give of their best in pursuit of our public health mission to improve the health of Caribbean people.

My goals at CAREC are to improve relevance and service to countries, the financial health of organization and the human competencies and systems needed to deliver our mission. In summary, to serve as better instrument of Caribbean human and economic development.

I now want to share with you some of the milestones of the Centre over past 25 years. To do this justice would require hours, and so in the time available, I will deal only with some of the highlights. Apologies for any sins of omission. During this year, we will be developing the story a lot more as a written history of TRVL & CAREC, the first volume of which will be launched in March.

First, some of the early developments in epidemiology and laboratory services. At the first meeting of countries in May 1975, attended by all 16 countries, surveillance was agreed to be the main priority for the Centre. Surveillance is the continued watchfulness over all aspects of a disease that are pertinent to effective control, through a process of collection, analysis, feedback and use of information for policy making, planning and evaluation of interventions.

In that meeting, all countries designated a physician as national epidemiologist. A subsequent development was the designation of Deputy Epidemiologists to assist, especially in investigations. Grenada was one of the first countries to put this all together in national surveillance unit. The monthly CAREC Surveillance Report was launched, and by December 1975, all countries were submitting data for inclusion in the publication. Circulation rapidly reached over 2,000 copies. The CSR was the main instrument for incorporation and publication of all the disease surveillance data of the countries and for proactively managing the data. Dr Elisha Tikasingh had the honour of being the first editor.

In July 1976, a printing press was procured to enable in house printing of the CSR, Epi-Notes, disease investigation forms, etc. In January 1977, a Telex machine was procured, which was a great advance at the time, facilitating the rapid transmission of data to and from countries. The first computer was purchased in December 1980!

In these early years of the development of the epidemiology and surveillance functions, special recognition must be made of the sterling support of the US Centres for Disease Control (CDC), which assigned four epidemiologists over an eight-year period to assist the development of the Centre’s programs. Dr Jeffrey Koplan, now Director of CDC, was the first such to serve. Dr Roscoe Cox, now Deputy Director, Office of Global Health, CDC, was the next. Dr John Andrews, now Senior Scientist, ATSDR, USA, was the 3rd. Dr Chad Helmick, now in Chronic Disease Centre at CDC, was the 4th. In the mid-eighties, we received further support in the secondment of Dr Richard Keenlyside as an occupational health epidemiologist, who focused on the Eastern Caribbean and T&T. He is now the Associate Director for Global Health in the US Centre for HIV/AIDS/STD and TB. Today, we still enjoy a special relationship with CDC.

Other epidemiologists of note include Dr. Peter Diggory, who was to become Director in 1992. Dr Mirta Roses, who served till 1986, and who is now the Asst. Director of PAHO in Washington. Dr Xavier Leus, now in WHO Geneva. Dr Chris Bartlett, now Director of the UK Communicable Disease Surveillance Centre, who in the mid-80s played a catalytic role in starting many hospital infection control programs in many member countries. Most of these CAREC-TERS have expressed their interest in returning in June for a re-union of CAREC-TERS that we plan in as part of the 25^th Anniversary celebrations in June.

[Work of Dr Peter Diggory in the investigation of presumed Thallium poisoning contained in contaminated flour, Guyana, 1985.... on Food Safety - surveillance, training, outbreak investigations 70s and 80s.]

The development of epidemiology capacity in countries was greatly enhanced by a Training grant from USAID, which lasted from 1979 to 1985. The first training officer was Dr Cox, a position which was then taken by a professional training officer, Abdool Hosein. It certainly is one of my intentions, as Director, to re-establish a core unit at the Centre to support training in applied public health to help build country capacity.

Training in epidemiology over the next eight years focused largely on supporting specific disease control initiatives, such as the Expanded Program on Immunization, cholera prevention, and HIV/AIDS. However, from 1993 to 1996, another grant was secured from the UK Overseas Development Administration for training in applied epidemiology. Through this, some 250 persons in countries had their skills upgraded, including the conduct of community surveys in chronic disease risk factors, and the hands on use of computers and Epi-Info.

