Journal of Clinical Epidemiology 68 (2015) 1101e1104
Epidemiology is an important contributor to clinical and public health practice in the Caribbean Rainford Jonathan Wilks* Epidemiology Research Unit, Tropical Medicine Research Institute, The University of the West Indies, 7 Ring Road, Mona, Kingston 7, Jamaica Accepted 24 September 2014; Published online 7 February 2015
1. Epidemiology: skills, attitude, and mind-set Simply put, epidemiology documents the burden of health-related states, identifies causal associations between health-related states and risk factors, and applies these insights to ameliorate disease. It requires a systematic approach to problem solving, involving measurement, generating and testing of hypotheses as well as alertness to new developments. Epidemiology follows rules that have to be learnt for proper and skilled practice. Some of its key activities include (1) characterizing populations/denominators, (2) defining cases/numerators, (3) selecting representative samples for study, (4) estimating burden of disease, (5) describing natural history of disease, (6) classifying diseases, (7) identifying causes and risk factors, (8) developing proposals for intervention, (9) evaluating interventions, (10) developing predictive models, and (11) synthesizing evidence for informed practice. Epidemiologists draw competence from several older professions (medicine, biostatistics, demography, and so forth), but in addition to these skills, they are characterized by a special attitude and mind-set including a deep understanding of epidemiologic principles, open-mindedness, alertness to error and alternative explanations, and are critical, practical, and pragmatic [1,2]. Early misgivings of the relevance of epidemiology to clinical medicine and reluctance to embrace the term ‘‘clinical epidemiology’’ [3] have given way to evidence supporting the principle of extrapolating research evidence to clinical decision making [4e6]. Newer techniques of evidence synthesis, meta-analysis, and systematic review have improved the feasibility of converting evidence to practice. 2. Pioneers of Caribbean evidence-based practice The Caribbean has benefited from an ethos of enquiry and innovation in efforts to address health issues. Pioneers * Corresponding author. Tel.: (876) 927-2471 ext. 234; fax: (876) 9272984. E-mail address: [email protected] or rainford.wilks@ uwimona.edu.jm (R.J. Wilks) http://dx.doi.org/10.1016/j.jclinepi.2014.09.027 0895-4356/Ó 2015 Elsevier Inc. All rights reserved.
such as Sir Kenneth Standard [7] and Professor Waterlow [8] tackled the prevailing issues of their time making global contributions to the relief of undernutrition and infectious diseases. Standard’s vision charted the route to achieving this by mobilizing low-skilled community health aides in the health response. Waterlow’s contribution to understanding the metabolic perturbations of undernutrition as the basis on which to develop effective treatment and prevention is legendary and marks the Caribbean’s contribution to evidence-based medicine (EBM).
3. Responding to the current situation The current scenario, with several new challenges including increasing populations, the emergence of chronic noncommunicable diseases (CNCDs) with their uncertain web of causation along with globalization, and economic changes, is more complex requiring more rigorous and careful application of epidemiologic principles. As well, the unevenness of the health transition mandates that countries and regions while drawing lessons from each other’s experience must generate their own indigenous knowledge of health-related patterns and associations to tailor appropriate interventions. The Caribbean region needed a strategic approach to enquiry, which included a steady stream of researchers skilled in the evolving research techniques to meaningfully respond to the current health agenda. The region benefited in earlier years from visiting researchers who recognized the differences in disease patterns between the United Kingdom and the Caribbean. The pioneering work of Ashcroft and Miall [9], Miller and Ashcroft [10], Ashcroft [11], Cochrane and Stuart [12], and Ashcroft and Desai [13] documented the early features of the CNCD epidemic and the differences in disease patterns. These efforts suffered from the evanescent character of ‘‘grant-funded projects,’’ which cannot build sustained progress, the latter requiring regional commitment to identify and address the domestic agenda. This deficit did not escape the attention of the region’s biomedical ‘‘think-tank,’’ the Commonwealth Caribbean
1102
R.J. Wilks / Journal of Clinical Epidemiology 68 (2015) 1101e1104
What’s new? Key Findings Over the last three decades the Caribbean has made significant progress in developing an indigenous cadre of epidemiologists and health researchers, thus reducing its reliance on expatriates in the specialty. Evidence-based-medicine (EBM) is now a legitimate component of the region’s training. programme as well as its clinical and public health practice. Research from the region has had significant impact on clinical practice and health policy. What this adds to what was known? The region now has the capacity to train its specialist health researchers as well as to imbed and inculcate the research evidence-based culture in clinical and public health practice. The opportunities to further develop and sustain this capacity have been highlighted. What is the implication and what should change now? In order to sustain this capacity for EBM the region must create career paths for its practitioners including the strategic and systematic realignment of clinical workload in order to encourage clinical research.
