For Immediate Release

24th June 2019

Organisations from the Caribbean, US, UK and France have joined forces to launch a global campaign calling for a greater focus on fibroids.

The campaign highlights the need for a global change where all stakeholders (healthcare professionals, women and their families) are better informed about fibroids so they are empowered to take action to improve the health and wellbeing of the many women affected by this condition.

Specifically, organisers are calling for a greater awareness of:

• The symptoms of fibroids to facilitate an early and accurate diagnosis;
• All the treatment options available so that women can make an informed decision about the treatment that best suits their situation; and
• What actions women with fibroids can take to improve both their physical, mental and spiritual wellbeing

Fibroids are non-cancerous growths that develop in or on the outer surface of the womb affecting an estimated 171 million women worldwide in 2013 and, in 2010, fibroids were estimated to cost the health sector in Europe €163 Million.^1,2

Despite being very common it has been shown that there is a low level of awareness of fibroids and women don’t feel equipped to make an informed decision about their treatment^3,6.

Studies have also shown that fibroids are more common in black women with an estimated 80% of black women being affected⁴. In addition, black women are known to develop fibroids at a younger age, are more likely to develop larger, multiple fibroids, and tend to develop more severe symptoms⁵.  The reason for this is unknown, but it is thought to be a combination of genetic, environmental and lifestyle factors. Compounded experiences of racism and internalised racism are also seen to be contributory factors.

Fibroids tend to be overlooked because they are not life-threatening, but fibroids can significantly affect a woman’s quality of life leading to both physical and psychosocial effects.  It’s important that a greater focus is placed on fibroids to ensure that more research is conducted to fully understand this important women’s health issue, and to ensure that more support and information is available that empowers all women with fibroids.

Julia Mandeville, Public Health and Advocacy Manager, Barbados Association of Endometriosis and P.C.O.S explained that:

“Women’s health has not received the level of attention warranted. We stand now, as a collective, understanding that the gaps in women’s health care can lead to significant public health problems if left unaddressed. One such problem is the lack of awareness and education surrounding menstruation and menstrual health disorders which research has shown, negatively impacts the psychological, physical, social and financial wellbeing of those diagnosed with these conditions. Thus, it is critical that women and girls are equipped with relevant, evidence-based information to become more competent and confident advocates of their health, and obtain the resources and treatments needed to improve their health-related quality of life.”

Abi Begho, Founder of Lake Health and Wellbeing, based in St Kitts and Nevis said:

 “For too long women with fibroids have been neglected and it’s time for society to step up and address this. We need to ensure that women with fibroids have easy access to accurate information, appropriate support and a high standard of care to improve their wellbeing.”

Whilst Dr Sydney Dillard, Associate Professor at Du Paul University stated:

“Throughout the world fibroids tend to be trivialised without a real appreciation for the way fibroids can impact a women’s quality of life. The impact is wide-reaching affecting women’s physical health, mental wellbeing, relationships and creating challenges in the work environment. By everyone being better informed we can ensure early diagnosis; prompt, appropriate treatment and the chance to adequately address the psychosocial impact of fibroids.”

The organisers behind this campaign are encouraging women to access more information by visiting the campaign page and to contact the organisations in their region if they would like further support.

Ends

Notes to Editors

This is a joint campaign of the following organisations who raise awareness, provide information and support to those who have been affected by fibroids and advocate on behalf of women to improve the quality of care.

Barbados Association of Endometriosis and PCOS – The Barbados Association of Endometriosis and PCOS is a registered non-profit organization in Barbados which seeks to educate citizens and advocate for those who have Endometriosis, Polycystic Ovarian Syndrome and other pelvic conditions (including Uterine Fibroids).

Website: http://endoandpcosbb.com/

Email: julia.mandeville@endoandpcosbb.com

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CARE About Fibroids – CARE About Fibroids is a Washington, DC-based non-profit whose mission is to elevate uterine fibroids as a women’s health issue and drive change. Bringing together many of the nation’s most respected women’s health advocacy and policy-focused organizations to advance solutions, CARE About Fibroids is a catalyst for increased awareness, research and education about uterine fibroids, leading to earlier diagnosis and improved treatment.

Website: http://www.careaboutfibroids.org

Contact: http://www.careaboutfibroids.org/contact.html

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Fibroid Awareness Trinidad and Tobago – is a registered NGO based in Trinidad and Tobago that focuses on educating and empowering girls and women through advocacy and driving awareness on fibroids and other issues of the uterus.

Website: https://www.ttconfidenceproject.org/

Email address: factt2014@gmail.com

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Fibrome Info France – Fibrome Info France is the first patient association in France that informs, educates and supports women with uterine fibroids. The association was born out of the lack of information and awareness on this disease which affects 30 to 60% of women of childbearing age and is the main cause of removal of the uterus in France. Fibrome Info France has a triple mission:

• Information and awareness on uterine fibroids
• The support of women with fibroids in the care process
• The implementation of actions to improve the management of fibroids

Website http://fibrome-info-france.org/

Email address: contact@fibrome-info-france.org

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KMT Rising – KMT Rising is a UK-based organisation that is dedicated to the optimum health and wellness of all women around the globe; ensuring that their personal, emotional and health-related needs are catered for through a range of bespoke holistic packages. They also provide very unique Fibroid products on sale internationally:

• Fibroid Assessment Check List
• So you have Fibroids – Next steps guide
• Get yourself checked for Fibroids guide

Website: https://www.kmtrising.com/

Email address: kmtrisingltd@gmail.com

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Lake Health and Wellbeing – Lake Health and Wellbeing is based in St Kitts and Nevis and aims to improve the health and wellbeing of their local, regional and online community through health promotion, public health interventions, conducting research and offering information and support to those with concerns about their health. They have a fibroids information and support program which consists of events, publications, campaigns and more.

Website: www.lakehealthandwellbeing.com

Email address:  info@lakehealthandwellbeing.com

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Noire Wellness – Noire Wellness is a UK-based organisation that takes a public health and wellbeing approach to reducing health inequalities through culturally sensitive interventions

Website: www.noirewellness.com

Email address: info@noirewellness.com

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OH Counselling Services – OH Counselling Services is a UK-based organisation that provides one-to-one Counselling, EMDR Therapy, Group Therapies, Workshops and Seminars.   Their services are offered to adults, young people and all groups from different backgrounds and walks of life.

