GOVER N ME N T O F BE R MU DA

Ministry of Health

Chief Medical Officer’s Annual Report 2023:

A Post-Pandemic Focus on Health Inequalities
 G OVER N ME N T O F BE R MU DA
Ministry of Health

Chief Medical Officer’s Annual Report 2023:

A Post-Pandemic Focus on Health Inequalities
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Foreword

The publication of an annual report written by a country’s Chief Medical Officer or Surgeon General
is a longstanding public health tradition across the globe. The purpose of these annual reports is to
provide an independent assessment of the state of public health, highlighting issues, which in their
opinion, should be the current focus of policy and action to improve the health of the population.

The publication of the Chief Medical Officer’s Annual Report in Bermuda has been delayed for sev-
eral years, partly due to the COVID-19 pandemic, which dominated the attention of all those work-
ing in the Ministry of Health.

As we emerge from the pandemic, I am keen to re-establish the Chief Medical Officer’s Annual Re-
port on a firm footing. My intent is to publish annually, outlining key public health trends in Bermu-
da, focused around a central theme.

The theme for my report in 2023 is health inequalities in the post-pandemic era. COVID-19 has
enormously impacted health, including its upstream determinants disrupting normal economic
and social life. International evidence suggests that COVID-19 is exacerbating underlying health
inequalities, which will need to be addressed to prevent COVID-19 from having a long-term scarring
effect on our health. I have written this report as a short thematic essay that sits alongside longer,
more technical reports such as the Bermuda Joint Strategic Needs Assessment of Health 2023 and
Health in Review 2023. The underlying data used to write this report is presented in a supplemen-
tary appendix.
I hope you find this year’s report helpful in gaining a greater insight into health inequalities in Bermu-
da and that it helps you understand my priorities as well as the considerable uncertainty surround-
ing some of the areas of interest.

Dr. Ayoola O. Oyinloye M.B;B.S, MSc, MPH, FFPH

Chief Medical Officer

April 2023

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Contents
Foreword..............................................................................................................................................................1
Key Messages:....................................................................................................................................................4
Health Inequalities..............................................................................................................................................5
Inequalities in Bermuda.....................................................................................................................................6
Variation in Mortality & Morbidity....................................................................................................................9
Variation in access to healthcare....................................................................................................................14
Vulnerable Groups and Inequalities...............................................................................................................16
People with Disabilities.................................................................................................................................16
Homeless Population.....................................................................................................................................16
Migrants.........................................................................................................................................................16
COVID-19 and Inequalities..............................................................................................................................17
· Infection Risk.........................................................................................................................................17
· Severe disease and mortality................................................................................................................17
Public Health Measures...................................................................................................................................18
Health Inequalities: Implications for Bermuda..............................................................................................20

Table of Figures
Figure 1. Socioeconomic markers by census district
(details in each panel), 2016, Department of Statistics..........................................................................................7
Figure 2. Population without health insurance coverage,
2016, Department of Statistics................................................................................................................................8
Figure 3. Distribution of causes of mortality,
2010-2019, Epidemiology and Surveillance Unit...................................................................................................9
Figure 4. Distribution of causes of mortality,
preliminary 2020-2021, Epidemiology and Surveillance Unit..............................................................................10
Figure 5. Distribution of diagnoses for health insurance claim costs,
FY2020-2021, Bermuda Health Council...............................................................................................................11
Figure 6. Factors contributing to health inequalities
(adapted from Labonte model)..............................................................................................................................12
Figure 7. Major risk factors for chronic diseases..................................................................................................12
Figure 8. The Four Stages of Prevention..............................................................................................................13
Figure 9. Cancer diagnoses, excluding non-melanoma skin cancer,
by stage at diagnosis and race, Bermuda National Cancer Control Plan.............................................................15
Figure 10. Distribution of persons vaccinated for COVID-19 through December 2021
using data from Government of Bermuda Pandemic Administration System via Locus Limited.......................18
Figure 11. Vaccination uptake by race through December 2021 using data
from Government of Bermuda Pandemic Administration System.......................................................................19
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Chief Medical Officer’s Annual Report 2023:

A Post-Pandemic Focus on Health Inequalities

“Of all the forms of inequality, injustice in health is the most shocking and inhumane.”

Martin Luther King Jr.1

Key Messages:
• Health inequalities result from social inequalities. Action on health inequalities requires
action across all the social determinants of health.

• Bermuda continues to show considerable societal inequalities, linked to socioeconomic

status, race, sex, and migration status.