Turning next to the early development of the laboratory services, the TRVL had a well established range of virology and entomology/parasitology services. A breakthrough occurred in 1977, when a bacteriologist, Dr David Bassett, was appointed, permitting the offering of a more complete range of services. In January 1977, another milestone was achieved with the signing of an agreement with LIAT Airlines, for the gratis transport of specimens for laboratory testing, which truly facilitated the work of the laboratory and cooperation with countries, especially in the Eastern Caribbean. Similar agreements were subsequently signed with Guyana Airways and, in 1985, with BWIA. Thus, the airlines became and remain partners in this exciting regional enterprise.

In 1976, a special project on leptospirosis was started, which for the first time studied in detail the prevalence of the disease in humans, animals, and examined associated risk factors. Barbados was established as a reference laboratory for this work, and remains so till today.

The Dengue fever pandemic of 1977-8 then posed a challenge and opportunity for the laboratory. The techniques of mosquito cell cultures to isolate the virus was developed, and was to serve in good stead in the ‘78/79 outbreak of yellow fever. An adequate response to YF necessitated partnership between virologists, entomologists, veterinary public health, and insect vector control depts in the MOH. This partnership was and is an enduring theme. Another key partnership note was struck in 1978, when the National Laboratory Directors and Epidemiologists held a one-day, joint meeting to exchange and coordinate actions for greater effectiveness. In the USA, such a joint meeting did not occur till the early 90s! Today, the work on dengue fever and vector borne disease prevention continues, with persons like Dr Sam Rawlins conducting research into bio-control techniques, community involvement, and the monitoring of insecticide resistance among mosquitoes, to help guide national programs on the cost-effective use of insecticides.

In 1977/8, the work of the laboratories made another sterling contribution towards the preventing of disease and decreasing health care costs, through research into the cause of gastro-enteritis. At the time, T&T was experiencing hospital wards crowded with children suffering from gastro-enteritis and dehydration. With funding from the International Development Research Centre of Canada, Dr Barbara Hull was able to demonstrate for the first time in this part of the world that a main cause of the gastro-enteritis was a rota-virus. Meanwhile, a young T&T physician, Dr David Bratt, armed with this evidence of a viral cause, not requiring antibiotic treatment, became the champion for programs of Oral Rehydration in health Centres and hospitals. This was hugely successful in preventing dehydration and speeding recovery, which literally emptied the hospital wards within a few years of the program being adopted. Today, the treatment of acute diarrhea with ORS is taken for granted by mothers and pharmacists, etc.

Another key area of laboratory work that contributed to the prevention of kidney disease in the population was the research on the Streptococcus bacteria of Dr Hugo Reid and its association with Post Streptococcal Acute Glomerular Nephritis (PSAGN) in Trinidad & Tobago. This work showed that a particular strain of skin Streptococcus was associated with PSAGN, which frequently led to kidney failure. The Ministry of heath acted on this, and promoted the treatment of eczemas and scabies with special soaps, mounting a big thrust via health centres. The result was a large decrease in this type of problem, and a reduction in related health care expenditure. The preceding two examples show once again the close partnership between the Centre and Ministries of Health and the direct benefits of the work to the health of people.

Organizationally, the big development of the first five years, sustained until today, was the establishment in 1977 of the Expanded Program on , with the Centre acting as the focal point for the PAHO/WHO EPI program in the Caribbean. Through this program, the Caribbean has become the first region in the world to successfully eliminate polio and measles transmission. This has had huge positive human and economic benefits for the region from these efforts. Lives saved, suffering prevented as tens of thousands of cases annually averted, health care costs avoided as hundreds of hospitalizations from pneumonia and other complications avoided. Here I want to pay special tribute to Mr. Henry Smith, a citizen of Belize, who was the quiet hero of this movement for over 15 years. Now followed by Jamaican Dr Beryl Irons, who is working to try and eliminate rubella (German measles) and congenital rubella syndrome from the Caribbean. Again, when we succeed, there will be tremendous cost savings to countries in terms of not having to care for mentally and physically impaired people for life.

