The beaches are white sand, cruise ships meander through its warm azure waters and Rihanna is its global champion. But there is major trouble in Barbados’s 167 square miles of paradise. You could call it obesity, you could call it heart disease, diabetes and high blood pressure. Or you could call it the postcolonial predations of Big Food and Big Sugar.
Barbados, like other small island developing states, is fighting for its people’s survival. On this beautiful island, people wander daily into danger, swinging two-litre flasks of sugary drinks such as Coca-Cola as they step out of their cars, buying local fast food from the back of a van for lunch and queueing at Kentucky Fried Chicken or the local chain Chefette in the evening. The blessings of the modern convenience world have been visited upon small islands, with the result that more than half their people are dying prematurely from heart and lung conditions, cancer, diabetes and other non-communicable diseases.
Blame is being laid at the door of the food industry. The world’s 57 small island developing states, or SIDS, as the UN collectively calls them, have particular vulnerabilities. They cannot grow enough fresh food for their populations and, as the climate crisis worsens, water is scarcer and storms wipe out entire fields of crops every year. So they are reliant on importing their food: for some islands as much as 90% of it. And much of what they import is ultra-processed food, high in calories with very little nutritional value.
This month, the World Health Organization will convene a ministerial meeting of small-island states in Barbados to forge a united response to killer non-communicable diseases (NCDs) and mental health.
The problems in Barbados are rooted in colonialism and slavery. People labouring on the sugar plantations were given the rejected parts of pigs – the tails, the ears, the feet – while the landowners ate or exported the lean meat. Such fatty food, heavily salted, seasoned and pickled for taste, has become the traditional Saturday staple, called pudding (sweet potato mash) and souse.
If that early diet taught a love of salt, the sugar cane may have nurtured the taste for very sweet food that is also evident in Barbados today. Even coconut and peanuts come sweetened. The historian Sir Hilary Beckles, vice chancellor to the University of the West Indies, has demanded reparations. “Britain left behind a pandemic of chronic diseases. The hypertension, the diabetic pandemic collectively have constituted a threat to the existence of Caribbean society,” Beckles told Jamaica’s newspaper the Gleaner in 2020. Barbados and Jamaica had become the amputation capitals of the world, he said, as the taste for sugar fuelled the rise of type 2 diabetes.
The human toll of non-communicable diseases (NCDs) is huge and rising. These illnesses end the lives of approximately 41 million of the 56 million people who die every year – and three quarters of them are in the developing world.
NCDs are simply that; unlike, say, a virus, you can’t catch them. Instead, they are caused by a combination of genetic, physiological, environmental and behavioural factors. The main types are cancers, chronic respiratory illnesses, diabetes and cardiovascular disease – heart attacks and stroke. Approximately 80% are preventable, and all are on the rise, spreading inexorably around the world as ageing populations and lifestyles pushed by economic growth and urbanisation make being unhealthy a global phenomenon.
NCDs, once seen as illnesses of the wealthy, now have a grip on the poor. Disease, disability and death are perfectly designed to create and widen inequality – and being poor makes it less likely you will be diagnosed accurately or treated.
Investment in tackling these common and chronic conditions that kill 71% of us is incredibly low, while the cost to families, economies and communities is staggeringly high.
In low-income countries NCDs – typically slow and debilitating illnesses – are seeing a fraction of the money needed being invested or donated. Attention remains focused on the threats from communicable diseases, yet cancer death rates have long sped past the death toll from malaria, TB and HIV/Aids combined.
'A common condition' is a Guardian series reporting on NCDs in the developing world: their prevalence, the solutions, the causes and consequences, telling the stories of people living with these illnesses.
Tracy McVeigh, editor
Not everybody agrees with that diagnosis, but there is no doubt today’s Barbadian diet is unhealthy. Fried fishcakes from a roadside stall for breakfast, lunch of macaroni pie loaded with a vast amount of cheese. Mac pie is also offered as a side dish with other meals such as fried chicken or fried fish with chips. Cake shops sell as snacks muffins three times the size of those in the UK, heavily sweetened and sugar-coated. Bread is mostly white and denuded of nutrients.
Lack of exercise doesn’t help. The climate means it’s hot to jog, but although nowhere is far from a beach, many Barbadians cannot swim. “The sea has no back door,” grandmothers used to tell children. And the damaging culture they have adopted comes from wealthy America, where the car is king. There are very few bikes on the Bajan roads.