Medical Research Council (CCMRC) (previously the Scientific Advisory Council and subsequently the Caribbean Health Research Council). The CCMRC commissioned a report by George Miller in 1981 to review the priorities for addressing the emerging problems of CNCDs. The report articulated the need for the region to invest in developing its own capability and human resource to address these problems. This required a cadre of skilled health researchers with sound basic training in epidemiology, specifically clinical epidemiology [14]. Miller foresaw epidemiology embracing all specialties and urged the region to invest in persons to pursue this essential component of health practice. This was consistent with the proposal by Sackett et al. [3] that epidemiology should be regarded as a basic science for medical practice. The region’s response to this charge appeared to have had a long gestation but has built progressively over the period since 1984 to where few would argue against its success. The benefit of this investment over time has become evident over the last decade. Over the last 30 years, the
region has committed to the training of talented young investigators. Some training has taken place in our developed country neighbors with some individuals returning to contribute to the creation the regional pool of skilled health researchers. Their efforts have contributed immensely to the creation of regional knowledge providing policy makers of our nations with the confidence to lead the United Nations ambition to ameliorate the global burden of noncommunicable disease (UNHLM 2011) [15]. This cadre has brought the principles of epidemiology and scientific research to the training of health researchers in other specialties, enriching the learning experience of students of nutrition, public health, and medicine. There have been setbacks with epidemiology emerging as a competitive career in the developed countries, retaining recruits from outside the region was difficult. The combination of loyalty, the vision to be part of a pioneering movement, and the development of opportunities for relevant research projects led to the retention of committed individuals who have over the last decade strengthened epidemiology and confirmed its relevance and importance to regional health workers. It could be argued that the region’s exemplary response to the human immunodeficiency virus/AIDS epidemic benefited from its history and culture of health research and intervention as well as the growing cadre of health researchers schooled in the principles of epidemiology. At the same time, our response to the chronic disease epidemic is less developed but improving steadily. The last decade has seen several positive developments indicating the deepening roots of epidemiology and its principles in the region’s health psyche. These include an increasing number of persons from varied fields (medicine, biomedical sciences, social sciences) seeking training in epidemiology; embedding of epidemiology and research training in the medical school curriculum of the University of the West Indies (UWI), where third year medical students are immersed in a 10-week course of ‘‘Understanding Research,’’ including clinical epidemiology and EBM; development of a Master of Science degree in epidemiology at the UWI; incorporation of the UWI epidemiology group into the International Clinical Epidemiology Network and its regional branch CanUSACLEN; development of the Caribbean Branch of the US Cochrane Center; creation of a Caribbean branch of the London School of Hygiene and Tropical Medicine alumnae association; and the graduating of the first PhD candidate in epidemiology. This region’s response has been nurtured by several factors including: (1) the opportunity for young researchers to engage in pragmatic, relevant population health research that has found favor with the editors of reputable international journals [16,17] and clinical practice research that has been equally informative [18e21], (2) regional career opportunities in academia and policy, (3) increasing opportunities to collaborate with scientific investigators in developed and developing countries, (4) uptake of research findings by governments and other regional agencies into
R.J. Wilks / Journal of Clinical Epidemiology 68 (2015) 1101e1104
