The stroke crisis in Jamaica

Dr. Christopher Tufton 

Gleaner Archive – August 21, 2022

Cerebrovascular accidents, what are more commonly referred to as strokes, or brain attacks, kill Jamaicans at a higher rate than violence, even though Jamaican has one of the highest murder rates in the world. The annual number of deaths from stroke events, as shown by the most recent data, is over 2,400. Jamaicans die from strokes at a rate of 82 deaths per 100,000 people, almost twice the murder rate; this makes it the leading cause of death in the country. Death from stroke in Jamaica is also twice that of the cumulative incidence of death from the COVID-19 disease over the January 2020 to December 2021 period.

Death is the greatest concern but not the only one.

Stroke can lead to long-term disability and permanent brain damage. Over 7,300 people in Jamaica each year experience a stroke event. Most are ischaemic – a condition in which the blood flow (and thus oxygen) is restricted or reduced in a part of the body – due to a blockage of small or large vessels to the brain.

Furthermore, a stroke can create a financial burden on individuals and their families. Only 40 per cent of stroke patients, according to World Health Organization (WHO) data, recover sufficiently to return to work. This leads to loss of work, livelihood, and income, and the corollary negative effects those losses have on the stroke victim and his or her family, and sometimes, employees. The cost of treatment is high: estimates for 2021 show that post-stroke care costs, including speech therapy and anti-coagulants (blood thinners), amounted to approximately J$1.4 million over just a six-month period, per person. As a whole, the annual burden on Jamaican families is over J$46 billion. These costs and losses extend to the entire country: the stroke impact on GDP amounts to 2.42 per cent.

GLOBAL AND REGIONAL CONTEXT

The global and regional picture is no better than what obtains in Jamaica. According to the WHO, stroke is the second leading cause of death globally and the third leading cause of disability. Stroke affects over 100 million people globally and is responsible for approximately five million deaths each year. The WHO further notes that one in four people is in danger of stroke in their lifetime. While stroke is a global problem, low- and middle-income countries are disproportionately affected, with an estimated 70 per cent of strokes and 87 per cent of stroke-related deaths and disability occurring in low- and middle-income countries.

RISK FACTORS

Some risk factors for stroke can be changed, treated, or medically managed. These include high blood pressure, heart disease, diabetes, cigarette smoking, obesity, lack of exercise, high cholesterol, and alcohol abuse. While these are modifiable risk factors, other risk factors such as age (getting old), race (of African descent), gender (eg, men may have a higher incidence of strokes, but women suffer more from stroke’s effects), genetics, and a history of the disease are not. Where someone lives and their socio-economic status can also impact on the likelihood of them suffering from a stroke. History also factors in the explanation of the pervasiveness of stroke in the Jamaican population. Dr Azma Ali, senior consultant neurologist, has suggested that our history of enslavement is important in this regard.

Many risk factors for stroke are prevalent in the Jamaican population, particularly diabetes, high blood pressure, and obesity. Over 68 per cent of stroke victims are hypertensive, over 30 per cent diabetic, and some 27 per cent are smokers. The prevalence of high blood pressure is almost 40 per cent in Jamaicans over 15 years old, with a higher prevalence among women (36 per cent) compared to men (32 per cent). More than one in two Jamaicans (54 per cent) 15 years or older are also overweight, and we have seen a 68 per cent increase over a seven-year period in childhood obesity. Too many Jamaicans also do not engage in physical exercise.

POLICY INTERVENTIONS

The Ministry of Health and Wellness has been attempting, albeit with significant challenges, to address the problem of non-communicable diseases such as hypertension through both preventive and curative measures. Jamaica’s good primary care system will be strengthened by a reform programme that is intended to yield major transformations, changes that will benefit all Jamaicans, including and especially those at the community level and in remote areas.

In 2020, the Jamaica Stroke Alliance was formed by healthcare professionals and corporate Jamaica, and represents an important public-private initiative. We have attempted to implement acute stroke care interventions seen in efforts at IV Thrombolysis at the University Hospital of the West Indies. There is still more to be done.

CHALLENGES

Our senior consultant neurologist has pointed to a number of challenges. These include: the lack of stroke centres in our hospitals, difficulties for patients in rural areas, patchy ambulance coverage, limited availability of CT scanning, even in major tertiary hospitals, availability and expense of tPa (tissue plasminogen activator), inadequate number of stroke-trained physicians, nurses, and other healthcare workers, and people’s lack of knowledge of what to do when someone is having a stroke. We will be attempting to address these gaps by increasing the number of stroke care centres in Jamaica to meet the needs of the entire population, at the same time as we will work to address challenges with our ambulance service, improve our neuroimaging services, and our occupational and physiotherapy sessions. We will also build public awareness around the FAST method, which is important for detecting and responding to the symptoms of stroke. The acronym FAST refers to facial drooping, arm weakness, speech difficulties, and time. The first three are signs of a stroke, and the matter of time refers to how important it is to move as quickly as possible in getting help for someone experiencing a stroke.

Prevention is certainly always better than cure, and we are investing in prevention as a key policy intervention. This is an approach I have championed as minister. On the prevention side, the Ministry of Health and Wellness is implementing a number of programmes and policies to reduce people’s exposure to significant risk factors. We have conducted baseline studies on sodium and trans fats; we are using these studies to inform policies, one of which is Front of Package Label (FOPL). The FOPL enables consumers to exercise their right to know what is in their foods. We are working towards banning industrially produced trans fats, and towards designing an information campaign to encourage a more health-conscious society. We also have created a School Nutrition Policy. Additionally, we are in the final stages of passing legislation to control tobacco use in Jamaica, a major risk factor for stroke. The Jamaica Moves programme, which has gained critical regional and international acclaim, is another important measure in our efforts to boost prevention.

The most important initiatives, however, are dependent on each individual Jamaican, which include developing the habits of routine physical activity, knowing what is in their foods, cutting back on salt, sugar, and fats, and getting their annual check-up. The Government can only do so much to prevent people from getting strokes, and lowering stroke risks; Jamaicans must also take responsibility for their own health, and do what they can to avoid this common and often deadly affliction.