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Health Issues

Problems in a small, isolated population

The doctors of the future will give no medicine, but will instruct their patients in the care of the human frame, in diet and in the cause and prevention of disease.{2}{a}

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In a physically isolated and largely closed population health issues will develop

Operating Theatre, 1974
Operating Theatre, 1974{1}

Most medical services are provided at our General Hospital in Jamestown.

Much of the current information presented here is summarised from the Joint Strategic Health Needs Assessment, 2022 report.

Why is there a problem?

There are several reasons why health issues can be a problem for the residents on St Helena:

Below: Healthcare is limitedGenetic diversity is limited

Healthcare is limited

Inevitably with a population of around 4,000 people, the medical care available locally is limited. Why procure a vastly expensive piece of equipment that may only be used a few times a year? Why employ a specialist in an uncommon condition when they might only be needed once or twice a year?

To some extent this is offset by overseas health referrals. People with conditions that cannot be treated locally, or with suspected conditions that cannot be diagnosed locally, are sent to a hospital in South Africa or the UK for diagnosis and/or treatment. In emergency cases transport can be by Medevac - a dedicated medical flight.

Before the airport opened the fastest route to South Africa was by ship - either the RMS St Helena or by flagging down a ship that was passing the island in the right direction. Critically ill patients frequently died before reaching hospital.

Genetic diversity is limited

St Helena has a largely closed population, which means that Saints mostly have children with other Saints. This restriction on genetic diversity can cause relatively unusual diseases to become widespread in the population. Some examples of this can be found below.

What are the health issues?

Below: Common ConditionsUncommon Conditions

Common Conditions

Many of the conditions suffered on the island are also common in other areas of the world:

Below: Cardiovascular DiseasesDiabetesCancerLung DiseaseAnxiety & DepressionOthers

Cardiovascular Diseases

Cardiovascular diseases (CVD) are diseases of the heart and blood vessels. The most common are ischaemic heart disease (IHD), stroke, and peripheral vascular disease (PVD), which affects blood vessels in the limbs and can lead to amputation. About 20% of overseas health referrals between April 2018 and December 2021 were for heart disease, including IHD.

Diabetes

Locally known as ‘The Sugar’, Diabetes is common and rates increase with age. Overall, 24% of adults aged 20-79 years took some sort of medication for diabetes in 2021. Most suffer from type 2 diabetes, whose major risk factors are being overweight, physically inactive and smoking.

Cancer

22% of all deaths in the last 20 years were due to cancer. The four cancer types that caused the most deaths are lung, bowel, stomach, and pancreas. All four are more likely to develop in people who smoke or are overweight.

Lung Disease

Lung disease is less common than CVD, diabetes or cancer, but there is a significant burden of chronic obstructive pulmonary disease (COPD), most of which is due to smoking. Roughly 10% of adults had a prescription for asthma or COPD in 2021. Almost 75% of deaths due to COPD in the last 20 years were in men, who are more likely to smoke.

Anxiety & Depression

Anxiety and depressive disorders accounted for 38.4% of contacts with the adult mental health team from March 2020 to September 2021. Roughly 10% of adults had a prescription for an anti-depressant in 2021.

Others

Other diseases worthy of note are Dementia, Falls and fragility fractures due to osteoporosis, and Osteoarthritis, which may lead to joint replacements and short-term care needs during rehabilitation, and ‘Tightness’ (asthma).

As you can see, having a larger than normal proportion of older people increases the island’s healthcare needs pro-rata to the population numbers.

It should also be noted that, according to a recent survey, only around 10% of people eat the recommended five portions of fruit and vegetables per day. This can largely be explained by the routine shortage of both fruit (little is locally grown, so fruit is only available in a short period immediately after the arrival of the Sea Freight ship, and not for the rest of the month) and fresh vegetables - the cost of water makes agriculture uneconomic against the prices of imported processed foodstuffs so demand is limited and supply follows suit.

Uncommon Conditions

Some of the conditions commonly suffered on the island are unusual in other areas of the world:

Below: Swelling DiseaseChristmas Disease

The Swelling Disease

The proper name is hereditary Angioedema. Any part of the body can be affected by a sudden swelling which lasts 24-48 hours. An arm or leg can swell up, which simply causes discomfort, but swelling in the mouth can make breathing difficult, and in the intestines it can cause a temporary blockage which might lead to further complications. Boys and girls are equally affected. It is caused by a recessive gene - if one parent has this there is a 50% chance of any particular child having it; if both parents have the condition it is certain their children will have it. It is also known as Quincke’s Disease, after surgeon Heinrich Quincke.