their policies and programs, (5) a more globalized approach to health research encouraging collaborations between developed and developing countries (e.g., the Global Alliance for Chronic Diseases [22]); (6) the region’s leadership in the global response to the CNCD epidemic with the Declaration of Port of Spain in 2007 [23] and the United Nations High Level Meeting on CNCDs in 2011 [15], (7) The USA National Institutes of Health (NIH) encouraging international collaborations, for example, National Institute of Health and Health Disparities, (8) journals (e.g., Tropical Medicine and International Health) insisting on indigenous academic participation in research from developing countries, and (9) an evolving source of research grant funds from regional bodies including academia, government, and quasigovernment agencies (universities, the Culture, Health, Arts, Sports and Education Fund, National Health Fund in Jamaica, and so forth), the private sector in Barbados. 4. Future steps The ethos of epidemiology has definitely taken root in the Caribbean, and this has been recognized and affirmed by regional governments, academic institutions, the international epidemiology community, and international donor agencies. This must be sustained with continued support by regional and international stakeholders, the creation of career paths for persons in the specialty, epidemiologists justifying their relevance by investigating and solving regional health issues, and the creation of a sustainable regional source of research grant funds. 5. Conclusion The region can feel proud of its legacy and justified that the beacon of EBM, the Cochrane Reviews, is named after an earlier contributor to Caribbean research and knowledge generation [12]. But its responsibilities for the future loom even larger as it tackles the double burden of infectious and nutritional deficiency diseases as well as CNCDs. Major challenges remain as clinicians are burdened with enormous clinical service load and opportunities for clinical epidemiology training and clinical practice research remain limited, requiring extraordinary effort by the most committed. To ensure that we do not fail, the region must protect the gift provided by epidemiologic principles as crucial to this mission. Achieving this will require innovative delivery of courses, which does not compromise clinical practice time and improved incentives in career advancement for the lifelong clinician learner who is committed to generating new knowledge from research in clinical practice.
Acknowledgments The author acknowledges the contribution of Professor Alan Jackson from the University of Southampton for his
1103
insightful comments on this article. The article pays tribute to the generations of expatriate and regional health researchers who have contributed to where we are now. The central role of the University of the West Indies is acknowledged. Thanks to colleagues, past and present, in the Epidemiology Research Unit and the Tropical Medicine Research Institute of the UWI who have contributed to the present reality and continue to work toward a better future.
References [1] Rothman KJ. Modern epidemiology. 1st ed. Boston/Toronto: Little, Brown and Company; 1986. [2] Webb P, Bain C, Pirozzo S. Essential epidemiology: an introduction for students and health professionals. New York, USA: Cambridge University Press; 2005. [3] Sackett DL, Haynes RB, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. Churchill Livingstone; Boston/Toronto. 1st ed 1985. [4] Sackett D, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. Edinburgh/London/ New York/Philadelphia/Sydney/Toronto: Churchill Livingstone; 1998. [5] Haynes RB, Sackett DL, Guyatt GH, Tugwell P. Clinical epidemiology: how to do clinical practice research. 3rd ed. Philadelphia/ Baltimore/New York/London: Lippincott Williams & Wilkins; 2006. [6] The Evidence-Based Medicine Working Group. Users’ guide to the medical literature: a manual for evidence-based clinical practice. 2nd ed. New York/Chicago/San Francisco: McGraw Hill; 2008. [7] Standard KL, Ennever O. Training health auxiliaries. West Indian Med J 1974;23(4):217e25. [8] Forrester T, Picou D, Walker S. The Tropical Metabolism Research Unit, The University of the West Indies, Jamaica, 1956-2006. Kingston: The House that John Built; 2007:344. [9] Ashcroft MT, Miall WE. Cardiothoracic ratios in two Jamaican communities. Am J Epidemiol 1969;89:161e7. [10] Miller GJ, Ashcroft MT. A community survey of respiratory disease among East Indian and African adults in Guyana. Thorax 1971;26: 331e8. [11] Ashcroft MT. A review of epidemiological research in a rural Jamaican community, 1959-1975. West Indian Med J 1979;28(1):3e16. [12] Cochrane E, Stuart KL. Cardiovascular disorders in Barbados. West Indian Med J 1963;12:275e84. [13] Ashcroft MT, Desai P. Blood-pressure and mortality in a rural Jamaican community. Lancet 1978;1:1167e70. [14] Miller GJ. The current status of cardiovascular disease research in the Commonwealth Caribbean. Commonw Caribbean Med Res Counc 1981;1981. [Report No]. [15] Assembly UNG. 2011 High Level Meeting on Prevention and Control of Non-communicable Diseases 2011: Available at http://www.un.org/ en/ga/president/65/issues/ncdiseases.shtml Accessed November 25, 2013. [16] Cunningham-Myrie C, Younger-Coleman N, Tulloch-Reid M, McFarlane S, Francis D, Ferguson T, et al. Diabetes mellitus in Jamaica: sex differences in burden, risk factors, awareness, treatment and control in a developing country. Trop Med Int Health 2013; 18(11):1365e78. [17] Tulloch-Reid MK, Younger NO, Ferguson TS, Francis DK, Abdulkadri AO, Gordon-Strachan GM, et al. Excess cardiovascular risk burden in Jamaican women does not influence predicted 10-year CVD risk profiles of Jamaica adults: an analysis of the 2007/08 Jamaica health and lifestyle survey. PLoS One 2013; 8(6):e66625. [18] East JM, Mitchell DI. Emergency open cholecystectomy is associated with markedly lower incidence of postoperative nausea and vomiting