Website https://www.ohcounsellingservices.com

Email address: ohservices@counsellor.com

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The Fibroid Forum – The Fibroid Forum is UK-based and raises awareness, shares information, promotes women’s wellness and supports fibroid sufferers

Email address: thefibroidforum@gmail.com

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References

1. Theo, V., et al. (2015). Global, regional, and national incidence, prevalence, and years lived with disability for 301 acute and chronic diseases and injuries in 188 countries, 1990–2013: a systematic analysis for the Global Burden of Disease Study 2013. Lancet 386 (9995), pp. 743-800
2. Hunt, P., Sathyanarayana, S., Fowler, P. and Trasande, L. (2016). Female Reproductive Disorders, Diseases, and Costs of Exposure to Endocrine Disrupting Chemicals in the European Union. The Journal of Clinical Endocrinology & Metabolism, 101(4), pp.1562-1570.
3. Lake Health and Wellbeing (formerly known as The Lake Foundation), (2014). Understanding the Needs of Women With Fibroids.
4. Wise, L. and Laughlin-Tommaso, S. (2016). Epidemiology of Uterine Fibroids. Clinical Obstetrics and Gynecology, 59(1), pp.2-24.
5. Radmila S., et al.  (2016).  Epidemiology of Uterine Myomas: A Review. Int J Fertil Steril, Volume 9 (4), pp. 424.
6. All-Party Parliamentary Group of Women’s Health, (2017). Informed Choice? Giving Women Control of Their Healthcare.

On 1^st June 2019, we’ll be hosting a webinar on the emotional impact of fibroids, an issue that is often neglected, but we believe this is a very important area to focus on.

When many of us think about fibroids and its effects, we tend to think about the physical and medical symptoms, such as heavy menstrual bleeding, prolonged periods, abdominal pain, anaemia and back pain.  The emotional and psychological impact of fibroids is not at the forefront of women’s minds or even their doctor’s, but it is very important that this is addressed to ensure a complete recovery.

We first identified the importance of exploring the emotional impact of fibroids in 2014, when we conducted a survey to understand the needs of women with fibroids. As we were analysing the results of the survey, we noticed that a significant number of women were describing how living with fibroids was affecting their mental wellbeing. For example, women said the following:

 “I have hated life at times because of fibroids. I feel like I am being punished for something.”

“Depression from feeling that my only options were drugs or surgery”

“Fear of not being able to have children”

“Just a constant fear of what they could become”

As a result of this, we started to explore this issue further by speaking to women who attended our events and soon realised that this was a much wider problem. To compound this issue there was little information available, at the time, about the emotional impact of fibroids and no services to support women in addressing these issues.

We decided that going forward, the emotional and psychological impact of fibroids would be embedded in all our work. This would ensure that women are able to identify, understand and address the emotional impact of fibroids. We hope this will allow women to get help promptly and develop the resilience and skills required to improve their mental health, should it be affected by their experience with fibroids.

So far, we have organised two conferences aimed at women with fibroids, one in London and one in St Kitts, and both covered the emotional impact of fibroids. We worked with accredited counsellor Olivia Haltman to develop a fact sheet on this topic and we’ll soon be updating our fibroids booklet to include information on fibroids and women’s wellbeing. We were also delighted to see that Olivia Haltman has developed the first online course on the emotional impact of fibroids after our work together revealed this was much needed.

Our latest initiative is our webinar on 1^st June which will feature Olivia Haltman, founder of OH Services and Jo-Ann Hamilton, founder of Rare Birds.

In this webinar, Olivia will take attendees through how living with fibroids can affect a woman’s mental health and how women with fibroids can improve their emotional wellbeing.

We’re also honoured to have Jo-Ann Hamilton, the Founder of Rare Birds, sharing her 10-year experience with fibroids, how this experience affected her mental wellbeing and how she overcame this challenging journey.

If you’ve been affected by fibroids, you are very welcome to attend this webinar. register for this webinar here or if you have any questions, please email us at events@lakehealthandwellbeing.com

From 2^nd April to 7th May 2019, we facilitated our first chronic disease self-management course in St Kitts giving us the opportunity to support members in our community who have been affected by non-communicable diseases (NCDs).

Data has demonstrated that NCDs are becoming an epidemic in St Kitts and Nevis with 83% of deaths in the Federation being due to these conditions. To prevent these premature deaths and ensure that those living with an NCD can live well and have a good quality of life, support, information and guidance are required.

Providing patients with self-management skills is an effective and empowering way to ensure that those affected by a chronic disease can take control and improve their health and wellbeing. The Chronic Disease Self-Management Course helps us achieve this outcome.

The course that we facilitated is part of the Stanford University Chronic Disease Self-Management Program (CDSMP). This is an evidence-based prevention and health promotion program that addresses common issues faced by people with chronic conditions. The program has been implemented in 19 countries showing several benefits including:

• Improved wellbeing
• Improved health of participants
• Fewer hospitalisations
• Fewer days spent in hospital

Last year, we took part in the CDSMP training program which was delivered by the Ministry of Health in St Kitts. We were honoured to have come through the process and are now certified CDSMP facilitators allowing us to implement a free program of support for members in our community with an NCD.

Over the six-week period from the 2^nd April to 7^th May, we were delighted to guide our 18 participants through key self-management techniques. These techniques included action planning, problem-solving, decision making, medication management, communication skills, pain management, healthy eating, physical activity and more.

What we like about the course is that it is very interactive. Participants had the opportunity to take part in various activities, share their experiences, learn from one another and support each other. There was also homework every week to ensure that participants could start practising their self-management techniques immediately in their day-to-day life. It was wonderful to see and celebrate their successes every week.

We had a very engaged group who were a pleasure to work with. They got involved, asked questions and were keen to make the necessary changes in their lives to improve their health.

Facilitating this course has been one of the most rewarding experiences we have had in a long time. It was so touching to hear participants share how their lives have been impacted by the course. We look forward to seeing them continue to make great progress in taking control and more effectively managing their health.

A big thank you to everyone who attended and if you live in St Kitts and have been affected by a chronic illness like diabetes or high blood pressure and would like to attend a chronic disease self-management course, please do get in touch with us by email or call 765 8702

Our next 6-week course is due to start in July, all are welcome to attend.