Post-slavery, people in Caribbean islands were still physically active, working in agriculture, and eating a healthier diet, says Dr Kenneth Connell of the University of the West Indies, a hypertension specialist and vice president of the Healthy Caribbean Coalition (HCC). “Then modernity kicked in, they became more industrialised,” with Trinidad and Jamaica ahead of the rest. “And then there was this kind of paradox where modernity that was supposed to bring a more affluent and comfortable lifestyle, brought with it an unhealthy lifestyle.
“But unlike other territories where this was slowly happening, I’m not sure the Caribbean realised at an early enough stage where our environment was becoming unhealthy. And so for instance, not walking became something to brag about. I don’t have to walk to church, you know, I have a vehicle, or I don’t have to eat food coming from a garden because I can go to the supermarket and buy processed foods.”
His generation, he said, was totally influenced by the US “enjoying the convenience of the KFC because it was on television and going to this thing called a drive thru. You don’t even have to get out of your vehicle, so you can walk less.”
Sir Henry Fraser, former professor of medicine and founding director of the leading research centre on chronic diseases in the Caribbean, was involved with a study published in the mid-90s comparing rates of hypertension (high blood pressure) in black populations from West Africa with those from the Caribbean and from Chicago. “What became very clear was that there were two amazing trends for obesity and hypertension, from very low incidences in West Africa, through Jamaica, St Lucia, Barbados, to a peak in Chicago. People got fatter and fatter as they moved west and the hypertension went up in sync. So there was a huge relationship with obesity, but probably an even bigger relationship with modern society.
“The changes in the Caribbean were quite dramatic. As they went through the era of the 60s, lifestyles changed dramatically, hotels were built, people stopped working in agriculture.”
There are now 15 Chefette outlets in Barbados. KFC has 12 stores, or more than four for every 100,000 people – only the Cayman Islands and Trinidad and Tobago have a higher ratio. The supermarkets are expensive and the shelves are loaded with imported Spam and other tinned meat, salty snacks, sweetened tinned fruit and highly sweetened breakfast cereals. In St Lucia, the Waitrose Essentials line was on display, from sweetcorn to frozen roast potatoes to ice-cream – at higher prices even than in the UK.
In Barbados, 40% of people over 25 are hypertensive and more than 20% have type 2 diabetes – in the UK, the respective proportions are about 30% and 10%. “We have a massive NCD burden,” says Dr Arthur Phillips, the government’s senior medical officer of health with responsibility for NCDs. Prof Karl Theodore, director of the Health Economics Unit at the University of the West Indies, based in Trinidad and Tobago, has estimated that NCDs cost Barbados $375m (£150m) annually, or 3% of GDP. He predicts the illnesses could drain the Caribbean region of as much as 10% of GDP.
Mia Mottley, prime minister of Barbados, has made the NCDs a government development priority. It’s no longer just a matter for the Ministry of Health and Wellness. “People are getting diabetes, getting their limbs cut off. We need to raise taxes. The minister of finance says I didn’t sign up for this. But we say this is a drain on economic activity,” says Phillips.
In 2015, the government introduced a 10% tax on sugary drinks. Coca-Cola, the biggest producer of sugar-sweetened beverages on the island, asked why the government was not instead just taxing sugar and promoting physical activity. “Then they said if you do it, we will pull out of Barbados,” said Phillips. The prime minister refused to meet the company. The tax came in and weekly sales of sugar-sweetened drinks dropped by an estimated 4.3%.
In 2022, the tax was increased to 20%. This time a coalition of companies arrived for talks and launched an advertising campaign. Billboards on bus stops now declare: “Balance what you eat, drink and do.” In other words, says Phillips, “burn it off”. He knows that in Barbados, where 43% of adults and 82% of adolescents take no exercise, that isn’t going to happen.
Coca-Cola says it wants to be part of the solution and is partnering with the government now, offering training for small shops and distributors and developing a calorie-counting app for the Caribbean – an initiative that has raised eyebrows. “It plays into the idea that all calories are created equal, which is not true,” says Phillips. “It plays into the idea of individual responsibility as the key plank, as opposed to a supportive environment being important. It’s saying: ‘It’s up to you, we’ve given you a counter. So your job is just to look at everything you eat and then if there’s something wrong with you, it’s your fault.’”
Mottley has asked the health ministry to look at the possibility of a salt tax, which would be a first in the Caribbean. But the bigger battle Phillips and colleagues are fighting is over food labelling.