1104
R.J. Wilks / Journal of Clinical Epidemiology 68 (2015) 1101e1104
(PONV) than elective open cholecystectomy: a retrospective cohort study. BMC Surg 2010;10:6. [19] East JM, Valentine CS, Kanchev E, Blake GO. Sentinel lymph node biopsy for breast cancer using methylene blue dye manifests a short learning curve among experienced surgeons: a prospective tabular cumulative sum (CUSUM) analysis. BMC Surg 2009;9:2. [20] Ferguson TS, Tulloch-Reid MK, Younger NO, Boyne MS, WrightPascoe RA, Elliott VE, et al. Cardiovascular disease among diabetic in-patients at a tertiary hospital in Jamaica. Diab Vasc Dis Res 2010; 7:241e2.
[21] Ferguson TS, Tulloch-Reid MK, Younger NO, Wright-Pascoe RA, Boyne MS, McFarlane SR, et al. Diabetic foot complications among patients attending a specialist diabetes clinic in Jamaica: prevalence and associated factors. West Indian Med J 2013;62(3): 216e23. [22] Global alliance for chronic diseases. Available at: http://www.gacd. org/, Accessed November 25, 2013 [23] CARICOM. The Declaration of Port of Spain 2007: Available at http://www.caricom.org/jsp/pressreleases/pres213_07.jsp Accessed November 25, 2013.
Epidemiology is an important contributor to clinical and public health practice in the Caribbean Rainford Jonathan Wilks* Epidemiology Research Unit, Tropical Medicine Research Institute, The University of the West Indies, 7 Ring Road, Mona, Kingston 7, Jamaica Accepted 24 September 2014; Published online 7 February 2015
1. Epidemiology: skills, attitude, and mind-set Simply put, epidemiology documents the burden of health-related states, identifies causal associations between health-related states and risk factors, and applies these insights to ameliorate disease. It requires a systematic approach to problem solving, involving measurement, generating and testing of hypotheses as well as alertness to new developments. Epidemiology follows rules that have to be learnt for proper and skilled practice. Some of its key activities include (1) characterizing populations/denominators, (2) defining cases/numerators, (3) selecting representative samples for study, (4) estimating burden of disease, (5) describing natural history of disease, (6) classifying diseases, (7) identifying causes and risk factors, (8) developing proposals for intervention, (9) evaluating interventions, (10) developing predictive models, and (11) synthesizing evidence for informed practice. Epidemiologists draw competence from several older professions (medicine, biostatistics, demography, and so forth), but in addition to these skills, they are characterized by a special attitude and mind-set including a deep understanding of epidemiologic principles, open-mindedness, alertness to error and alternative explanations, and are critical, practical, and pragmatic [1,2]. Early misgivings of the relevance of epidemiology to clinical medicine and reluctance to embrace the term ‘‘clinical epidemiology’’ [3] have given way to evidence supporting the principle of extrapolating research evidence to clinical decision making [4e6]. Newer techniques of evidence synthesis, meta-analysis, and systematic review have improved the feasibility of converting evidence to practice. 2. Pioneers of Caribbean evidence-based practice The Caribbean has benefited from an ethos of enquiry and innovation in efforts to address health issues. Pioneers * Corresponding author. Tel.: (876) 927-2471 ext. 234; fax: (876) 9272984. E-mail address: [email protected] or rainford.wilks@ uwimona.edu.jm (R.J. Wilks) http://dx.doi.org/10.1016/j.jclinepi.2014.09.027 0895-4356/Ó 2015 Elsevier Inc. All rights reserved.
such as Sir Kenneth Standard [7] and Professor Waterlow [8] tackled the prevailing issues of their time making global contributions to the relief of undernutrition and infectious diseases. Standard’s vision charted the route to achieving this by mobilizing low-skilled community health aides in the health response. Waterlow’s contribution to understanding the metabolic perturbations of undernutrition as the basis on which to develop effective treatment and prevention is legendary and marks the Caribbean’s contribution to evidence-based medicine (EBM).