Henry joined the Centre in 1977 and immediately set about getting countries to designate national EPI Managers. By 1979, 15 countries were part of the PAHO vaccine revolving fund. The first EPI managers meeting was held in 1980, and the 16^th last week in Grenada! In 1978, Henry made a presentation to the Conference of Ministers of Health on the gravity of the polio situation, and that was to lead to the Centre taking a leadership role in the elimination of polio from the Caribbean, the last case having occurred in Jamaica in 1982. Having had that success, in 1988, concerned about the impact of epidemics of measles, Henry again took to the Ministers of Health a proposal for the elimination of indigenous measles transmission by 1995, which was accepted.

The cornerstone of this strategy was a "Big Bang" vaccination campaign. In May 1991, over 2 million children, 92% of the target population of 1-14 years olds, was vaccinated in 19 countries. This remains the largest single coordinated public health effort in the history of the Caribbean, for which the countries and the organizations involved, particularly CAREC and PAHO are to be congratulated. Since that time, eight new graduating classes of doctors have not seen measles except for sporadic imported cases! When the history of the global eradication of measles is written, the Caribbean will have a special place, in having led the world. Lest you disbelieve, last week in Grenada, at the 16^th EPI managers meeting, people from the UK, the USA and Canada were there, testifying to what they had learned in the early 90s from the Caribbean, and how they had successfully applied these lessons in their countries.

In the late 70’s, CAREC began to branch out non-communicable disease control, with activities in cardiovascular disease research and traffic injury prevention.

The landmark St James Cardiovascular study, which ran initially from 1977-1981, is one of the finest pieces of longitudinal cardiovascular research in the world... followed some 3,000 men and women in St James and Woodbrook. The study described the burden of chronic disease and high levels of diabetes (1 in 10), hypertension (1 in 6), and sedentary lifestyle in population, and the risk of these conditions for heart disease, stroke and early death. Tribute to Dr George Miller and Dr Gloria Beckles, the researchers, and their research team. A special feature of this study was the full partnership with the T&T government, who seconded a Medical Registrar, Dr Gloria Beckles, to the Centre, for the duration of the study.

In 1979, Dr Diggory and Statisticians Adrian Lambourn and Yvette Holder began to tackle the issue of injury prevention, initially working on standardizing data collection between countries. On the subject of traffic injuries, advocacy for seatbelt legislation was embarked upon and multi-sectoral national injury prevention committees formed in several countries, including health, police, works, insurance companies, etc. This was to eventually bear fruit first in Trinidad & Tobago with the enactment of seatbelt legislation in 1995, following which there was an immediate 25% decrease in traffic fatalities in the following year.

Yellow Fever epidemic of 1979 – assistance provided to Trinidad and Tobago in the investigation and control of the epidemic. Last time there were human cases of YF in T&T. Although cycles of jungle yellow fever still occur among monkeys – 1989 and 1995 – CAREC documented transmission in forested areas.

One can see therefore, that the first 5 years at CAREC were very eventful ones. Many new projects, new avenues embarked upon. The Centre’s first five-year multilateral agreement came up for review by the Heath Ministers in 1980. Two major questions were posed: Should CAREC continue to operate? And should it continue under PAHO management? Given the relevance and quality of service provided in those first 5 years, the answer to the first question was in the affirmative, as was the answer to the second question.

I am now going to fast forward a bit to one of the next major milestones, one which is arguably the watershed event in the life of the organization, in that the necessary response to this challenge caused CAREC to adopt a more explicit health promotion and public communication thrust. Of course, this was also a watershed event for the rest of the world and the public health community. I refer here to the fight against HIV/AIDS, the premier emerging infectious disease of the Century.

Since the early 80s and the first cases of AIDS in Trinidad and Jamaica, HIV/AIDS was put under surveillance and laboratory testing was offered to countries as soon as the test became available. Research began in the 1985/6 on high risk groups and migrant workers. Today we know that the Caribbean has the second worse epidemic in the world after sub-Saharan Africa. Now major cause of death in males and females aged 15-44 years.