“Thank you for the life lessons you have shared. Anyone who attends this course will never be the same again. The teachings will always be on one’s mind and heart. We must make a change! Eating, exercising and managing our lives better and being in control, this is an awesome feeling” – CDSMP Course Attendee

When it comes to the health and wellbeing of African people both on the continent and in the Diaspora at large,  there are a number of challenges and health inequalities that exist. These inequalities include the black community having poorer health outcomes, being at an increased risk of developing a number of diseases and not always having access to adequate support to cope during periods of ill-health. In order to address these issues, many have suggested that the black community come together to develop solutions for us, by us. Before exploring unity as an approach to tackling some of these challenges,  it’s useful to look back through history to understand the concept of unity so that if we are to come together, we develop partnership models that are most effective. 

In today’s blog, we hear from guest blogger IC Blackman who takes us through the history of African unity and encourages us to think deeply about this concept.

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One cannot deny the importance of an accurate grasp of history, particularly ancient history, for possessing a deeper understanding of our position, or lack thereof, in the world. Much has been argued about the relevance and authenticity of the terms ‘black’ or ‘African’ to describe peoples richly melanated in skin – for the purposes of demonstrative example as to the challenges of the realization of unity, we hold no fast consensus as to what we would prefer to be called. Arguments rage – all valid, I might add – for and against nomenclature that honours our history and invaluable contributions to the development and advancement of civilization. This begs the question: did we ever have a consensus, and if so, when, and how does this impact our concepts of Pan-Africanism, or black unity, today? The term to which one leans, whether black, African or some other, may be telling about how one views oneself vis-à-vis the world: identity, links to a certain landmass, being referenced as a colour or caste, and the legal implications and historical connotations of the latter.

To examine this predicament of a consensus beyond merely what we choose to be called, but in terms of the more pressing issue of unity, we ought to start from the beginning, or as close to the beginning as we can. Because of its startling symbolism, I choose to start with one of the most recent supercontinents and also the best known, Pangaea. There were other supercontinents that preceded it, but the further back I go, the more pushback I may get from certain scientific quarters about the presence of ‘thinking’ man in those times. Personally, I believe Homo sapiens sapiens is much older than the record books will allow.

As I describe certain geological phenomena in this post, one should also in tandem remember the Law of Correspondence. Hold tight – there is method to my madness.

The earth’s outer shell is made up of plates. Most activity occurs where plates meet or divide. Plates move in three ways: convergent (moving towards each other, even colliding in some instances), divergent (moving away from each other), and transform (where plates slide past each other). Movement of plates produces volcanic eruptions, underwater volcanoes, earthquakes, and, specifically by convergent plates, mountain ranges; thus, there are several cycles of creation and destruction, periods of volatility and rest, all natural, all inevitable, all a part of existence. The most volatile processes create new forms, it would seem, adding to the topographical features of the earth – mountains and valleys, the highs and the lows. Movement can occur slowly or violently, changing the architecture of Planet Earth. Each continent as we know it today rests on these plates, that is, tectonic plates. They are in constant motion and interaction, a process called plate tectonics.

Using geological time collapse, let’s agree on a single landmass called Pangaea – a supercontinent, consisting of lakes and rivers, which existed before the latest continental drift, i.e. the divergent movement of major plates that created the large and distinct landmasses we call continents today, in their latest configurations and geographical locations. Let us also agree that easy human migration out of Africa was facilitated by the most recent supercontinent Pangaea and its many incarnations prior to the most recent and significant continental drift. We can further argue about the origins of the name Africa, but if we are to have a consensus about nothing else, it should be about coming to terms with the usage of this epithet.

Let us also observe the signature feature of African civilizations to form along rivers, the best known being the Nile Valley civilization, from its origins in the south heading down the Nile to the north, its pinnacle manifesting as Kemet or Egypt. It is important to note here that rift valleys occur where a continental landmass is ripping itself apart – this happens in geological time. Modern Africa, i.e. the continent we know today, is projected to split along the Great Rift Valley system sometime in the very distant future, forming a double continent. In other words – change is supreme, movement is inevitable.

And like nature, like tectonic plates, we as a people are in constant motion, a constant state of flux, producing what I call the Dispersion Factor. This first manifested as migration to all continents before they were so-called, and the subsequent development of distinct civilizations on these landmasses after continental drift. One mindset, but a myriad of manifestations. Physical unity, then, would seem to go against this natural tendency towards dispersion and dissemination, as opposed to the more challenging but urgently needed spiritual and mental/thought unity.

Encoded in the DNA of African peoples may be the genetic roadmap for dispersion and multicentricity. We know that Africans as a group have more variations in their DNA within their group than between Africans and other groups. This phenomenon of what I call genetic non-cohesion may well be the reason why breeding farms in chattel slavery in the New World, which used a high degree of consanguinity, could produce ‘normal’ populations for far longer than logic would dictate. It could also be the reason why as a group we will adapt, include, and assimilate with ease. The downside is that this will occur in hostile as well as conducive environments, the former producing cultural distortion and disintegration, the latter producing cultural catalysts. There is no doubt that both processes have global knock-on effects and implications. We do ourselves a disservice to underestimate the profound effect of our state of being, both positive and negative, on the planet at large.

It’s very conceivable that the theory of Pangaea holds true – at the very least, it makes perfect sense. If you look at all the continents on the planet, they do appear to potentially fit together, much like the pieces of a jigsaw puzzle. Let’s continue to entertain the Law of Correspondence here. It is also conceivable that man existed at the time of Pangaea, or a forme fruste of Pangaea, and migrated outward from a pivotal focal point of creation. I call this point, adapting a term from embryological science, the pluripotent stem cell, from which all major cells of the human body originate – the pluripotent locus, or the progenitor cell from haematological science, the mother cell of all haematological bodies (red blood cells, white blood cells, platelets, etc.). These cells, being multi-hued and multi-functional, together form an efficient body system. That pluripotent locus, or primogenitor cell, we know today as the continent of Africa, remembering that it was once part of a contiguous landmass. For those who want to call it the Garden of Eden, I have no ready rebuttal. Whatever we choose to name this pivotal location, we must appreciate that now these disparate landmasses have been christened continents with bestowed names, some of which have changed over time, e.g. India was once Hindustan, and perhaps the continents were perceived differently prior to continental drift and after it, including in name.

Map courtesy National Geographic

Anthropological evidence and copious historical data would indeed confirm an ‘African’ presence on what we now know as the seven continents. Perhaps more accurate would be First Man and Woman, Ancient or Aboriginal Peoples. Genetics would suggest they were very diverse people.