Christmas Disease

Christmas Disease is the local name for Haemophilia B, the blood clotting disorder causing easy bruising and bleeding. Christmas Disease is caused by an inherited mutation of the gene for clotting factor IX, and resulting in a deficiency of factor IX. It is less common than factor VIII deficiency (haemophilia A). Most individuals who have Christmas Disease and experience symptoms are men. The prevalence of Christmas Disease in the worldwide population is about one in 40,000, but is much higher on St Helena. Most women carriers of the disease have no symptoms.

Health inequalities

Health inequalities are avoidable, unfair, systematic differences in health between different groups of people. Health inequalities can be caused by socio-economic factors, geography, specific characteristics or excluded groups.

In the Joint Strategic Needs Assessment 2022 people identified these major sources of health inequality on St Helena:

Racial discrimination in healthcare lasted until at least the 1960s. Dr. Ian Shine arrived in 1960 and in his book ‘Upon This Rock’ he noted:

There were two clinics in Jamestown. The Saints lined up to be examined on a wooden table in a hut behind the General Hospital (which doubled as a mortuary); ex-pats and the privileged came to the front of the hospital to be examined on a comfortable examination couch inside the hospital. Once the senior medical officer left St. Helena, I combined the clinics requiring everyone to join a single queue for the comfortable couch. A single line was more efficient, and it did wonders for ex-pat health - after this change they hardly ever attended the clinic.

Census data

The following data, from the 2021 Census, documents the self-reported health status of the population:

Sex and age

Good or very good

Fair

Bad or very bad

Male

73.3%

22.2%

2.1%

0-9

91.7%

4.4%

0.0%

10-19

94.0%

4.3%

0.0%

20-29

91.9%

3.8%

0.0%

30-39

84.7%

13.7%

0.0%

40-49

79.6%

17.3%

1.3%

50-59

70.2%

24.6%

2.9%

60-69

67.0%

26.3%

4.2%

70 and over

45.1%

49.0%

4.1%

Female

71.6%

23.3%

3.2%

0-9

91.4%

6.3%

0.0%

10-19

93.6%

5.2%

0.0%

20-29

81.4%

10.6%

0.6%

30-39

86.2%

11.5%

1.4%

40-49

76.9%

20.6%

1.6%

50-59

67.0%

29.6%

1.7%

60-69

68.1%

25.2%

4.7%

70 and over

41.5%

47.5%

9.6%

Other Facts

In 1966 it was observed that a common cause of death in small children was poisoning, the blame being placed on the widespread practice of storing paraffin in old lemonade bottles.

Many mostly-older Saints still make use of the ‘traditional remedies’ that they relied on in the ‘before days’. Some of these are documented on our page Edible Wild Plants.

Read More

Below: Article: Pharmacies, Signs and PostcardsArticle: Health of St Helena: Remarkable decrease of death-rate

Article: Pharmacies, Signs and Postcards

By Cliff Masters, published in the St Helena Connection #16, May 2014{3}

My interest in St Helena postcards brought me to the man who published photographs and picture postcards of St Helena from about 1902. Thomas Jackson, Island Chemist was a chemist and general merchant. Prior to Jackson only the photographer A. L. Innes, who had his studio next door to Jackson, had published St Helena postcards.

Thomas Jackson was born in 1843 in the small village of Walkerfield, Co Durham. Having studied at Durham University and graduated as a pharmacist in around 1863, he emigrated to St Helena. Being a young man he was unlikely to have had enough money to buy a chemist shop, so we can assume he was employed by the family who owned the ‘Pharmacy’ at Burton’s House. This was opposite the Officers’ Quarters (now the Post Office) where the Colonial Surgery was located and next door to Essex House.

Jackson married Mary Ann Stewart in 1868 and they had a son Thomas Kipling, Kipling being Thomas’ mother’s maiden name. He must have had high hopes for his boy to take over the business from him. He married in 1891 and lived in Putney working as a chemist’s assistant but died relatively young in 1913, five years before his father. Thomas Kipling’s mother Mary Ann also died young in 1887. Thomas Jackson married his second wife, Emily Louise Warren, in 1889. She was a school teacher on the island and in 1889 had come to the end of her three year contract as head of Jamestown girls’ school.

How long Jackson stayed in employment at the Pharmacy is not clear but by 1883 he had opened his own shop, included by Benjamin Grant in his Descriptive Guide. While running his description up the shops of the south side of Main Street Grant wrote the Polytechnic Warehouse, Mr Jackson’s showy dispensary and drapery shop, the commodious Officers’ Town Mess House, the fine shop called ‘The Star’ and a neat little shop to the left of which are the Lower Bazaar, Mr. M George’s Dispensary, in front of which are three peepul trees, under whose grateful shade auction sales are held, and a roofless building called the Cannister.

