On what it really takes to lead in public health in the Caribbean — and why the region deserves leaders who refuse to wait for permission.

There is a particular kind of meeting I have attended many times across the Caribbean. The room is full of intelligent, well-meaning people. There are PowerPoint slides with excellent data. Everyone agrees that the problem is serious. The conversation is stimulating. And then the meeting ends, the recommendations go into a report, and on the ground — in the clinics, the communities, the households — nothing changes.

I started the Sickle Cell Cares Foundation in Dominica in 2013, when I was in my early twenties, because I understood, viscerally, that nobody was coming to save us. Not because people didn’t care. But because the Caribbean’s public health challenges — real, urgent, and complex — are routinely addressed at a level of abstraction that leaves the people most affected completely out of the room.

Twelve years later, I have learned a great deal about what public health leadership actually looks like in a small island context. Very little of it resembles what I was taught to expect.

The burden we carry — in numbers

33% of Dominicans carry the sickle cell gene — among the highest rates in the world. A 70% reduction in under-5 SCD mortality is achievable through early newborn screening. And before SCCF began this work, there were zero national newborn SCD screening programmes in Dominica.

These numbers tell a story about a gap — between what is known to work and what is actually implemented — that is depressingly familiar across Caribbean public health. We are not short of evidence. We are not short of guidelines, frameworks, or regional strategies. What we are short of, consistently, is the bridge between knowledge and action at the community level.

That bridge is leadership. Specific, grounded, locally embedded leadership that understands the terrain — not just in the epidemiological sense, but in the human sense. Who are the gatekeepers of trust in this community? Which health worker will champion this programme? What happens to this initiative when a hurricane hits and the health system goes into emergency mode for three months?

These are not questions that get answered in a regional policy brief. They get answered by people who are present, consistently, over years.

“We are not short of evidence. We are not short of guidelines or frameworks. What we are short of is the bridge between knowledge and action at the community level.”

What Caribbean public health leadership actually demands

When people ask me about leadership in global health, they often want to talk about vision, strategy, and influence. And those things matter. But in the Caribbean context, the most essential leadership qualities are less glamorous and harder to teach.

The first is patience without passivity. Systems change slowly in small island states — partly because institutions are under-resourced, partly because political cycles create instability in health priorities, and partly because the same small group of people are managing every crisis simultaneously. Learning to maintain momentum without burning bridges, to advocate persistently without becoming an adversary, is a skill that takes years to develop. I have not always gotten it right.

The second is knowing your data better than anyone else in the room. Civil society organisations in the Caribbean are often dismissed as advocates rather than technical actors. The antidote is rigour. When SCCF partnered with Boston Children’s Hospital to map NCD mortality following Hurricane Maria, we were not just generating research. We were establishing our right to lead a technical conversation. In a region where external consultants frequently arrive with less contextual knowledge than the local NGOs they are nominally supporting, this matters enormously.

The third is building coalitions before you need them. The neonatal screening programme we are implementing now is possible because of relationships I have been cultivating for a decade — with the Ministry of Health, with clinical partners in Jamaica and Barbados, with community members who trust SCCF enough to bring their newborns for testing. None of those relationships were formed in a conference room. They were built through years of showing up — to the community meeting, the health fair, the antenatal clinic session — when there was nothing immediately in it for us.

The particular position of women in Caribbean public health

I would be dishonest if I wrote about leadership in Caribbean public health without acknowledging the gendered dimensions of that experience. The Caribbean health workforce is predominantly female — nurses, midwives, community health workers, and health educators are overwhelmingly women. Caribbean public health NGOs are largely founded and led by women. And yet the highest levels of health system governance, the bodies that make decisions about resource allocation and health policy, remain disproportionately male.

This creates a particular kind of cognitive dissonance that many of my peers will recognise. You are trusted enough to do the work — to be in the community, to earn the trust of families, to design and deliver programmes. But you are not always trusted enough to set the agenda. You are consulted, but not always heard. Your data is used, but not always credited. Your organisation is partnered with, but not always funded at the level that reflects the value it is generating.

I do not say this to be bitter. I say it because naming a structural reality is a prerequisite to changing it. The Caribbean public health space needs more women at the tables where decisions are made — not as a matter of representation for its own sake, but because the women who are doing this work at the community level carry knowledge that is genuinely irreplaceable. We cannot afford to waste it.

“You are trusted enough to do the work. But you are not always trusted enough to set the agenda.”

What I want for the next generation

There are extraordinary young public health professionals emerging across the Caribbean right now. I meet them at conferences, in mentorship programmes, through networks like One Young World. They are sharp, they are motivated, and they are often working in conditions that would exhaust anyone — managing complex programmes with minimal budgets, navigating bureaucratic obstacles, rebuilding after every disaster.

What I want for them is not a smoother path. Difficulty builds competence, and the Caribbean context will always involve difficulty. What I want for them is a better-resourced ecosystem: funders who understand the value of long-term, flexible support for grassroots organisations; regional institutions that engage civil society as genuine partners rather than stakeholders to be managed; governments that invest in their own public health workforces rather than relying on international consultants to deliver what local expertise could do better and more sustainably.

And I want them to resist the impulse — which the funding landscape constantly reinforces — to frame their work in terms that are legible to external audiences at the expense of terms that are meaningful to their communities. The people we serve are not beneficiaries. They are the reason the work exists. That distinction is not semantic. It shapes every decision you make.

In 2013, I founded SCCF with no funding, no office, and no guarantee that anyone would show up. In 2026, we are implementing a national neonatal screening programme, building a patient registry, and training health workers across every district in Dominica. None of that happened because someone gave us permission. It happened because we decided that the gap between what existed and what was needed was our problem to solve.

That is what public health leadership looks like in the Caribbean. Not waiting for the perfect conditions. Building something real, in imperfect conditions, for the people who need it now.

#PublicHealth #Caribbean #Leadership #WomenInHealth #SickleCellDisease #GlobalHealth #SIDS #Dominica #CommunityHealth #HealthEquity