Herein lies Ponder Point No. 1. This multifocal presence and the early civilizations it birthed aren’t as well-known as one would think. It certainly isn’t taught on the scale it should be, despite the evidence to support it. Africans therefore have been as a group multicentric, dispersed, and migratory from their very inception, and have had varying phenotypes, and within recent times, lighter hues in certain regions of the Earth. They set up civilizations wherever they landed – the Indus Valley civilization, the Nile Valley civilization, the Olmec civilization – and kept it moving. This has been a modus that has taken many incarnations throughout history, and up until modern times, it does not seem to have slowed, though immigration laws have had an impact on the freedom of movement enjoyed in antiquity.

The push and pull factors that sustain such movement are however very different, perhaps more unfavourable, but not at all exclusive to negative experience, than in the past – pioneering waves of voluntary, exploratory migration vs the more recent exploitative waves of forced migration. Ponder Point No. 2 eagerly cranes its neck for keen observation – the concept of unity, especially physical unity, I would therefore challenge further, is a very tenuous one. We tend to use ‘Africa’ as one would a collective noun, but there would be no harm in saying one was African and Senegalese, for example, or African and Ghanaian, or African and Guyanese, understanding that as one leaves the continent more qualification is required. You may also want to add Christian or Muslim, for example. We should be used to complexity by now. We’ve been here from the beginning. Our history is complex – multilayered, multidimensional, multifocal, and multiethnic. We’ve been here from the beginning – it is complex. And that complexity lends itself to both confusion and a timely consecration. One would be more inclined to speak of, and place greater store on, a core African mindset with its many global manifestations, i.e. cultural diversity even within the collective – on the mother continent of Africa, and in the Diaspora at large. Here, we may need to entertain further clarification and qualification of an ancient vs a modern Diaspora.

And while we’re at it, we may also need to make a distinction between ancient Africans and modern Africans (an ever-evolving entity). A distinction also needs to be made, using a chronological timeline, as to when this conversion – ancient to modern – took place. I would set that time at 1492 and the expulsion of the Moors from what we now know to be Spain – the Iberian Peninsula may be a more accurate term. For this pivotal historical event would generate a series of further historical events – the Spanish Inquisition and the Crusades, chattel slavery, colonialism and neocolonialism. All these would produce the modern African, who would be designated many names and pseudonyms through space and time, all with a growing patina of mistrust, disrespect and contempt (I’ve excluded some for good reason) – Ethiops, Ethiopian, Maure, Moor, blackamoor, Negro, black.

Superimposed on this, and perhaps contributing to our wounding in 1492, subsequent conquest and present predicament, we must also appreciate ancient African civilizations in decline, their peak in Kemet (Egypt). These would include the fall of the empires of Kush, Mali, Benin, Axum and Songhai and the kingdoms of Ghana and Mossi, and the phenomenon of infighting amongst nations and their weaker neighbours, a growing insularity of thought and the emergence of maladaptive forms of self-preservation in response to repeated foreign invasion. This decline, and it would happen over millennia, would also herald a new African, or modern African, and a new Africa. Stronger nations usurped weaker ones, and their captives, the spoils of war or POWs, created fodder for the transatlantic slave trade. Empires fell due to loss of life and loss of intellectual property, the draining of resources, human and mineral, brain and brawn. We, however, seem to have moved from physical wars and battles to ideological ones with physical elements and consequences – wars of class, wars of colour, wars of identity, fueled by hubris, greed, deception, envy and a forgotten self-knowledge.

All of these could be significantly ameliorated if we saw ourselves as privileged beyond the banal or the physical. One would argue these character chinks and ideological imbroglios were with us before 1492 – that we grappled with these human failings more and more as civilizations declined over time – but were exacerbated, perhaps entrenched by the Maafa. If one studies African mythology deeply in all its facets, for example Yoruba or Akan – the roadmap that would assist us in this journey of becoming whole or indeed returning to wholeness – they all address these human foibles.

One would argue that the first real unification or semblance of physical unity occurred in the West, i.e. the Americas, and under horrific conditions – nations and empires gelling under the remit of one plantation and one master. Ponder Point No. 3: is there any doubt, therefore, as to why unity is such a challenge? In a thriving plantocracy, betrayal was rewarded – the Meritorious Manumission Act of 1710 – while gathering in public was punishable by death, that is, laws prevented congregation. Non-cohesion was ratified in law.

But was ancient African success ever leveraged on physical unity, or was it a unity of mind and principles, a spiritual unity – a quantum mindset/thought, intangible yet effective? Certainly, unity, if it is to occur at all, would not be sustained if forged from the negative – anger, hate, dissatisfaction or a preoccupation with adversity, that is, under duress. (The adversity, however, should be recontextualized as a perfecting catalyst, refining thought back to the depths of the visionary, the mystic and the natural scientist. Challenging? Absolutely.) But take heart, this volatile process of unification seems to mirror the earth.

Should we be seeing unity as the Ancients would suggest, that it isn’t about the physical at all? Is the challenge mental, internal, and will it eventually manifest naturally in our external world? Is this a call to transcend the physical domain and its vicissitudes and aim even higher, to a more symbolic existence beyond the mundane, beyond the constraints of a dominating cultural lens? Perhaps we fell low to rise higher than we’ve ever been – ascension. Perhaps it’s all in the mind – we should be in one mind. The time is now. If we don’t get it, who will?

More and more it would appear that as Africa and Africans go, so goes the earth. This is our life-altering inheritance as the Mother and Father. If there is to be any pre-occupation, it should be, how do we honour the Mother and Father? What does it look like, feel like, taste like, sound like? Is it truly all in the mind? How we perceive it may be everything. And here’s the good news – despite the Great Rift Valley divergence, the earth’s tectonic plates continue to move, their motion slowly bringing the continents together again. Pangaea will be re-formed, a new supercontinent by a different name that may bear little resemblance to the Pangaea of old. Symbolic? Think about that Law of Correspondence and rest your mind there – as within, so without; as without, so within. It would seem feasible to conclude that continental drift is as inevitable as its reversal. How quickly or slowly the process unfolds may be within our grasp; certainly the process of continental rift is. This is not a hypothesis, but an inevitable process that will also reverse, and at a pace we determine. You don’t have to agree, just consider.

©2019 IC Blackman

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We would like to say a big thank you to IC Blackman for this very insightful blog piece. If you have any comments or questions, please leave them in the comments section below.