3. Responding to the current situation The current scenario, with several new challenges including increasing populations, the emergence of chronic noncommunicable diseases (CNCDs) with their uncertain web of causation along with globalization, and economic changes, is more complex requiring more rigorous and careful application of epidemiologic principles. As well, the unevenness of the health transition mandates that countries and regions while drawing lessons from each other’s experience must generate their own indigenous knowledge of health-related patterns and associations to tailor appropriate interventions. The Caribbean region needed a strategic approach to enquiry, which included a steady stream of researchers skilled in the evolving research techniques to meaningfully respond to the current health agenda. The region benefited in earlier years from visiting researchers who recognized the differences in disease patterns between the United Kingdom and the Caribbean. The pioneering work of Ashcroft and Miall [9], Miller and Ashcroft [10], Ashcroft [11], Cochrane and Stuart [12], and Ashcroft and Desai [13] documented the early features of the CNCD epidemic and the differences in disease patterns. These efforts suffered from the evanescent character of ‘‘grant-funded projects,’’ which cannot build sustained progress, the latter requiring regional commitment to identify and address the domestic agenda. This deficit did not escape the attention of the region’s biomedical ‘‘think-tank,’’ the Commonwealth Caribbean
1102
R.J. Wilks / Journal of Clinical Epidemiology 68 (2015) 1101e1104
What’s new? Key Findings Over the last three decades the Caribbean has made significant progress in developing an indigenous cadre of epidemiologists and health researchers, thus reducing its reliance on expatriates in the specialty. Evidence-based-medicine (EBM) is now a legitimate component of the region’s training. programme as well as its clinical and public health practice. Research from the region has had significant impact on clinical practice and health policy. What this adds to what was known? The region now has the capacity to train its specialist health researchers as well as to imbed and inculcate the research evidence-based culture in clinical and public health practice. The opportunities to further develop and sustain this capacity have been highlighted. What is the implication and what should change now? In order to sustain this capacity for EBM the region must create career paths for its practitioners including the strategic and systematic realignment of clinical workload in order to encourage clinical research.
Medical Research Council (CCMRC) (previously the Scientific Advisory Council and subsequently the Caribbean Health Research Council). The CCMRC commissioned a report by George Miller in 1981 to review the priorities for addressing the emerging problems of CNCDs. The report articulated the need for the region to invest in developing its own capability and human resource to address these problems. This required a cadre of skilled health researchers with sound basic training in epidemiology, specifically clinical epidemiology [14]. Miller foresaw epidemiology embracing all specialties and urged the region to invest in persons to pursue this essential component of health practice. This was consistent with the proposal by Sackett et al. [3] that epidemiology should be regarded as a basic science for medical practice. The region’s response to this charge appeared to have had a long gestation but has built progressively over the period since 1984 to where few would argue against its success. The benefit of this investment over time has become evident over the last decade. Over the last 30 years, the
region has committed to the training of talented young investigators. Some training has taken place in our developed country neighbors with some individuals returning to contribute to the creation the regional pool of skilled health researchers. Their efforts have contributed immensely to the creation of regional knowledge providing policy makers of our nations with the confidence to lead the United Nations ambition to ameliorate the global burden of noncommunicable disease (UNHLM 2011) [15]. This cadre has brought the principles of epidemiology and scientific research to the training of health researchers in other specialties, enriching the learning experience of students of nutrition, public health, and medicine. There have been setbacks with epidemiology emerging as a competitive career in the developed countries, retaining recruits from outside the region was difficult. The combination of loyalty, the vision to be part of a pioneering movement, and the development of opportunities for relevant research projects led to the retention of committed individuals who have over the last decade strengthened epidemiology and confirmed its relevance and importance to regional health workers. It could be argued that the region’s exemplary response to the human immunodeficiency virus/AIDS