The HCC has been pushing for black octagonal warning signs on the fronts of packages, stating in alarming capitals: “HIGH IN SUGAR”, “HIGH IN SALT” or “HIGH IN FATS”. It works in Chile. The food industry is strongly opposed to such a move. The Caricom Private Sector Organization (CPSO) commissioned a study that suggested detailed nutritional traffic-light-style labels were better than the stark warnings. “It’s No 1 in the playbook of the tobacco industry: how do we counter the research with our own research?” says Maisha Hutton, executive director of the HCC, which is funded by Bloomberg.
Tobacco companies are excluded from governmental discussions. So far, the food industry is staying at the table. Its argument has always been that everybody has to eat.
The CPSO is represented in the labelling negotiations at the regional intergovernmental organisation Caricom, which have been taking place since 2018. In the latest vote, six out of nine governments were in favour of the octagonal warnings, but it will take 75% to trigger change.
Some countries are concerned for their homegrown industries. In Trinidad and Tobago, SM Jaleel makes Busta and Chubby drinks for the region. Jamaica has its own processed foods industry. Neither country voted for the warning labels, although Jamaica’s health minister, Christopher Tufton, was strongly in favour, against the position of the island’s ministry of commerce. Heavy alcohol use is also clearly a risk factor in mental and physical health, but there are few sanctions against rum manufactured in the Caribbean. Barbados does not even have a breathalyser test or blood alcohol concentration limit for drivers.
Barbados’s minister for health and wellness, Sonia Browne, says the government has been in talks with Coca-Cola and Chefette, which in principle express willingness to help. But Chefette is entrenched across Barbados: playgrounds at every store, a toy with every meal and sponsorship and sales at school sports events. Browne says tackling this will be “the hardest thing”. Even in the countryside, there is Chefette, Burger King, Little Caesar (“the saltiest thing”) and Subway.
“All these things are now situated in St Philip, which was unheard of because traditionally St Philip was rural. This is where you get the sweet potato, and people share the cassava and bread fruits. Now they share Chefette snack boxes. So this will be something that we really have to figure out how to tackle and hope for their input,” she said.
The strategy now is to change children’s diet through a school nutrition plan. Sales of sugary drinks this term are banned in the privately run secondary school canteens, and the government has produced lists of acceptable snacks, while the state-supplied lunches in primary schools are being overhauled. Yams, cassava, breadfruit and sweet potatoes are being brought back into meals. “Have children develop a palate for it? A lot of the parents are young and have been brought up on not too healthy foods, so that is what they know,” said Browne.
At Queen’s College, a secondary school in Saint James, Joyann Clarke and Akilah Martin, who have the canteen concession, mix pureed pumpkin and carrots into the cheese sauce of their mac pie. Barbadians don’t much care for vegetables. When carrots were visible, the children would either avoid the meal or pick them out to throw away. “The kids love lamb stew, macaroni pie and chicken,” says Clarke, but all must now contain a vegetable.
Until last term, 85% of their students ate fries every day – often with mac pie as well – and the drinks contained 15 to 20g of sugar. Now they sell grilled potatoes and salads dressed with garlic and olive oil, in smaller containers. Burgers are still on offer, but with lettuce, cucumber and tomatoes. Flavoured waters are on sale, but no sugary drinks.
“Sales are down,” says Clarke. “There’s no doubt about that.” It’s also more work. “We used just to slap a burger between bread.” But, says Martin, “they are going to have to get used to it.”
Some schools are struggling. Martin and Clarke have formed an association to bring the canteen concession holders together and support each other. It’s important, they say. “These are our children who 20 years from now are going to be diabetic,” said Martin.
The ministerial meeting beginning on 14 June will be focused on what to do about NCDs, including those involving mental health. In 2019, the WHO began to look at the commercial determinants of health, which Monika Kosinska, who leads on the issue for the organisation, describes as “how commercially driven processes impact broadly across public health”. It’s about food, but includes alcohol, tobacco, pharma and the extractive industries: how the interaction of commercial interests with economies, governance, trade and other areas contributes to health inequities. The WHO hopes to produce a global report next year.
Kosinska says concerns, particularly about food, have come out “extremely strongly” from the small islands since a January meeting in preparation for the June summit, “highlighting the imbalance of power between the large commercial actors and small islands”. Nobody expects any miraculous solutions to the huge and intractable problems affecting small islands that have too little money and a history of being exploited. But the food industry must now be on notice that the fightback has begun.