You can find out more about IC Blackman and her work here or you can follow IC Blackman on Twitter.

From 29^th April to 3^rd May 2019, the counselling department at Verschilds High School hosted their Health and Wellness Week and we were delighted to have been invited to take part in two of their planned events.

On 29^th April, we spoke, bright and early, at the school’s assembly on the topic of stress management. During our 15 minute presentation, we talked about what stress is, what types of situations cause stress, the impact of stress and how we can manage stress.

We encouraged students to think about their own personal situations, especially during this exam period, to see how they can address any stressors that may be affecting their wellbeing and provided tips on managing these, which included – identifying stressors, elimination/delay of stressors, preparation, stress relief techniques, building resilience and getting support.

We had a great session with the student body and therefore were very happy to return on the 3^rd May for their health and wellness fair.

During their health and wellness fair, we set up a stall and promoted living a healthy lifestyle. We spoke to students and staff about the importance of children and teenagers getting enough exercise and physical activity (WHO recommends 60 minutes per day), drinking more water, eating 5-7 portions of fruit and vegetables per day and cutting down on sugary drinks.

We had information showing how much sugar is in many popular soft drinks and students and teachers were shocked to learn that one can of coke contains 8 teaspoons of sugar.

To encourage children to swap their unhealthy snacks for healthier snacks, we had some lovely mangoes for staff and students to sample and this included some dried mangoes. Dried mango is a great alternative to candy and chocolate and it tastes great –  the students (well…most of them) loved it.

We also held a competition where we asked students how many minutes of physical activity children and teenagers should take part in every day and three lucky students won a comic book – congratulations.

Finally, it was great to connect with the other stallholders, some of whom were familiar faces, such as the team behind Mother Becky Bush Tea and Sugar Town Organics. It was nice meeting the Gideon  Force Organic Agriculture  Cooperative, Close to Nature and the Drugs and Substance Misuse Team and learning about the great work they are all doing.

We had a great time at Verchilds High School and would like to thank the staff for their kind invitation and both staff and students for their warm welcome, visiting our stall and asking some great questions.

On 26^th April, we attended the Ministry of Health’s focus group on sugar-sweetened beverages (SSBs). This event was part of the Ministry’s consultation process to get feedback as well as inform the public and key stakeholders on the progress being made to develop a national SSB policy.

This event was a follow-up to the Ministry’s SSB National Consultation which took place in November 2018 and provided an update on the policy imperatives that were presented last year.

From the focus group we learnt that the updated policy recommendations are:

• A 32% excise only tax on SSBs
• The tax will apply to calorically sweetened beverages including carbonated drinks (sodas), sweetened carbonated water, sugar-sweetened juices, sports drinks, energy drinks, tea and coffee drinks, sweetened milk/milk alternatives, milk powdered blended drinks, powdered drink mixes and drink mix syrups
• Excluded from taxation would be fresh fruit juice (no sugar added), unsweetened milk/milk alternatives, infused water, unsweetened carbonated drinks and non-caloric sweetened drinks
• Alternatives to SSBs will be suggested to the public. These would include: fruit/vegetable infused water, plain water, unsweetened carbonated water, unsweetened herbal (bush) tea and fresh-poured coconut water (unsweetened coconut water)
• The tax revenue will be used to provide: a water infrastructure, water fountains in schools, reusable water bottles in schools, healthier school meals, public health campaigns, National Health Insurance, implementing a marketing ban to children, policy development for safe school zones and to improve agriculture education especially in primary schools

What About Artificially Sweetened Beverages?

One area still to consider, which is an interesting one, is whether to tax artificially sweetened beverages (ASBs).

ASBs are drinks that have been sweetened with non-nutritive sweeteners which include saccharin, acesulfame, aspartame, neotame, sucralose and stevia.

The field of ASBs is a confusing one. It has been hard to answer the simple question of whether they are beneficial or not. Therefore  WHO funded a large global study to answer this question, but this still didn’t answer the question with health officials stating the following:

“The inconclusive results of the review of the evidence suggest that we need to see better, bigger and longer-term studies of non-sugar sweetener use, to find out for sure their benefits and risks. The review suggests that there could be some benefits in terms of preventing weight gain, but the evidence so far is not strong and does not show consistent enough results to be sure.”

Whenever there is doubt, we recommend that the public keeps things simple and uses products where there are clear health benefits and there is no doubt. The best option at the moment is to consume unsweetened beverages.

In the meantime, the Ministry will evaluate whether ASBs should be taxed as part of their SSB policy.

 Why Tax SSBs?

Childhood obesity is a significant challenge here in St Kitts and Nevis. A PAHO report revealed that 33% of secondary school children in the twin-island state were overweight and 14% were obese. More recently, in 2017, a UNICEF report published that 26% of children in St Kitts and Nevis are obese.

SSBs have been linked to weight gain and obesity. Therefore, the taxation of SSBs has been utilised throughout the world as a method of tackling obesity by creating a deterrent which leads to a reduction in the purchase and consumption of SSBs.

Taxation of SSBs has three important aims. The first it to incentivise manufacturers to reformulate or replace their products to create healthier options, the second is to deter the public from purchasing and consuming SSBs by making them unaffordable and the third is to raise funds from the tax revenue that can be used to support initiatives aimed at improving the health of the public.

Next Steps

The Ministry of Health will now take all the feedback from their consultation, focus group and other engagement activities to draft a policy which will be circulated to stakeholders for any final comments before it is sent to Cabinet for approval.

References

1. UNICEF, Situation Analysis of Children in the Federation of St Kitts and Nevis, UNICEF Office for the Eastern Caribbean Area and the Government of St Kitts and Nevis, Christ Church, Barbados, 2017
2. PAHO, Health in the Americas, 2012: St Kitts and Nevis, PAHO, 2012

March was International Women’s Month, Women’s History Month and International Women’s Day, the perfect opportunity to put the spotlight on the pressing issues that women face every day.

International Women’s Day was on the 8^th March and this year’s theme set the tone for the month.

This year’s theme was #BalanceForBetter and aimed to stress the importance of creating a gender-balanced world.

This campaign didn’t just begin and end in March but continues all year long. The team behind the  #BalanceForBetter theme is hoping that over the year society can work towards gender-balance in all sectors so that we can see more gender-balanced boardrooms, governments, media coverage, wealth, businesses and more.

