Paul Greaves shares the experiences of the effects of politics on health care in the developing nation of Grenada--a tropical paradise with a chequered history

At the most southern tip of an arc of small volcanic islands in the Caribbean lies a tiny nation. It may have remained anonymous among the many island paradises speckling the globe between Florida and Venezuela but for a few weeks of violence in the 1980s. This is Grenada--its name is the only relic of Spanish colonisation.

The years since independence from British influence have left Grenada different from any other nation in the eastern Caribbean. Radical left wing idealism and an unlikely alliance with Cuba created a nation doing better than others with similar demographic, geographic, and economic problems--until this radicalism fell prey to its own extremists.

A coup, provoked by the prime minister forging closer ties with the United States, plunged the nation into brief but bloody chaos. The presence of medical students on the island was used to justify familiar US foreign policy: it wielded its might against a nation whose politics contradicted American ideals. The United States maintain a presence, if not a political influence on the island, in the form of the 30 year old medical school--True Blue--perched dramatically on a southwestern peninsula.

Grenada is one of the world's hotspots for rheumatic fever, a syndrome resulting from streptococcal infection. The high prevalence in Grenada reflects the developing world generally, yet prevention is neglected.

Fortunately, new impetus for intervention has recently emerged, thanks to both successful public health initiatives in the neighbouring republic of Trinidad and Tobago and all important US backing, at a time when infectious disease is becoming a problem of the developed world again.

Researchers based at the True Blue campus saw this as an opportunity to intervene in their own country. The resulting project is probably the most ambitious undertaken here--at all levels, from policy makers to blood takers--involving the coordination of researchers, paediatricians, and health centres. The remit is to determine the extent of the rheumatic fever problem in Grenada, while developing a more effective diagnostic, referral, and follow up programme, all with limited healthcare resources.

Trevor Noel, project coordinator, ensured that my elective here would involve me in most aspects of the project, from the paediatric wards of the General Hospital to the laboratories at True Blue.

Grenada's rundown General Hospital--its Cuban funded replacement, Havana, is still under construction--overlooks the capital. St George's is one of the most picturesque and unspoilt towns of the Caribbean, surrounding the flooded volcanic crater that is now the harbour.

There are few medical resources outside of St George's: any care beyond general practice and midwifery involve a crowded minibus journey along the island's often treacherous roads. As the island lacks facilities, patients must often be transferred--usually at their own expense--to the neighbouring islands of Trinidad or Barbados.

Surgery for victims of rheumatic heart disease takes place in the United States, one of the happier outcomes of Reagan's 1983 intervention. With his army present on Grenadian soil, the American president heard of a child unable to afford desperately needed valve replacement surgery. His dramatic response was to dispatch Air Force Two to Grenada, collect the child, and fly her to an American facility for surgery. The repercussions of this gesture have been enormously beneficial: awareness of the problem was raised, charities set up, and long term US help assured.

The key to this project's success is exposure: public health messages are uncompromising and everywhere on this island, from preaching abstinence to combat HIV to keeping dengue spreading "suckers" at bay. The rheumatic fever project hasn't neglected the media and sends out equally prominent messages on everything from billboards to cable television.

Another aspect of the project is a clinic dedicated to detection and follow up of children with rheumatic fever. This was run in the old Town Hall--matched only in crowds, noise, and apparent anarchy by the market below.

The clinic was run by Nurse Perotte, a formidable woman, raised on the rugged mountainous island of Dominica 320 km north of Grenada. She worked at the clinic and on the epidemiological aspect of the project--collecting samples to estimate the extent of group A streptococcus infection of island schoolchildren. A resident with more extensive knowledge and opinions of island culture would be hard to find.

She became my mentor in the ways of schoolchild discipline and headmaster chastisement, blood letting and throat swabbing, mountain-road driving, and, most importantly, island politics.

The potential difficulties of tackling 50 schoolchildren at a time, armed only with cotton wool buds and a crateful of butterfly needles, were no match for Perotte: she soon had the kids lined up, pushing for views of their impending fate.

Tears came from teenagers, not 5 year olds; looks of abject terror replaced by grins of excitement as blood shot from successfully located veins, down plastic tubing, and into test tubes. And when a vein wouldn't show itself, Perrote would look up to the sky and ask Jesus to guide her--that never failed.

I arrived in Grenada not knowing where it was and even less of its tumultuous history. My elective provided a glimpse of its 130 square miles of lush rainforest, secluded beaches, and an insight into the lives of its 100 000 inhabitants.

Two months on this tropical island gave me some brief understanding of life far from the comforts and complacency of Britain. A place where politics has affected health care vastly more than we experience in the developed world.