The Special program on Sexually Transmitted Infections (orig. Special Program on AIDS) began in 1987 with the hiring of two staff – a laboratory technologist Esther de Gourville, and an Media/Information Advisor, Mr Leslie Fitzpatrick, representing at CAREC, a new type of partnership between bio-medical science and communication and behavioural science. In November 1987, a "Donors Familiarization Meeting" was held at the Kapok hotel in POS. Well do I remember it, as the electricity failed as I was about to present an epidemiological update to the meeting, causing me to have to paint word pictures.

During the next 12 months, we had a blitz of travel, together with partners from the Global Program on AIDS (GPA), to help in the preparation of 19 national plans for prevention and control, as well as a regional plan. Some funding was secured from GPA for the hiring of an epidemiologist, Dr Jai Narain. In November 1988, a "Donors Pledging Conference" was held and over $US 12 million was pledged for HIV/AIDS prevention and control, with $3 million for a regional plan to be implemented by CAREC.

Since then, the program has made huge strides in helping the development of National policies, plans, and programs; in the establishment of a Caribbean surveillance system – although we are aware of need to improve here. High levels of awareness now exist of HIV/AIDS in the population and how it is spread. We have a safe blood supply. There is involvement of people living with HIV/AIDS in the fight via partnership with CRN+, the Caribbean Regional Network of People living with HIV. There is involvement of youth and other NGOs.

In more recent years, concerned about the continuing spread, and potential impact of the impact, staff of the Centre, together with colleagues from the Health Economics Unit of UWI, have conducted an advocacy campaign with seven governments of the region, meeting with Cabinets, Parliaments, and business leaders, to sensitize them to the problem and to secure an expanded response to the epidemic. This has been bearing fruit, including in Trinidad and Tobago, with the establishment of an Inter-Ministerial Committee on HIV/AIDS, the de-regulation of condom sales, etc.

Special recognition needs to be given to the financial and technical partners in this struggle, who have supported CAREC and the region since the inception of the formal program, including the US Agency for International Development; the UK Dept for International Development (DFID); the Canadian International Development Agency (CIDA); the German Technical Cooperation (GTZ); the French Technical Cooperation (FTC).

The HIV/AIDS challenges today include – the prevention of sexual transmission; prevention of mother to child transmission; improving care and support, including access to anti-retroviral drugs, and decreasing stigma and discrimination. The successes of the program to date have meant that the region has avoided the huge adverse impact as in some other parts of the world where large numbers of the population have been literally wiped out. But there is no cause for complacency. HIV/AIDS continues to spread and constitutes a real threat to the region’s development.

This brief HIV/AIDS story is not complete without mention of the collaboration in support of the research work undertaken by Prof. Courtenay Bartholomew, first at UWI, and then at the Medical Research Foundation of T&T. This began in 1984 with a research project on HTLV-1, which was the first of the retro-viruses to be discovered by science. With support and funding from the US National Institutes of Health, this work has spanned over a decade and resulted in many findings and publications. It has resulted in a more complete understanding of the epidemiology of the HIV/AIDS epidemic in T&T. This research is the best of its type in the Caribbean. The success of Prof. Bartholomew and his team was a major factor in T&T being considered as a site for the trial of candidate HIV vaccines, as part of the global scientific search for a safe and effective vaccine.

Another major milestone in the life of the Center was the response to the Cholera epidemic. Cholera, having not occurred in this Century in the Americas, first appeared in Peru and rapidly spread through South and Central America, and reached our countries, Belize, Suriname, and Guyana in 1992/3. In 1991, CAREC coordinated the response among countries, holding an emergency meeting in May 1991, jointly with the PAHO/CPC office, and developing a risk analysis, which suggested that epidemic cholera was unlikely to become established in the island countries, because of fairly good water and sanitation supplies, although each country had pockets with poor supplies, that could sustain transmission once introduced. Then helping with the planning of programs, and the mobilization of resources, public education, setting up of surveillance, conducting training, and investigating outbreaks.

The CAREC epidemiologist, myself, together with the Ministry of Health in Belize, Dr Jose Lopez, investigated the first outbreak in the English-speaking Caribbean in early 1992. The disease was traced to the consumption of contaminated fish, with a human trail leading back to Honduras. The findings led to intensified health education, to the elimination of the "sea toilets" on the Caribbean coast, particularly near fishing depots, one of which had been implicated in the chain of transmission, and to intensification of the rural water and sanitation programs.