Since March, organisations throughout the world have launched their own #BalanceForBetter campaigns to either explore what needs to be done to create a more gender-balanced world or to showcase women in various fields who are creating gender-balance through their work. One such organisation was Noire Wellness and we were delighted to have been featured in their campaign (thank you!).

Noire Wellness’ campaign focused on balance in the wellness sector. Their campaign featured women in this sector, showcased their work and explored what balance means to them.

We took the opportunity that this campaign presented to call for gender-balance in public health approaches.

Having spent the last few years slowly developing a fibroids health and wellbeing programme, we have seen first-hand the effect of not creating gender-balance in public health.

By not taking gender into account many health conditions, particularly gynaecological conditions,  are overlooked with their impact not being fully appreciated. This means that women with conditions like fibroids lack the information and support that they require to make informed decisions about their treatment, to improve their own health and wellbeing and navigate the many challenges that living with fibroids presents. Furthermore, there is a lack of research and a lack of understanding of the causes of fibroids.

We aren’t the only ones calling for a gender-balanced approach.

We recently attended a webinar on women and non-communicable diseases (NCDs)  and it was stressed that there needs to be a more gender-balanced approach to public health to avoid placing women at a disadvantage.  One of the speakers explained that when it comes to medical research the male body is well-known, most research is conducted on white men and data is simply (and with a false expectation) extrapolated to women.  This means there is no appreciation of the biological differences that exist between males and females and how this impacts health. The speaker stated that, for example, we now know that:

• Women’s lungs are smaller than men’s which has an impact on women’s risks of developing lung diseases and the type of lung diseases that women develop
• Women’s hearts are smaller
• Women are more likely to develop a different form of bowel cancer
• Women process alcohol differently

These gender differences, and others, have gone unnoticed by the medical profession and this has led to misdiagnosis and inappropriate treatment. This would not have been the case if there was a gender-balanced approach in the health sector.

More work is needed to address the gender imbalance that has been created in public health and medical research. By creating gender-balance in these areas we can begin to address the gender inequalities that exist and ensure that we can improve the health of all women.

At the end of last year, we started developing our two-year strategy after a year of exploring the public health landscape in St Kitts and Nevis, and the wider Caribbean region.

After careful consideration, we settled on focusing on women’s health and the prevention of childhood obesity.  In a previous blog we explained why we decided to focus on women’s health and today we’ll discuss why we’re also going to focus on childhood obesity.

 Why Childhood Obesity?

Childhood obesity is a major health issue in the Caribbean with 1 in 3 children being overweight or obese.  The rate of childhood obesity in the Caribbean is higher than the global average and is reported to be on the rise.

Being obese and overweight in childhood is linked to the development of several health issues such as type 2 diabetes and hypertension, and it also negatively impacts a child’s mental health. These health issues can follow children into adulthood with children affected by obesity, or who are overweight, having an increased risk of becoming overweight or obese adults and developing non-communicable diseases (NCDs) such as cancer and heart disease in later life.

Childhood Obesity in St Kitts and Nevis

Childhood obesity is a significant challenge here in St Kitts and Nevis. A PAHO report revealed that 33% of secondary school children in the twin-island state were overweight and 14% were obese. More recently, in 2017, a UNICEF report published that 26% of children in St Kitts and Nevis are obese.

Data has demonstrated that NCDs are becoming an epidemic in the Federation with 83% of deaths in St Kitts and Nevis being due to NCDs. We must do something about this to prevent our citizens from dying prematurely and one approach is to tackle childhood obesity.

To combat childhood obesity, we have to ensure that children adopt a healthy lifestyle and we also have to create a healthy environment at schools, in homes and within society so that children can make healthy choices.

Tackling Childhood Obesity in the Caribbean

The Healthy Caribbean Coalition (HCC) is a civil society member organisation that was established to combat NCDs and their associated risk factors.

One of their key focus areas is childhood obesity prevention and as part of their work, they published their Civil Society Action Plan for Preventing Childhood Obesity in the Caribbean. This plan provides guidance on how HCC members (we are a member) can strategically address this significant health challenge in their specific island states.

Lake Health and Wellbeing is thus aiming to align its strategy for childhood obesity prevention in St Kitts and Nevis with the following HCC priority areas:

• Trade and fiscal policy (taxation of unhealthy foods)
• Nutrition literacy (mandatory front-of-pack-labelling of foods)
• Early childhood nutrition (enacting legislation related to the International Code of Marketing of Breast Milk Substitutes)
• Marketing of healthy and unhealthy foods to children (Banning the marketing of unhealthy foods and beverages to children)
• School and community-based interventions (Banning the marketing and sale of unhealthy foods and beverages in and around schools, mandatory physical activity in schools)

What We’ve Done So Far

We’ll be taking our time and starting slowly with the implementation of our childhood obesity prevention strategy. We’re delighted to say that we have started making some progress and have achieved the following:

• We took part in the HCC’s regional campaign which aimed to raise awareness of childhood obesity in the Caribbean and influence the region’s leaders to champion and implement critical policies that will improve the health of our children and reduce childhood obesity. One of the key parts of this campaign was their childhood obesity prevention petition (call-to-action) which called on our Heads of Government to enact key policies and legislation which have been demonstrated as effective measures to combat childhood obesity. We got involved by gaining support for the HCC’s petition in St Kitts and raising awareness of this issue through a four-part podcast series. You can find out more about this here

• We’ve started advocating for front-of-pack nutrition labelling as this is an easy way for parents to assess the health of the foods they purchase. We submitted a response to the CARICOM Regional Organisation for Standards and Quality‘s consultation on pre-packaged food labelling which included front-of-pack food labelling and are now a member of the SKNBS Technical Committee for Labelling.

• We have also started advocating for the introduction of a sugar-sweetened beverage tax in St Kitts and Nevis. As part of this process, we attended the Ministry of Health’s National SSB Consultation, have prepared a position statement of SSB taxation in St Kitts and will be attending an SSB focus group, at the end of April 2019, organised by the Ministry of Health.

• We launched a childhood obesity social media campaign for World Cancer Day

Next Steps

We’ll be continuing with the above and exploring the development of resources to encourage children to get active.

We’re really excited about this work and are looking forward to making a difference in this area.

References

1. UNICEF, Situation Analysis of Children in the Federation of St Kitts and Nevis, UNICEF Office for the Eastern Caribbean Area and the Government of St Kitts and Nevis, Christ Church, Barbados, 2017
2. PAHO, Health in the Americas, 2012: St Kitts and Nevis, PAHO, 2012

On 30th March, we were delighted to join forces with Because We Care to host our first Girl Talk event.