Mathew George was St Helena’s first pharmacist. He was known as the ‘doctor’ and was married to Louise George whose death was noted in an article in the August 1958 edition of the Wirebird It is with many regrets that the whole island will know the passing away of Mrs Louisa George at the ripe old age of 90 [᠁] she was born in the 1860s and [᠁] married Mr Mathew George and together they ran the chemist shop. Her husband died many years ago, but the shop still stands with its old time furnishing - drawers and bottles, with their once contents painted in Latin in gold lettering.

At some point ‘doctor’ George moved his business down the street to the Pharmacy and we can only assume that the fine sign and bottles, shown in the pictures, which can only be found in fine chemist shops in England, must have come with George from England. I first saw the chemist bottles in Eva Benjamin’s shop in 1970 and wondered why they were there when I found out that the shop had never been a chemist. Some 44 years later in 2004 I discovered Eva was a ‘George’ and to my delight in 2008 I discovered that the George family still lived in Burton House although now it is known to all as ‘The Georges’.

When exactly it became a residential property is not clear but it has been well preserved. The only change seems to be that the shop window has been taken out and a door fitted. Also in 2008 I found those same bottles at Jamestown’s museum.

The ornate ‘Pharmacy’ sign has an interesting history. In 1902 the Innes’ left the island and E.J. Warren took over their shop. As the picture below shows he removed the sign from ‘the Georges’ and placed it over his new pharmacy business.

E.L. ‘Pop’ Warren came to St Helena when his sister Emily Louise married Thomas Jackson, Island Chemist in 1889 and he was sixteen years old. It is believed he stayed to help his brother-in-law in the shop. Edwin James Warren was born in Paignton at the old school house in Jan 1874. He seems to have returned to England and took up lodgings in London and worked at a chemists. He spent Christmas 1900 on St Helena but was back in London lodgings for the 1901 census. It seems he bought the shop in 1903 and the photographic plates and equipment started to be used by Jackson around this time. After Jackson died in 1918 the shop was sold and his plates began to be used by Warren although the postcards were printed in England. Since then the shop has changed hands many times but it is still known as Warrens.

In the early 1960s Warren retired and went back to England. The new owner, believed to be his nephew, modernised the store and took down the sign as he was not a pharmacist. The sign was then re-painted and taken to Hutts Gate. By 2008 the store building was approaching dereliction and the sign was removed to the Longwood House museum.

As far as St Helena’s postcards are concerned it now seems relatively certain that the island’s first publisher, A.L. Innes, was active from about 1897 to 1902. His plates were then taken over by Thomas Jackson who produced cards from 1903 to 1913. From about 1914 cards were published by the ‘Pharmacy’ by E.L. ‘Pop’ Warren. From 1960 cards were published by the ‘Polytechnic’ by E.L. Warren’s nephew whose name is not clear. This succession shows that from about 1897 to 1980 postcards were published from this same premises and next door Jackson’s store - well over 80 years. C&M stores, who took over the premises in the 1980s, never published postcards but in the 1990s it was still possible to purchase odd cards at the shop which had been printed many decades earlier.

Our Comment: Since this article was published Hutts Gate Store has been restored as a private house. More on our Saved Buildings page.

Article: Health of St Helena: Remarkable decrease of death-rate

Published in The Lancet, 13th August 1910{3}

In the report of Lieutenant-Colonel H. L. Gallwey, C.M.G., Governor and Commander-in-Chief of St Helena, on the Blue-book of the colony for the year 1909, the section devoted to vital statistics, hospitals, &c., contains, as will be seen by the subjoined summary, much matter of more than usual interest. The present estimated population is 3,553, and the death-rate in 1909 was abnormally low, being 6.4 per 1000, as compared with 9.6 per 1000 in 1908. There were only 23 deaths. Of these, six were of children under 1 year of age and five of persons between 83 and 90 years. Excluding those 11, only 12 deaths occurred among the islanders between the ages of 1 and 80 years, a rate which works out at 3.4 per 1000. Looking at the fact that St Helena is situated in the tropics, the figures furnish a very remarkable testimony to a wonderful climate. The death-rates among the civil population for the last eight years have been as follows: 1902, 34.8; 1933, 23.2; 1904, 14.4; 1905, 14.5; 1906, 11.9; 1907, 9.4; 1908, 9.6 and 1909, 6.4. It will be seen that the death-rate in eight years has decreased by no less than 28 per 1000. This wonderful result is not a little due to the greatly improved hygienic conditions under which the islanders live to-day as compared with a decade ago.

