By Way of the British Virgin Islands
The Weight of Small
Field Notes Series: The Soft Side
Entry #3 of 6
Disclaimer
Field Notes reflect the editorial analysis and personal reflection of the Managing Editor, informed by direct professional experience across Caribbean healthcare systems. These observations are the author’s own and do not represent the official positions of any government, institution, or commercial partner.
The British Virgin Islands does not look, from the outside, like a place where healthcare access is a problem.
It is one of the wealthiest territories in the Caribbean — offshore financial centre, superyacht destination, a per capita GDP that flatters the aggregate picture considerably. The water is extraordinary. The sailing is world class. For a period of nearly four years, beginning in 2012, it was my base. I was there because of a personal relationship, and because the territory offered something that mattered to me at that stage: a foothold in the region while I built a management advisory practice that was, by then, reaching well beyond the Caribbean.
From the BVI, I traveled. Across the region, across the globe — building a portfolio of work in international patient services and medical travel that would, by 2016, contribute to the development of the Global Accreditation Program: the world’s first ISQua-accredited medical travel accreditation. The standards I helped architect during those years addressed not only clinical quality but the standardisation of key business processes — the operational infrastructure that determines whether a patient’s experience across borders is consistent, transparent, and trustworthy from first inquiry to final follow-up. Both dimensions matter. Quality without process standardisation produces outcomes that cannot be reliably replicated or measured.
But it was not the global work that taught me the most during those years. It was the territory itself.
The BVI taught me that aggregate wealth is not the same as equitable access. And that geography, in a multi-island state, is always a health determinant.
The British Virgin Islands is not one island. It is a constellation of them — over sixty in total, of which four are inhabited: Tortola, the largest and the seat of government and services; Virgin Gorda, known internationally for The Baths and for the particular kind of concentrated wealth that accumulates around places like Bitter End Yacht Club on its northern shore; Anegada, flat and remote, a coral island sitting apart from the rest; and Jost Van Dyke, small and community-minded, accessible primarily by boat.
To think of the BVI as a single health system serving a single population is to misunderstand it entirely. It is four communities, each with its own geography, its own character, and its own relationship to the services concentrated primarily on Tortola. When a resident of Anegada needs hospital care, they do not drive to the hospital. They arrange to get to the water. They cross to Tortola. They navigate a system that was not designed around the assumption that the patient begins their journey at sea.
This is not unique to the BVI. It is the structural reality of multi-island small states across the Caribbean — a reality that aggregate statistics consistently obscure. A territory can be wealthy, in the aggregate, and still have populations for whom access to timely, appropriate care depends on weather, on ferry schedules, on whether someone with a boat is available, on whether the patient can afford to wait or cannot.
A territory can be wealthy in the aggregate and still have populations for whom access to care depends on weather, on ferry schedules, on whether someone with a boat is available.
The BVI is far from alone in carrying this burden. Across the Caribbean, dispersed populations place a particular and persistent strain on health systems that centralised planning models were never designed to absorb. The Bahamas — with its 700 islands and cays stretching across 100,000 square miles of ocean — knows this intimately. So does the Turks and Caicos, St. Kitts and Nevis, Antigua and Barbuda, and St. Vincent and the Grenadines, each managing the reality that the population requiring care and the infrastructure providing it are not always on the same piece of land. The political and financial cost of maintaining services across multiple islands is significant. The human cost of not doing so is greater. This is one of the defining structural challenges of Caribbean health systems — one that regional bodies acknowledge in principle and that individual territories navigate, imperfectly and persistently, in practice.
The political and financial cost of maintaining services across multiple islands is significant. The human cost of not doing so is greater.
What I observed in the BVI — and what I carried forward from those years — is that the soft side of health systems in multi-island states requires a different kind of imagination than it does elsewhere. It is not enough to ask whether the institution is functioning well. You have to ask who can reach the institution, under what conditions, and at what cost — not only financial cost, but the cost of time, of distance, of the particular anxiety that comes with being unwell on an island and knowing that the care you need is on another one.
Similar to what I had observed in the Dominican Republic, where vast degrees of wealth existed alongside significant inequality, the BVI presented its own version of that pattern. Wealth, visibly concentrated. Access, unevenly distributed. And a population that understood this not as a policy abstraction but as a lived condition — something you thought about when you chose where to live, when you calculated the distance between your home and the nearest point of care.