Girl Talk is our new event series that aims to provide a forum for informative, informal and empowering discussions about women’s health. We hope that these events will enable women to take control of their health and that of their families, and therefore build a stronger, healthier nation.

Our first event focused on fibroids. This is an area that is often overlooked leading to a lack of awareness, information, and support for those who have been affected. We want to correct that. We also want to overcome the stigma that can be associated with fibroids by creating a safe space to discuss fibroids, its impact on women and solutions.

We were delighted to have a panel of esteemed speakers covering various aspects of fibroids. Speakers included:

• Dr Hazel Laws, Chief Medical Officer, St Kitts – Fibroids and Women’s Health in St Kitts
• Dr Deborah Williams, Professor of Pathology – What Are Fibroids?
• Tammy Cook – My Fibroids Story
• Dr Lescott, Medical Doctor – Fibroids and Nutrition
• Dr Pereira, Clinical Psychologist – Living well with fibroids and chronic illness
• Dr Lawrence, Medical Doctor – The treatment of fibroids

We also had a small wellness market, fantastic raffle prizes and free health checks for all attendees.

 A Summary of the Day

 Fibroids and Women’s Health in St Kitts and Nevis

The event started with a presentation by Dr Hazel Laws who provided an overview of women’s health in St Kitts and Nevis.

Dr Laws explained that data suggests that women in the Federation are more likely to be affected by non-communicable diseases (NCDs) like cancer and diabetes, but the data may not be giving the full picture as it may be that women are more likely to visit their doctor and seek help than men, and this is what the data is reflecting.

Dr Laws also summarised some of the work that the Ministry of Health is doing to improve women’s health through projects like:

• The ASSIST (Applying Science to Strengthen and Improve Systems) Project which is exploring improving the quality of care offered to pregnant women and children
• WHIP (The Women’s Health Improvement Plan)

Then Dr Laws focused specifically on fibroids and explained that 78 women in St Kitts and Nevis had a surgical intervention for fibroids in 2018. Furthermore, anecdotal evidence collected from OBGYN specialists suggest that over 60% of 35-50-year-old women in St Kitts and Nevis have uterine fibroids with 30% of these women being symptomatic.

Based on this data, Dr Laws stated that fibroids should be raised as a public health concern especially as the lived experience of women with fibroids can be very challenging and very often women suffer in silence. She ended by saying that there is a need to educate women and improve access to care.

What Are Fibroids and their Impact on Women

Next on the agenda was Dr Williams who provided an overview of what fibroids are and touched on their impact on women.

Dr Williams raised some concern that there is little research being conducted on fibroids so the information available on the causes is very limited which then makes it hard for women to take steps to prevent or reduce their risk of developing fibroids.

In summarising the impact of fibroids on women, Dr Williams used data from the US which showed the following with respect to quality of life:

• 28-40% of women with fibroids report missing work because of their symptoms
• 25% reported that having fibroids prevented them from meeting their career potential
• Black women with fibroids are 77% more likely to miss work than their white counterparts
• 36% reduction in work productivity

Dr Williams explained that fibroids also affect self-image with research showing the following:

• 68-88% of women feeling self-conscious or embarrassed about their stomach size and appearance
• 22-51% stated that having fibroids had a negative influence on their femininity and sexuality
• 44% reported painful intercourse
• 60% reported a lack of interest in sex
• 53% said it negatively impacted their relationship with their husband
• 14-46% stated it affected their ability to take care of their home and children

Dr Williams ended her presentation by summarising the significant impact that fibroids have on women and society:

• Fibroids present a significant burden for those affected
• It has an enormous economic impact
• Fibroids negatively affects work productivity, sexuality, self-image, relationships, social and emotional wellbeing
• Black women and younger women are more affected by fibroids
• Many women delay seeking treatment often for several years

Diet and Fibroids

We also heard from Dr Lescott who gave a presentation on diet and fibroids. Similar to Dr Williams, Dr Lescott also explained that there is limited research exploring this topic, but the limited amount  of data on diet and fibroids suggests the following:

• Fibroids are more common in women who consume more red meat and alcohol
• For women who drink at least one beer a day, there was a 50% increase in their risk of developing fibroids
• Compounds from green tea may inhibit the growth of fibroids cells
• Women who consume more citrus fruits are less likely to develop fibroids, possibly due to the presence of flavonoids in citrus fruits
• Vitamin D was protective when it comes to fibroids
• Vitamin A from animal sources are linked to the development of fibroids (not vitamin A from fruits and vegetables)

Living with Fibroids and Chronic Illness

Dr Pereira then covered a very important but often neglected topic – how to live with an ongoing illness like fibroids.

Many women with fibroids are forced to live with several uncomfortable symptoms, in some cases for many years. Dr Pereira explained that this can challenge many aspects of a woman’s life.

Some of the challenges that women may encounter include difficulties related to pain, fatigue, missed work, reproductive health issues, uncertainty, stress, anxiety, relationship and family difficulties, loss of self-confidence, financial issues and more. All these issues can be very hard to cope with.

Because complete eradication of the symptoms and effects of fibroids is not always possible, it is important that women learn strategies to cope. This can be achieved through cognitive behaviour therapy (CBT) which focuses on looking at how we think about certain situations in order to develop resilience so we can better deal with the challenges that are associated with living with fibroids.

Dr Pereira also demonstrated one simple CBT technique, relaxation breathing, which is used to reduce the symptoms of anxiety.

Treatment of Fibroids

We also heard from Dr Lawrence who gave an excellent presentation on the treatment of fibroids. Dr Lawrence explained that treatments included surgery e.g. (hysterectomy, myomectomy), medication to treat the symptoms or shrink the fibroids, non-surgical options (e.g. embolization) and MRI-guided procedures. Dr Lawrence explained that some of these procedures are not available in St Kitts and Nevis.

Dr Lawrence gave attendees the opportunity to ask any questions they had about fibroids, treatment and symptoms. This raised a number of interesting issues such as the challenges associated with having both sickle cell anaemia and anaemia related to fibroids, the struggle that many women have with making treatment decisions and fertility concerns.

My Fibroids Story

In addition to the doctors who presented, we were grateful to Tammy Cook who delivered a powerful and moving talk about her personal experience with fibroids. Ms Cook bravely shared the many challenges she experienced and based on this experienced encouraged women to:

• Get to know their bodies
• Visit the doctor promptly if something doesn’t feel right
• Get a second opinion if you’re not happy with your care.