Later that year, cholera struck again in our member countries, this time in the interior of Guyana. The call came in one evening from Chief Medical Officer, Dr Rudy Cummings, and the following morning I was on the first flight to Georgetown. From there by Military aircraft to lead an investigation in the Northwest of the country, near the Orinocco River and Delta Amacuro, which separates Guyana from Venezuela. Working day and night for two weeks with colleagues from the Ministry of health, we treated cholera cases in the Mabaruma hospital, and conducted a case control study, which showed that drinking untreated or un-boiled river water was a major risk factor for the disease as was the eating of smoked fish. Conversely, boiling or treating water with bleach was highly protective. This information was used to develop appropriate health education messages, the epidemic waned, and to this date, cholera has not recurred in Guyana, although it continues to occur in nearby Venezuela. Among CAREC member countries, cholera remains endemic only in Western Belize near Guatemala. Benefit of this effort to countries – trade, human lives, etc.

In winding up this brief review and celebration of the past, I want to turn to two relatively new areas of programming, which again show the evolution of the Centre’s public health response beyond needs assessment and policy development, to the area of quality assurance and capacity building.

Just as with polio, measles and HIV/AIDS, the Centre now finds itself at the heart of service to the Caribbean in the development of standards to ensure a safe and healthy environment for the preservation and sustainability of the region’s tourism industry, and for the strengthening and monitoring of medical laboratories.

Although by its very nature, CAREC has always been involved in the business of travel associated illness, the first formal program on Travel and Health began in 1997, following a resolution of the Council. The background to this lay in the investigation of several outbreaks in the industry, such as traveler’s diarrhea and legionnaires’ disease, and the realization that preventable health and environment problems were having significant human and economic impact on the industry, in a world where news of adverse events spreads very fast, where tourists are more litigation conscious, and where global forces, such as the European Directive on Package Tours, make tour operators liable for travel associated problems.

Given that the Caribbean is the most tourism-dependent region in the world, and increasingly so with the transition from agriculture dependent economies in the Eastern Caribbean, for example, it was a highly relevant development for member countries.

In 1998, following advocacy to the regional tourism industry, we started the Caribbean Tourism, Health and Resource Conservation Project, often referred to as the "Healthy Hotels Project". This is part of a public-private partnership with the Caribbean Hotel Association (CHA) and its subsidiary company, the Caribbean Alliance for Sustainable Tourism (CAST). The program aims to improve the quality and competitiveness of region’s tourism industry through improved health and hygiene standards, training, audit systems, surveillance and response to disease problems. Funding is being provided by the Inter American Development Bank (IDB).

The second major quality assurance project, as I mentioned earlier, deals with medical laboratories. The background to this lies in the fact that most countries have no standards for medical laboratory practice, including safety standards, and in the proliferation of private laboratories in many countries. This has implications for the quality of information in all areas – HIV testing, cervical cancer smears, which in turn has implications for clinical decision making, surveillance, Life Insurance company decision making, etc. Beginning in 1996, at the request of member countries, a systematic and broad based effort to develop laboratory quality was commenced. This has resulted in the development of a large project for the Strengthening of Medical Laboratories in the Caribbean to be funded by the European Union, and to include Haiti and the Dominican Republic. Like the Tourism and Health Project, the laboratory project will develop standards, conduct training, develop a laboratory network, and a system of monitoring and accreditation of laboratories. In this way, we can enter the 21^st Century with a bit more pride and confidence in our laboratory system in the region.