• There is a lack of robust, population-wide data on health inequalities, particularly data that
can directly link health status with socioeconomic/information on disparities.

• The current health system is a driver of health inequalities. Lack of universal health coverage
is resulting in many of those with the greatest health needs being unable to access necessary
healthcare.

• COVID-19 is likely to have exacerbated societal and health inequalities, although the full
impact of the pandemic remains uncertain.

• Bermuda has a unique opportunity to address health inequalities through the Bermuda
Health Strategy 2022-2027 and the planned Universal Health Coverage programme.

• There is a need to develop measurable and objective indices of deprivation and inequalities.
This will assess the scale of the issues in Bermuda and monitor progress in addressing the
issues.

1 Luther King M. Jr. Presentation at the Second National Convention of the Medical Committee for Human Rights. Chicago, 25 March 1966

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Health Inequalities
Health inequalities are defined as “avoidable, unfair and systematic differences in health between
different groups of people”2. This is a broad definition which can be further broken down into in-
equalities relating to several areas of health:

• Social determinants of health such as income, quality of housing, education

• Health behaviours such as diet and physical activity

• Access to healthcare, such as health insurance status

• Quality and experience of healthcare, which may be related to the level of insurance coverage

• Health outcomes, both disease-specific and global outcomes, such as life expectancy

Research has shown that health inequalities do not only impact those living in income poverty but
display what is known as a social gradient in which life expectancy is correlated with an individual’s
or group’s relative socioeconomic position in society3. Health inequalities ultimately result from so-
cial inequalities.

The social determinants of health, “non-medical factors that influence health outcomes”, such as
an individual’s wealth, educational opportunities, social networks, and housing, are not equally
distributed throughout society. Whilst many of these factors can be addressed through focused
government policy, it should be recognised that these are influenced by wider socioeconomic, envi-
ronmental, and cultural conditions. From Bermuda’s perspective, as a small island state, the social
determinants of health will be affected as much by global economic trends as they are by local
conditions.

The social determinants will then feed into an individual’s health behaviours which can either pro-
mote health (e.g. through a balanced diet and physical exercise) or be detrimental to health (e.g.
poor diet, physical inactivity, and tobacco smoking). Higher risk health behaviours tend to be asso-
ciated with lower socioeconomic status.

Finally, lower socioeconomic status can limit access to healthcare, particularly in private insur-
ance-based systems such as Bermuda. Individuals may choose not to seek care due to cost or to de-
lay care, which may inadvertently result in higher healthcare costs for more complex manifestations
of conditions. Ultimately, this can result in what is known as the Inverse Care Law, in which people
with the greatest health needs are the least likely to receive the necessary healthcare4.

COVID-19 has exacerbated health inequalities globally. At a macro-level, this has seen populations
of wealthier jurisdictions being at lower risk from COVID-19 than the global poor due to better avail-
ability of non-pharmaceutical control measures enabled by social protection and access to sophis-
ticated healthcare, coupled with early access to vaccinations and therapeutics5. Even within the
wealthier jurisdictions, lower socioeconomic classes have been at greater risk from COVID-19 due
to increased exposure from frontline work, exacerbated by underlying health risks and challenges
in accessing care6. Interestingly, the uptake of COVID-19 vaccination has shown a social gradient
across a wide range of countries, including Bermuda7.

2 Williams E, Buck D, Babalola G, Maguire D. What are health inequalities? 2022. The King’s Fund. Available: https://www.kingsfund.org.uk/publications/
what-are-health-inequalities

3 Weil AR. Tackling Social Determinants of Health Around The Globe. Health Affairs. 2020;39(7). https://doi.org/10.1377/hlthaff.2020.00691

4 Tudor Hart J. The Inverse Care Law. The Lancet. 1971;297(7696):405-412 https://doi.org/10.1016/S0140-6736(71)92410-X

5 Launch: Special Issue of the International Journal for Equity in Health on COVID-19 and inequality (who.int)

6 McGowan VJ, Bambra C. COVID-19 mortality and deprivation: pandemic, syndemic, and endemic health inequalities. Lancet Public Health.
2022;7(11):e966-e975. https://doi.org/10.1016/S2468-2667(22)00223-7

7 ONS, 2023, Coronavirus and vaccination rates in adults by Socio-demographic characteristic and occupation, England: Dec2020 to March 2023. https://www.
ons.gov.uk/peoplepopulationandcommunity/healthandsocialcare/healthinequalities/bulletins/coronavirusandvaccinationratesinadultsbysociodemographic-
characteristicandoccupationengland/december2020tomarch2023
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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Inequalities in Bermuda
Getting a clear picture of health inequalities in Bermuda is far from straightforward. The recent
Bermuda Joint Strategic Needs Assessment of Health (JSNA) has brought together a broad range
of information relating to health and healthcare from across organisations in Bermuda.

