The Tribune

By LARRY SMITH

DR HAROLD Munnings is about to publish a book on the history of healthcare in the Bahamas. While the introduction describes what little is known of the medical traditions of the earliest Bahamians – the Lucayans – most of the book deals with the development of healthcare since the Bahamas became a British crown colony in 1718. One of the most interesting sections focuses on the social conditions of New Providence in the early 20th century – which fostered illnesses like typhoid, worms, dysentery and gastroenteritis - and the effort by healthcare professionals and others to improve these conditions. The following is an edited and abridged version of this part of the book.

• • • • •

In the early years of the 20th century, public health held a position of low priority on the government agenda, and swathes of the most populous areas of New Providence were like a giant cesspit. The poor sanitary conditions of these communities meant that typhoid fever and similar illnesses were endemic.

The social conditions that led to the prevalence of these diseases existed throughout the British Empire at the time. It was not until 1936 that the imperial government began to accept responsibility for the state of health in the Caribbean. That was when WM MacMillan shamed the Colonial Office with the publication of his Warning from the West Indies.

MacMillan was a Rhodes scholar and a respected historian who could not be ignored when he wrote that most of the Caribbean’s so-called “tropical diseases” were actually diseases of poverty and poor living conditions. He urged the British government to acknowledge that it had a duty to improve these conditions. But colonial governments remained largely disengaged from the health needs of their people.

Typhoid is an infection caused by bacteria, which serves up a four-week programme of misery that begins with a headache and weakness. This progresses to a continuous high fever, bellyache and delirium. Death often comes cruelly at the end of the illness, just when the sufferer seems to be improving. Before antibiotics, about 10 per cent of those who contracted the disease would die.

Typhoid is common wherever substandard sanitation results in faecal contamination of drinking water. In the 1800s, this was a fact of life in many great cities. Louis Pasteur, the famous chemist and bacteriologist, lost two of his daughters to typhoid and the death of Prince Albert from typhoid in 1861 sent Queen Victoria into mourning for the rest of her life. In The Bahamas, in the early 1900s, typhoid cases surged every summer.

In the 1920s, the Bahamian government launched a round of initiatives to boost tourism, including the opening of small guesthouses as well as the grand New Colonial Hotel on Bay Street. But the growing number of seasonal visitors were oblivious to the danger of typhoid that lurked just down the road and over the hill.

In 1921, the chief medical officer wrote that “the Colony must expect to be visited by (typhoid fever) every year as long as the present unsanitary conditions exist in Nassau and in the Out-islands”. He also recommended improvements to the healthcare infrastructure that, he said, were of vital importance to a colony which presented itself as a winter health resort.

In 1922, 50 cases of typhoid were reported, although the CMO had been sending a steady stream of explicit complaints to his superiors about sanitary conditions in the colony that were simply ignored. For example, a letter to the Board of Health reported on conditions along Dowdeswell Street after some 300 households were inspected:

“My experiences during the past week have surpassed anything I imagined possible to exist, and twice owing to the odours and filth I encountered I became ill, and had to retire from the work for the afternoon...Chaos and filth predominated in most of the yards. Barrels unprotected and full of mosquito larvae, water tanks and wells not properly covered, privies open and not fly screened. In the majority of cases these were full of water, broken down and in dangerous proximity to wells and dwelling houses.”

The CMO called for a modern water and sewerage system. At the time, nowhere in Nassau had the convenience of piped water or sewerage – not even the hospital, where drinking water was drawn from wells or collected from the roof, while patients, like everyone else in the Bahamas, deposited their waste into a pail.

But Bahamians continued to suffer from endemic typhoid while the government ploughed ahead with hotel construction. The inevitable clash came in 1925 during construction of the Montagu Beach Hotel. The disease struck ten tourists over a period of several months and one of them died. This development threatened to tarnish the image of the Bahamas as a health resort, and the government sought expert advice from overseas.

In 1927, two key consultants arrived. That March, Arthur LB Plunkett landed, followed in September by Sir Wilfred Beveridge. Plunkett remained in the Bahamas for three years while Sir Wilfred spent only a month here, but both men left indelible marks.

Beveridge was a public health specialist recruited from the London School of Hygiene and Tropical Medicine. His brief was to investigate medical conditions on New Providence and to advise the government on needed improvements. He visited the hospital and met with the staff. He inspected the quarantine station on Athol Island, the public market and the abattoir. He also toured Bain and Grant’s Town over the hill.