Our Present situation, as I mentioned earlier, includes 12 financial partners. In addition to those mentioned earlier, special thanks and recognition are due to the Canadian International Development Research Centre (IDRC), which is supporting Injury prevention work in 3 countries; the Netherlands Leprosy Relief Association (NSL) – Leprosy elimination; International Bank for Reconstruction and Development (World Bank) – Physician Sentinel Surveillance jointly with the Caribbean College of Family Physicians; to the Walter Reed Army Institute of Research (WRAIR) – Emerging Infectious Disease Surveillance and Control; US Centres for Disease Control (CDC) – Training, Distance Education; Emory School of Public Health & Fogarty International – Surveillance Training

One good consequence of the financial support from our partners accrues to the host country, Trinidad and Tobago. In 1998 the Centre expended $TT 15 million in the local economy to purchase goods and services, compared to a quota assessment of $TT 5.8 million and actual receipts of $TT4.8 million from Trinidad and Tobago. This represents a nearly 300% return on investment, if viewed from a fiscal point of view.

Mention to be made of the special relationship with T&T Public Health Laboratory

Ladies and Gentlemen: I have in the past 20 minutes, dealt with some of the achievements of the Centre and the benefits to member countries, which give us cause for celebration.

I would now like to turn our attention to the second part of the theme: "Imagine the future". A future guided by the Vision of the Caribbean Cooperation in Health Initiative, "Safer, Happier, Healthier, More Productive People, Living in Harmony within Cleaner and Greener Environments". In this, CAREC’s primary role, working with its member countries, will be working with countries to generate, provide and use information to support the Health Promotion and Disease Prevention effort, to act as a change agent.

The challenges are many, yet I believe that by the full adoption of the health promotion strategy and the engagement of other social actors and the people of the Caribbean to take greater responsibility for their own health, that we can realize that vision.

Demographic trends - Aging of the population, increasing chronic non communicable disease – heart disease, cancer, diabetes. Increase in mortality from diabetes. Even in younger people, diabetes and heart disease are increasing, given relatively sedentary lifestyles and high fat diets. However, a lot can be prevented through application of current knowledge.

Injuries and violence, traffic fatalities – much can be prevented – promote and enforce seatbelt laws, get tough on drinking and driving, road engineering at places of high risk where several have died – save hundreds of lives per year, thousands of serious injuries, avoid health care costs, decrease insurance premiums.

Men’s health issues – great inequity and inequality regarding male health. They are dying on average 6-8 years earlier than women. Violence and injuries are more prevalent. Men killing each other and partners and children. More high risk behaviours and addictions to alcohol, tobacco, and drugs. Less access to specialized health services and less utilization of services. Very importantly lower educational attainment, levels than females, a fact which was highlighted in a study of several commonwealth countries by UK DFID. Little or no policy recognition of this.

Global Environmental degradation is an over arching issue, which is playing out locally and regionally, witness the mudslides in Honduras and Venezuela in 1998 and 1999, which killed tens of thousands of mostly poor people. Global warming with increasingly frequent and severe hurricanes will challenge the Caribbean to adopt mitigation measures as a routine.

A key overarching issue is poverty, which is a multi-dimensional problem. As you may know, many of the developed countries have adopted a 2020 target of reducing by 50% the level of poverty in the world today. Good public policy must address this societal cancer, if we are to have sustainable development.

Communicable Disease: Latterly, after decades of decline, mortality rates from some of the early communicable threats, such as TB, have been on the rise. But most of this rise is due to the relatively new HIV/AIDS pandemic, now the major cause of death in Caribbean males and females in their most productive years. CAREC/UWI economic impact studies show possible 4-5% loss of national GDP to deal with HIV/AIDS. Main challenge – how to improve care and support for People with HIV and make them part of the solution.

Other emerging infectious diseases, yellow fever, malaria, dengue hemorrhagic fever; significant human and economic impact, particularly given the tourism dependent nature of Caribbean economies. The most recent of these threats, which CAREC has put its countries on alert about, is the emergence of the West Nile virus in the USA for the first time in history. This virus, spread by Culex mosquitoes, a common mosquito species in the Caribbean, may be imported into the Caribbean by migratory birds, hence the need for enhanced vigilance.

Communicable disease prevention and control have been one of the cornerstones of CAREC’s work and impact over the years. We will continue to accord priority to this, which is one of the priority areas under the Caribbean Cooperation in Health. Under CCH several sub-priorities are recognized in the area of communicable disease – Vector Borne Disease, Food and Water Borne Disease, HIV/AIDS/STI, Vaccine Preventable Diseases, Tuberculosis.