epidemic benefited from its history and culture of health research and intervention as well as the growing cadre of health researchers schooled in the principles of epidemiology. At the same time, our response to the chronic disease epidemic is less developed but improving steadily. The last decade has seen several positive developments indicating the deepening roots of epidemiology and its principles in the region’s health psyche. These include an increasing number of persons from varied fields (medicine, biomedical sciences, social sciences) seeking training in epidemiology; embedding of epidemiology and research training in the medical school curriculum of the University of the West Indies (UWI), where third year medical students are immersed in a 10-week course of ‘‘Understanding Research,’’ including clinical epidemiology and EBM; development of a Master of Science degree in epidemiology at the UWI; incorporation of the UWI epidemiology group into the International Clinical Epidemiology Network and its regional branch CanUSACLEN; development of the Caribbean Branch of the US Cochrane Center; creation of a Caribbean branch of the London School of Hygiene and Tropical Medicine alumnae association; and the graduating of the first PhD candidate in epidemiology. This region’s response has been nurtured by several factors including: (1) the opportunity for young researchers to engage in pragmatic, relevant population health research that has found favor with the editors of reputable international journals [16,17] and clinical practice research that has been equally informative [18e21], (2) regional career opportunities in academia and policy, (3) increasing opportunities to collaborate with scientific investigators in developed and developing countries, (4) uptake of research findings by governments and other regional agencies into
R.J. Wilks / Journal of Clinical Epidemiology 68 (2015) 1101e1104
their policies and programs, (5) a more globalized approach to health research encouraging collaborations between developed and developing countries (e.g., the Global Alliance for Chronic Diseases [22]); (6) the region’s leadership in the global response to the CNCD epidemic with the Declaration of Port of Spain in 2007 [23] and the United Nations High Level Meeting on CNCDs in 2011 [15], (7) The USA National Institutes of Health (NIH) encouraging international collaborations, for example, National Institute of Health and Health Disparities, (8) journals (e.g., Tropical Medicine and International Health) insisting on indigenous academic participation in research from developing countries, and (9) an evolving source of research grant funds from regional bodies including academia, government, and quasigovernment agencies (universities, the Culture, Health, Arts, Sports and Education Fund, National Health Fund in Jamaica, and so forth), the private sector in Barbados. 4. Future steps The ethos of epidemiology has definitely taken root in the Caribbean, and this has been recognized and affirmed by regional governments, academic institutions, the international epidemiology community, and international donor agencies. This must be sustained with continued support by regional and international stakeholders, the creation of career paths for persons in the specialty, epidemiologists justifying their relevance by investigating and solving regional health issues, and the creation of a sustainable regional source of research grant funds. 5. Conclusion The region can feel proud of its legacy and justified that the beacon of EBM, the Cochrane Reviews, is named after an earlier contributor to Caribbean research and knowledge generation [12]. But its responsibilities for the future loom even larger as it tackles the double burden of infectious and nutritional deficiency diseases as well as CNCDs. Major challenges remain as clinicians are burdened with enormous clinical service load and opportunities for clinical epidemiology training and clinical practice research remain limited, requiring extraordinary effort by the most committed. To ensure that we do not fail, the region must protect the gift provided by epidemiologic principles as crucial to this mission. Achieving this will require innovative delivery of courses, which does not compromise clinical practice time and improved incentives in career advancement for the lifelong clinician learner who is committed to generating new knowledge from research in clinical practice.
Acknowledgments The author acknowledges the contribution of Professor Alan Jackson from the University of Southampton for his
1103
insightful comments on this article. The article pays tribute to the generations of expatriate and regional health researchers who have contributed to where we are now. The central role of the University of the West Indies is acknowledged. Thanks to colleagues, past and present, in the Epidemiology Research Unit and the Tropical Medicine Research Institute of the UWI who have contributed to the present reality and continue to work toward a better future.