During the months of May and June influenza assumed epidemic proportions. Though many were severe, the bulk of the cases were mild. There were 35 cases of pneumonia, with three deaths: an old woman over 84 years of age and two others over 60 years of age, with constitutions enfeebled by long-standing poverty. In November and December, during the drought, several cases showing injurious effects from the sun’s rays came under treatment. During a prolonged period of dry weather the direct solar heat was unusually intense. The most severe case was that of a healthy man, aged about 45 years, who had had fever for ten days after exposure to a hot sun. The symptoms came on suddenly, and death followed during convalescence from a sudden cerebral haemorrhage before the patient had left his bed. These cases are worthy of note as the sun in St Helena rarely causes inconvenience, and therefore its occasional potency is apt to be disregarded.

With regard to the general aspect of the public health the colonial surgeon, Dr. W. J. J. Arnold, reports Frugality in eating and drinking has been a necessary consequence of the straitened economic condition of the islanders, and to this factor might be safely attributed a considerable share in the reduction of the death-rate. The mind of the average inhabitant of the island has always been swayed with the idea in regard to disease that it was the direct infliction of Heaven, and that little or nothing on the individual’s part could avail to avert sickness. This idea has been persistently combated in the course of some years’ daily contact with the sick and sound, and it is not altogether unwarrantable to conclude that the slow infiltration of a more reasonable view as to the influence of diet and all the habits of everyday life in preventing disease has had beneficial results. The practical application of the principles of hygiene in the schools has undoubtedly improved the standard of health amongst the children.

The Governor expresses full concurrence in these views, and adds that hygiene and sanitation in St Helena to-day are of a higher standard than they have ever before been in the history of the colony.

Although a great improvement is discernible among the poorer classes in connexion with the combating of disease and the putting into practice the simple rules of hygiene, yet amongst the more ignorant of the population, and even amongst those who have had some education, a belief in witchcraft and the power of the evil eye still survives. Different ailments are not infrequently attributed by the victims of this belief to a spell having been cast upon them by some person evilly disposed towards them. A few mischievous persons have traded on this deplorable credulity, and under the pretence of removing the spell (or poisons, as it is called) by means of potions or herbs have received much ill-gotten gain. The harmfulness of the evil referred to has been shown in numerous instances where people have drifted into a condition of bodily and mental wretchedness through believing they were under a spell when in reality no disease of any kind was present. Many ordinary ailments attributed by the victims to poison or evil influence, have dragged on for weary months when by proper medical treatment they would have been speedily cured. The quacks who have enriched themselves by trading on such ignorance and credulity have in the past carried on their nefarious operations unchecked, but an ordinance has now (1910) come into force which will restrain them. Under this ordinance it is unlawful for any person to practise medicine or surgery, or to prescribe any medical or surgical treatment in St Helena for fee or reward unless he is possessed of one or more of the qualifications which would entitle him to practise medicine or surgery in the United Kingdom.

A case of leprosy in a child, aged 7 years, was notified. The child contracted the disease from his grandfather, who died in 1908, after having suffered many years from leprosy. Suitable quarters were erected in Rupert’s Valley for the segregation of the child on a site well suited for isolation. The boy is cared for by his grandmother, who voluntarily undertook the duty, and has been under control and treatment since August, 1909. There were 164 admissions to the island hospital during the year and seven deaths. Over 3,000 outpatients were treated. Chloroform was administered in 44 cases, the majority being minor surgical operations. A small fund inaugurated three years ago to assist poorer patients in defraying hospital charges has proved of great service. At a time when so many of the population are without work and lack the nourishment indispensable to recovery from illness or injury, the importance of such a fund (which is derived entirely from voluntary contributions) is apparent. The Governor further writes: The medical care of the whole population during the year again fell entirely on Dr. Arnold’s shoulders. On more than one occasion he should have laid up, but could not possibly do so. I am glad to say that provision is made in the Colony’s estimates for 1910 for an allowance to the colonial surgeon to cover (in part) the salary of an assistant. I cannot testify too highly to the manner in which Dr. Arnold has performed his duties single-handed for over three years. His devotion to duty is thoroughly recognised and appreciated by the whole community.

LOL

Doctors at the hospital have gone on strike. Health officials say they’ll respond to the doctors’ demands as soon as they can get a pharmacist over there to read the picket signs.

Credits:
{a} Thomas Edison

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Footnotes:
{1} In case you were worried: yes, it has been updated since; most recently just a few years ago…{2} We slightly amended this quote. In the original, Edison assumed the doctor would be a he. Today we know better…{3} @@RepDis@@

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