Social Determinants of Health in Trinidad and Tobago

“If the house began as a shack on vacant land and grew from there, what evidence does he have that his house is his?” I asked Father Harvey. The Padre asked him.

“My life,” said his parishioner, a wiry 60 something year old. “I was born there, lived there all my life, it’s mine.” All said with a toothy grin. He had had dental work, a little too obviously.

“If there is no official land tenure,” I asked the Padre, “what happens when someone dies? Who gets the house?”

“It goes to the children but it can be problem,” said the Padre. “There was a lady who had a job as a laundress who earned enough to improve her house with the help of family and neighbours. That one over there,” pointing to a two story weatherboard house perched on the hill side, painted bright pink, “when she died one of her sons, addled by drugs and mental illness, was causing great problems for the others. Another son, bigger and stronger, had to be firm. He sat on him,” metaphorically, if not literally.

Laventille grew up as a typical squatter settlement on a hill with a panoramic view of Port-of-Spain and the Caribbean beyond. As with the favelas of Rio de Janeiro, Laventille confounds the more usual pattern of wealthy communities having the altitude and the view. Many people from other islands, coming to Trinidad because of its oil wealth, with no home or connections in Port of Spain, found themselves in Laventille. The settlement shows its past. Makeshift shacks, survivors of the old days, are in odd apposition with improved dwellings. The whole is an improvised higglediggy-pigglediggy cluster of dwellings making its way sinuously up the hill, via the “palace” of the steel band, to the church at the top. Snaking its way down midst the uphill ladders is the drain, unseemly, unsightly, and unhygienic, especially when blocked with rubbish when the rains come. Interesting to know whether, in the real life social “game”, the downwards snakes or the upward ladders predominate. My guess is that many of the residents would say there is a floor effect – life can only get better. There is no way but up.

I had asked my host in Trinidad and Tobago, Dr Solamain Juman, President of the Commonwealth Medical Association, if it was possible to visit the informal settlement. He lives in Port-of-Spain close to Laventille, but has never been there. With its justly won reputation for violence, it is not safe for outsiders. But he asked Father Harvey, the Catholic priest whose parish is in Laventille to take us there. (“Stick with me, Solly,” I said, “and I’ll show you Port of Spain.”)

Father Harvey is an understated hero. He leads a community development centre in Laventille and wherever we go he knows someone. The morning began in downtown Port of Spain with a man picking himself up from the street to chat to Father Harvey. The chat began with the Padre’s asking after the man’s health and well-being and ended with the priest giving him some money. I cannot imagine that the priest’s charity is the way to solve the problem, but it was an expression of the feelings of the man. In one city block we walked past three men sleeping on the street at 7.30 in the morning. Apparently there is simply no political will to solve the problem of homelessness. Laventille had been a solution in the past.

Physically, the problems of Laventille could be solved. The houses are being converted from shacks to something more substantial before our eyes. There are connections to the electricity grid and a water supply, intermittent though it may be. It would not take too much to fix the drain and put in proper sewage.

Socially, it is another matter entirely. Each block of the area is controlled by a gang chieftain. Although “block” implies something readily discernible – not quite so obvious in this maze. A former prime minister had the entirely commendable idea of creating employment for the residents of Laventille. The implementation was not good. He gave control of the jobs to the chieftains. It became their power base. I’ll give you a job if you give me 20%. Some of the gang leaders became quite rich. Then, of course, there was the issue of drug distribution, again controlled by rival gangs. Hence a great deal of gang warfare with cycles of revenge killings. And, of course, no one was prepared to come forward as a witness. One man was grateful to the priest for helping having him jailed. The man is convinced that the protection of prison saved his life.

Controlling the violence is a major challenge. Each gang is likely to have a police officer in their employ. In addition, T and T is a major route for drugs from Colombia via Venezuela to the US and Europe. The cartels, with tentacles that stretch to Europe, are much involved in this international traffic. The local gang leaders may well be offshoots of this global network. Now, we are talking about serious money and power.

I have pointed to the conjunction of crime and ill-health, both socially determined. Here was the crime playing out. Unfortunately, Trinidad and Tobago has a rather dysfunctional statistical system and we simply do not have the data on geographical distribution of mortality rates or life expectancy. No one, though, seemed in any doubt that the people of Laventille would be less healthy than the average.

When the Minister of Health heard that I was going to visit Laventille he was keen for me to visit the district of “Bangladesh” in his Port of Spain constituency. I had wondered if he was trying to make an issue of ethnic differences. Laventille is Afro-Caribbean, and I assumed that Bangladesh was East Indian – these are the two big ethnic groups in Trinidad and Tobago. But although the two big ethnic groups are, in general, geographically separate, Bangladesh is mixed. It is altogether a more benign affair, smaller in scale and a lay out that approximately resembles city blocks. Again, the issue is more social than physical.

I did the rounds in Port of Spain. The Trinidad and Tobago Medical Association were marvellous hosts and organised a two day meeting to review the evidence on social determinants of health with a second day on what can be done, involving much of the health and social community. I did two Television slots, talked to the faculty of the Medical School, had meetings with the Minister of Health and senior officials at the Health Ministry, did a Webinar for the United Nations, talked to the American Chamber of Commerce – a challenge to them and me both. Finally I crawled on to an early morning flight to Panama, there to raise the health inequalities flag once more.

The Minister of Health said publicly: I am a Minister of Health Care. But I want my legacy to be that I become a Minister of Health. He will be the champion in government for social determinants of health.

Sir Michael Marmot

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