References [1] Rothman KJ. Modern epidemiology. 1st ed. Boston/Toronto: Little, Brown and Company; 1986. [2] Webb P, Bain C, Pirozzo S. Essential epidemiology: an introduction for students and health professionals. New York, USA: Cambridge University Press; 2005. [3] Sackett DL, Haynes RB, Tugwell P. Clinical epidemiology: a basic science for clinical medicine. Churchill Livingstone; Boston/Toronto. 1st ed 1985. [4] Sackett D, Richardson WS, Rosenberg W, Haynes RB. Evidence-based medicine: how to practice and teach EBM. Edinburgh/London/ New York/Philadelphia/Sydney/Toronto: Churchill Livingstone; 1998. [5] Haynes RB, Sackett DL, Guyatt GH, Tugwell P. Clinical epidemiology: how to do clinical practice research. 3rd ed. Philadelphia/ Baltimore/New York/London: Lippincott Williams & Wilkins; 2006. [6] The Evidence-Based Medicine Working Group. Users’ guide to the medical literature: a manual for evidence-based clinical practice. 2nd ed. New York/Chicago/San Francisco: McGraw Hill; 2008. [7] Standard KL, Ennever O. Training health auxiliaries. West Indian Med J 1974;23(4):217e25. [8] Forrester T, Picou D, Walker S. The Tropical Metabolism Research Unit, The University of the West Indies, Jamaica, 1956-2006. Kingston: The House that John Built; 2007:344. [9] Ashcroft MT, Miall WE. Cardiothoracic ratios in two Jamaican communities. Am J Epidemiol 1969;89:161e7. [10] Miller GJ, Ashcroft MT. A community survey of respiratory disease among East Indian and African adults in Guyana. Thorax 1971;26: 331e8. [11] Ashcroft MT. A review of epidemiological research in a rural Jamaican community, 1959-1975. West Indian Med J 1979;28(1):3e16. [12] Cochrane E, Stuart KL. Cardiovascular disorders in Barbados. West Indian Med J 1963;12:275e84. [13] Ashcroft MT, Desai P. Blood-pressure and mortality in a rural Jamaican community. Lancet 1978;1:1167e70. [14] Miller GJ. The current status of cardiovascular disease research in the Commonwealth Caribbean. Commonw Caribbean Med Res Counc 1981;1981. [Report No]. [15] Assembly UNG. 2011 High Level Meeting on Prevention and Control of Non-communicable Diseases 2011: Available at http://www.un.org/ en/ga/president/65/issues/ncdiseases.shtml Accessed November 25, 2013. [16] Cunningham-Myrie C, Younger-Coleman N, Tulloch-Reid M, McFarlane S, Francis D, Ferguson T, et al. Diabetes mellitus in Jamaica: sex differences in burden, risk factors, awareness, treatment and control in a developing country. Trop Med Int Health 2013; 18(11):1365e78. [17] Tulloch-Reid MK, Younger NO, Ferguson TS, Francis DK, Abdulkadri AO, Gordon-Strachan GM, et al. Excess cardiovascular risk burden in Jamaican women does not influence predicted 10-year CVD risk profiles of Jamaica adults: an analysis of the 2007/08 Jamaica health and lifestyle survey. PLoS One 2013; 8(6):e66625. [18] East JM, Mitchell DI. Emergency open cholecystectomy is associated with markedly lower incidence of postoperative nausea and vomiting
1104
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(PONV) than elective open cholecystectomy: a retrospective cohort study. BMC Surg 2010;10:6. [19] East JM, Valentine CS, Kanchev E, Blake GO. Sentinel lymph node biopsy for breast cancer using methylene blue dye manifests a short learning curve among experienced surgeons: a prospective tabular cumulative sum (CUSUM) analysis. BMC Surg 2009;9:2. [20] Ferguson TS, Tulloch-Reid MK, Younger NO, Boyne MS, WrightPascoe RA, Elliott VE, et al. Cardiovascular disease among diabetic in-patients at a tertiary hospital in Jamaica. Diab Vasc Dis Res 2010; 7:241e2.
[21] Ferguson TS, Tulloch-Reid MK, Younger NO, Wright-Pascoe RA, Boyne MS, McFarlane SR, et al. Diabetic foot complications among patients attending a specialist diabetes clinic in Jamaica: prevalence and associated factors. West Indian Med J 2013;62(3): 216e23. [22] Global alliance for chronic diseases. Available at: http://www.gacd. org/, Accessed November 25, 2013 [23] CARICOM. The Declaration of Port of Spain 2007: Available at http://www.caricom.org/jsp/pressreleases/pres213_07.jsp Accessed November 25, 2013.