The soft side, in this context, is the work of holding both things at once: the genuine resources and capabilities a territory possesses, and the genuine gaps that its geography and its history of uneven development create. It is the work of not allowing the aggregate picture to substitute for the particular one. Not allowing the superyacht in the harbour to stand in for the family on Anegada deciding whether the ferry crossing is feasible today.
The soft side is the work of not allowing the aggregate picture to substitute for the particular one.
In 2014, a project that had been in development across more than one political cycle reached completion — the dedication of a new hospital facility within the BVI Health Services Authority. I was familiar with the project through personal connection; a family member had served as Minister of Health during an earlier phase of its long journey from vision to brick and mortar. I did not participate in its opening. But I watched, with the particular attention of someone who had spent years thinking about what health infrastructure means to the communities it serves.
What I understood, by then, was that the opening of a building is only one part of the story. The harder questions — who can reach it, who feels welcome in it, how it earns the trust of the communities it serves across four islands and decades of unmet expectation — are the questions that outlast any ribbon-cutting. They are, in every territory I have worked in, the questions that fall to the soft side.
The BVI years, 2012–2015, were years of movement. I was in and out of the territory, traveling to build something that was, in its own way, an attempt to answer the same questions I was observing at home: how do you create systems that move patients toward quality care, that build trust across distances, that ensure the standards governing that movement are rigorous enough to be meaningful?
The irony was not lost on me. I was helping build the global architecture for international patient movement while sitting in a territory where the movement of a patient from one island to another remained, for many, a significant and uncertain undertaking.
I was helping build the global architecture for international patient movement while sitting in a territory where crossing to the next island remained, for many, a significant and uncertain undertaking.
That tension did not resolve itself. It sharpened my understanding of what the soft side is actually for.
It is not a luxury layer added to functional health systems. It is the work of ensuring that the human experience of those systems — the getting there, the being seen, the trusting that the care on offer is meant for you — is not an afterthought. In a multi-island state, that work is inseparable from the geography. You cannot think about patient experience without thinking about the ferry. You cannot think about access without thinking about the four inhabited islands and the very different lives lived on each of them.
The BVI gave me that understanding. Not as a theory. As a landscape I lived inside, moved through, and came to know in the particular way that only time and proximity allow.
Small, I learned, is not simple. It is layered. And the weight of it — the weight of being a small state responsible for the health of communities distributed across water — is something that no aggregate statistic, however flattering, can carry for you.
Infrastructure built slowly, across political cycles, across years of uncertainty, is still infrastructure. When the storm comes, what was built is what remains.
On September 6, 2017, Hurricane Irma made landfall in the British Virgin Islands as a Category 5 storm — one of the most powerful Atlantic hurricanes ever recorded. I was not a resident by then. I watched from a distance as a territory I had lived in, worked alongside, and come to know closely absorbed something catastrophic. The images that came out of the BVI in the days that followed were of a landscape almost unrecognisable — roofs gone, boats destroyed, communities stripped to their foundations.
The hospital stood.
The facility that had been years in the making — built across more than one political cycle, absorbing the delays and debates that infrastructure projects in small states almost always absorb — held when it was needed most. Not perfectly, not without challenge, not without the profound strain that a Category 5 storm places on any health system. But it stood. And in standing, it became the place the territory turned to in its most acute moment of need.
I thought, watching from outside, about the long argument of those years. About how difficult it is to sustain the political will and the public patience that major infrastructure requires in a small island developing state — where budgets are tight, where priorities compete, where the case for a building not yet built is always harder to make than the case for immediate needs. About how the people who argued for it, who pushed through the difficult years, who held the vision across administrations, could not have known in those moments that they were building something that would stand through a catastrophe.
This is the long soft side — the one that operates across decades rather than months. The conviction that what you build today will matter to someone you have not yet met, in a crisis you cannot predict. Health infrastructure in the Caribbean is not built for ordinary days. It is built for the days when the fragility of life in a small island state becomes impossible to ignore — when the storm arrives, and the sea rises, and the question of what holds is no longer theoretical.
The BVI answered that question in 2017. The answer had been built, slowly and imperfectly, in the years before.
About This Series
The Soft Side is a seven-part Field Notes series tracing seventeen years of health system work across the Caribbean — and the people, places, and lessons that shaped it. New parts publish each Sunday.
Coming next Sunday:
Part 4 — By Way of Home: What Distance Teaches
The return to the United States. What you see about the region only when you step outside it — and why you came back anyway.
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