Risk behaviours: the final common pathway for most preventable ill-health and disease. Habitual diet and physical activity; alcohol, tobacco and drug use; road use behaviour; conflict resolution behavior; sexual behaviour; hygiene and environmental sanitation behaviour; and health care seeking behaviour, particularly preventive services.

Need for public health vision and leadership to effectively address challenges, and guide the health services.

Need for governments to Put their money where their health is!

The response demands a strong health promotion and disease prevention approach.

The Health Promotion paradigm recognizes the fact that health is determined by many sectors, not only the health services. Indeed, non-health sectors play a greater role in determining the health status of the population. Therefore other sectors of government and society must be engaged to successfully tackle tomorrow’s challenges.

Health promotion includes healthy public policy such as education for all and measures to combat poverty; genuine inter-sectoral collaboration and alliances; developing and fostering sound personal health skills and behaviours; re-orientation of health services; empowering communities; creating supportive environments; and the building of alliances, in which the media have a special role. Health promotion requires that we all become better at advocacy and learn to talk the language of the economic decision makers.

Successful health promotion is grounded on a strong science base and quality information to inform policy, plan and evaluate programs. A priority for us therefore is to work with countries to strengthen the science base for public health. I have a good staff, but an aging physical plant. We need to rebuild CAREC to meet member country needs safely, effectively and efficiently into the 21^st century. We will also work with countries to advocate for the need to maintain and strengthen their public health infrastructure, including laboratories.

To develop public health leadership to tackle the complex health situation, we plan to introduce a program of applied public health training and applied epidemiology (FETP). In this we have the active support of CDC, LCDC and the European EPIET program.

To provide to policy makers and health professionals with a range of quality, timely, accurate and relevant information, we will further develop and implement CARISURV – our Caribbean Surveillance System, as part of a Caribbean Health Network. Using the evidence from CARI-SURV and other sources, we will try to leverage the health reform process to benefit public health. As HSRP programs unfold, there is opportunity to preferentially develop and use cost effective public health technologies and the health promotion approach. There is also risk of damage to well-established, proven public health programs, and we have seen examples of this in the last two years. We will advocate and provide evidence to help provide framework for a reformed service, which is better at delivering public health services. A service which can better pass the health promotion test.

Successful health promotion is also grounded on effective communication of health information through a variety of publications and media to a range of publics: governments and policy makers, health professionals, general public, and people with certain conditions to empower them. We plan to establish a Caribbean Health Network, making use of modern information and communication technology, about which you will hear more in the months ahead.

The adoption of health promotion is the latest and globally accepted strategy to advance public health, the noble purpose of which remains constant. We will strike a balance between balance between continuity and change.

Health Promotion is also about Partnerships and alliances. As outlined in my presentation, CAREC has been pursuing the development of partnerships, including non-traditional ones, such as the tourism industry, in order to improve our service and relevance to member countries. This will continue, with the strengthening of existing relationships and the pursuit of new alliances.

Ladies and Gentlemen: As I conclude, I want to say that health, which is valued in and of itself, and for its contribution to development, is determined by three fundamental factors. These are our genetic inheritance, our environment and our life-choices. The latter can be either individual or collective. If we choose to use the information available to us on prevention, to adopt the health promotion approach, to put our money where our health is, supporting organizations like CAREC, then we stand a good chance of achieving the vision of Safe, Happy, Healthy more Productive People living in harmony with their environment.

In the medium term, until the end of 2003, we have the specific goals and targets of the CCH initiative. In the long term, what might some of hallmarks and indicators be in the year 2030, a generation from now?

By which time, I would probably have been retired for 10 years, writing my memoirs and indulging my grandchildren!

Thank you,
C. James Hospedales
Director
CAREC/PAHO/WHO

Caribbean Epidemiology Centre
16-18 Jamaica Boulevard, Federation Park
P.O. Box 164, Port of Spain
Republic of Trinidad and Tobago
Tel: (868) 622-4261, Fax: (868) 622-2792
E-mail: postmaster@carec.paho.org

Page last modified 24 October, 2000