The Beveridge Report, as Sir Wilfred’s momentous submission is known, devoted special attention to the problem of typhoid in Nassau. “The prevalence of typhoid fever, paratyphoid, dysentery, gastroenteritis and diarrhoea, especially infant diarrhoea, points to faulty sanitation and, in addition, a lack of efficient care of infants and children, especially under home conditions...The Chief Medical Officer for the last four years has adversely reported on the sanitation of certain areas, and has repeatedly drawn attention to the prevalence of typhoid, and has laid stress on the urgent need for radical reform.”

The report included a frightening warning: “The possibility of an explosive outbreak of typhoid fever must also be borne in mind. The writing on the wall is not to be disregarded. The effect of such an outbreak would be disastrous, not only financially, but also to the tourist traffic in such a way that its effects would long be remembered to the detriment of the Colony.”

So the government moved quickly to adopt the Beveridge Report recommendations, one of which was the construction of a sewerage and drainage system, which engineer Plunkett was assigned to build. At an eventual price tag of �250,000, it came at twice the cost of the waterworks.

Sir Wilfred also recommended that the CMO be given full executive control of the medical department, the hiring of additional sanitary inspectors and elevating their status by providing additional training. He caused the Board of Health to add dengue, paratyphoid fever and dysentery to the list of notifiable diseases and he brought about the launch of a campaign to educate the public on hygiene and infectious diseases.

Plunkett was 37 and a highly qualified civil engineer when he moved to Nassau with his wife and children. He had worked on the Oropouche Lagoon project in Trinidad and had been a member of the Sydney Harbour Bridge planning team. The government appointed him engineer-in-chief for the colony.

Plunkett oversaw construction of Nassau’s waterworks and sewerage system, reorganised the public works department, and supervised the widening and deepening of Nassau’s main harbour entrance channel. In addition to dredging a turning basin for cruise ships, Plunkett built the Prince George Wharf and the bridge that connected it to the city. He also supervised construction of Clifton Pier on the southwestern coast of the island.

In 1930, Arthur Plunkett returned to Britain a wealthy man and moved into a 110-acre estate in Devonshire. But within two years he had lost his fortune and his estate was auctioned off to pay bills. He then lived hand to mouth until he found work again, in Canada and later in Cairo. In 1937, Plunkett died in London of throat cancer.

Sir Wilfred Beveridge died in 1962 at the age of 97. By then, many of the public health measures he had recommended for the Bahamas were bearing fruit. And today, thanks in part to his advocacy, the Chief Medical Officer has considerable powers and is considered the head of the government’s public health administration.

The public water and sewer system that Plunkett built was slowly expanded. And by 1953 public standpipes serviced 71 per cent of New Providence households, with the remainder still dependent on wells. By 1973, more than 80 per cent of the island’s population had piped water inside their homes, while the municipal sewer system served 7 per cent of the population, with 26 per cent using outdoor privies and the reminder indoor toilets attached to a septic tank. By 2000 16 per cent of the population was connected to the municipal sewer system, with most of the reminder served by septic tank.

Despite these gradual improvements, typhoid continued to rear its ugly head, although with diminishing frequency. In 1965, there were ten reported cases, with one death. In 1973, there were just four cases. In 1986, typhoid was imported to The Bahamas as the nation hosted the Central American and Caribbean Games.

In the 1920s, the public medical staff for the island consisted of just four doctors and five nurses. Board of Health expenditure amounted to �43,006 – just over 8 per cent of the colony’s annual revenue.

Dr Ricardo (Carter) deGregory (an anaesthesiologist who died in 1998), was the first medical specialist born in the Bahamas. He was educated in London and served in the British Army Medical Corps during the war. In 1947, he returned home to a post at the Bahamas General Hospital.

The first Bahamians after deGregory were Cecil Bethel and John Lunn (internal medicine 1966), Granville Bain (orthopaedic surgeon 1970), Kenneth Knowles (ophthalmologist 1970) and George Sherman (obstetrician 1971). Bernard Nottage (gynaecologist), Perry Gomez (infectious disease) and Ronald Knowles (nephrologist) were the first specialists to return home following Independence.

Today, the Ministry of Health spends more than a quarter of a billion dollars a year overseeing more than 90 primary clinics distributed throughout the archipelago, and a new $100m expansion was recently added to the Princess Margaret Hospital in Nassau.

• What do you think? Send comments to larry@tribunemedia.net or visit www.bahamapundit.com.