Conclusion

The event ended with a short presentation from Abi Begho who summarised the day and explained what resources, information and support are available to women which included a self-management course which we’re hoping to organise in May specifically for women with fibroids.

Thank you!

We had a great day and would like to thank everyone who attended, asked questions, and shared their story.

We’d like to thank all the speakers for their thought-provoking, informative presentations and all the vendors – Mother Becky Bush Tea, Sugar Town Organics, Love the Skin You Wear, Pure Niceness By Winnielle and Rose Catering.

We’d also like to say a big thank you to the Chop Shop, the Emerald Mist Spa, Mother Becky Bush Tea, Love the Skin You Wear and Sugar Town Organics for donating lovely raffle prizes.

And, finally we’d like to thank the staff and students UMHS for all their support as we organised this event, we are very grateful.

More Information

For more information on fibroids, you can:

• Visit our fibroids blog and fibroids news sections
• Read through our My Fibroid Story section
• Read through the highlights of our fibroids Twitter chats
• Send a question to our Fibroids Ask the Expert panel
• Listen to our fibroids podcast interviews
  • My Ten Year Journey With Fibroids 
  • Fibroids, Hormones, Diet and Lifestyle
  • The Emotional Impact of Fibroids

You can also keep up-to-date with our fibroids events and news by subscribing to our fibroids newsletter below.

Welcome to part two of our ‘Discussions on Managing Conflict of Interest’ blog. In part one we provided some background to conflict of interest (CoI) and the challenges faced by those aiming to tackle NCDs in the Caribbean. Here, in part two, we’ll be providing highlights from the Health Caribbean Coalition’s (HCC) conflict of interest meeting which we attended a couple of weeks ago.

The HCC’s Meeting

The HCC’s CoI meeting was a two-day regional event held on 26^th and 27^th March 2019 that had a focus on conflict of interest in the prevention and control of non-communicable diseases (NCDs) in the Caribbean, and the overall aim of the meeting was to begin to build regional capacity to identify and manage conflict of interest.

Regional Experiences of Conflict of Interest

The meeting started with an interesting and insightful look at regional experiences of CoI from both civil society and the public sector. From civil society, we heard from the Heart Foundation of Jamaica, the HCC and the Trinidad and Tobago Heart Foundation, and from the public sector, we heard from representatives from the Ministries of Health in Antigua, the Bahamas and Jamaica.  Collectively they touched on industry interference and conflict of interest. Some interesting points that were raised included:

• In the Caribbean, in most instances, we have to live with CoI and so approaching this area from the point of view of managing CoI is a more practical and realistic approach
• The difficulty of dealing with the “smallness” of the Caribbean – everyone knows each other and in our professional lives, in tackling NCDs, we may have to fight against people we know and respect
• Absolutes are unlikely to work except with the tobacco industry where globally the public health community does not partner with tobacco companies. For other industries, like the food and beverage industry, we must explore degrees of conflict of interest (low, medium and high) and degrees of partnership or engagement. Not every engagement will be detrimental to public health and we must understand how to manage conflict of interest whilst getting the most benefit out of any relationship or partnership
• What happens after a conflict of interest has been identified? What is the process for review? Is it an actual, potential or perceived CoI? What is the process for recusal?
• Should an organisation’s CoI policy be generic or specific?
• Some good practice with respect to disclosure forms:
  • All CoI policies should have a supporting disclosure form
  • Disclosure forms are valid for a year
  • The obligation is on the person who is disclosing to report any changes within that year
  • Have a process for checking the accuracy of a completed disclosure form
• Managing conflicts of interest – ensure that if you’re going into a partnership with industry that a lawyer reviews the MoU and any non-disclosure agreements to prevent any CoI issues; don’t be afraid to negotiate so you can minimise any risks or exposures.

WHO/PAHO Tool for Preventing and Managing CoI In Nutrition

A core part of the HCC’s meeting was to explore the tools and support that could be offered to organisations to identify and manage conflict of interest in order to build regional capacity. Therefore, during the meeting, attendees were introduced to WHO’s draft tool for preventing and managing CoI, including an abbreviated ‘scoping’ version of this tool developed by PAHO,  and a draft of the HCC’s CoI guide and policy.

The PAHO scoping tool provides a simple method to evaluate potential engagements and is divided into three areas that enable organisations to reflect on important issues before deciding on whether to enter into an engagement with an external entity.  These areas include:

• Actor alignment
• Engagement profile
• Assessing the risk and benefits

Additionally,  this scoping tool complements the more comprehensive decision-making tree developed as part of the WHO draft tool. This is a 6-step process that takes the user through a structured process for analysing a potential engagement to identify and manage conflict of interest. The steps include:

• Exploring the rationale for engagement
• Profiling, due diligence and risk assessment of the external actor and the potential engagement
• Balancing risks and benefits
• Risk management
• Monitoring, evaluation and accountability
• Transparency and communication

Both resources provide users with an objective and comprehensive method of identifying and assessing conflict of interest, whether an engagement should be pursued and if so, what measures can be introduced to manage any conflicts of interest.

The HCC’s CoI Guide and Policy

Finally, the HCC presented their draft CoI guide and policy which is aimed at their staff, volunteers, board members, advisors, interns and consultants. Their policy and guide aims to prevent, identify, avoid and manage CoI. It also aims to serve as a general guide for civil society organisations and individuals as they develop their own CoI policies, the idea being that CSOs can simply adapt the HCC policy to suit local needs and situations.

Our Thoughts

We thought this was an excellent meeting which gave us a lot of food for thought.

Conflict of interest is an area that we considered on a simple level, but this meeting allowed us to explore this subject in depth and fully appreciate the risks of not properly analysing the relationships that we seek to enter.

The meeting was very timely as over the past few months we’ve started to explore organisations that we can approach to support some of our activities and during this process, we have found it challenging to determine whether we should pursue forming relationships with an organisation that promotes both healthy and unhealthy food and beverages. Attending this meeting has given us some clarity and by using the knowledge we have gained from this meeting and the PAHO tool we believe we can make a better decision.

Conclusion

We encourage Caribbean civil society organisations working in the NCD field to explore developing an approach to tackling conflict of interest to safeguard the credibility and integrity of their work, and for further information, please do reach out to the Healthy Caribbean Coalition