In contrast to other high-income jurisdictions, the health information picture in Bermuda is limited in
its population coverage and ability to link with other relevant socioeconomic data (such as income
or educational attainment) to form a granular view of health inequalities. In fact, on the surface,
these inequalities may appear somewhat hidden, especially when much of the information is reliant
on insurance data.

Therefore, this report has been developed by linking relevant local data sets with global trends and,
where appropriate, using proxy indicators to help build the picture of health inequalities in Bermu-
da in 2023. Evidently, this approach has limitations. However, it should still give the best picture to
date of Bermuda’s health inequalities along with making the case for strengthening public health
information systems.

The 2016 Population and Housing Census is the most valid and reliable source of information on
Bermuda’s societal inequalities. It has shown a link between race and wider markers of socioeco-
nomic inequalities8. Figure 1 has been compiled from census maps and demonstrates that those
census districts with a higher percentage population identifying as black tend also to be districts
with a higher percentage of working age adults with no academic qualifications, higher rates of
unemployment and lower median annual income. Therefore, race can be a useful marker of societal
inequalities, although these societal-level associations may not necessarily be seen at the level of
the individual.

The 2016 census also mapped the percentage of population without health insurance coverage
(Figure 2). This unsurprisingly follows the patterns shown for wider socioeconomic inequalities and
is likely to further contribute to the Inverse Care Law discussed earlier.

Insurance coverage will be discussed in more detail in the Variation in access to healthcare section
of this report.

8 Department of Statistics. Population and Housing Census. 2016. Available: https://www.gov.bm/sites/default/files/2016%20Census%20Report.pdf

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 1: Socioeconomic markers by census district 2016 (details in each panel)

Figure 1. Socioeconomic markers bySOURCE: 2016(details
census district Bermuda Census
in each Maps
panel), 1 Department of Statistics9
2016,

9 Department of Statistics, Government of Bermuda. 2016 Bermuda Census Maps. https://www.gov.bm/2016-bermuda-census-maps

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 2. Population without health insurance coverage, 2016, Department of Statistics

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Variation in Mortality & Morbidity

The distribution of causes of mortality in Bermuda (2010-2019) is shown in Figure 3. In Bermuda,
like other high-income countries, the leading causes of mortality (death) over the 10 years pre-pan-
demic were chronic non-communicable diseases. Diseases of the circulatory system and neoplasms
(cancers) accounted for approximately 60% of deaths annually. In contrast, deaths due to infectious
and parasitic diseases accounted for only 2% of all deaths during this period. More common were
deaths due to mental and behavioural and nervous system disorders, including Alzheimer’s disease
and dementia (10%), endocrine, nutritional, and metabolic diseases, such as diabetes (7%), respira-
tory diseases, including pneumonia (6%) and external causes such as accidents and violence (5%).

Figure 3. Distribution of causes of mortality, 2010-2019, Epidemiology and Surveillance Unit

Preliminary data for the distribution of causes of mortality in Bermuda (2020-2021) is presented in
Figure 4. This data shows that the proportion of deaths due to diseases of the respiratory system
more than doubled, mainly due to deaths with COVID-19 pneumonia documented as the cause.
This will be further explored in the COVID-19 and Inequalities section of this report.

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 4. Distribution of causes of mortality, preliminary 2020-2021, Epidemiology and Surveillance Unit

Data on disease-specific morbidity (ill health) as analysed by health insurance claim costs is shown
in Figure 5. This data shows a similar pattern with chronic non-communicable diseases, such as
cancer, chronic kidney disease, heart disease, stroke and hypertension and diabetes, contributing
substantially to insurance claim costs.

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 5. Distribution of diagnoses for health insurance claim costs, FY2020-2021, Bermuda Health Council

The impact of long-term ill health arising from these conditions can exacerbate pre-existing inequal-
ities resulting in individuals being unable to fulfil their full potential both in the workplace and in
society. Poorly managed chronic disease is a major cause of absence workplace, resulting in lost
income, psychosocial problems (such as isolation, loss of social support and loss of self-esteem
and self-worth) and loss of employment related health insurance. The end result is a vicious circle of
worsening health, increasing deprivation and reduced access to healthcare needed to solve wors-
ening health problems. The complex interplay between these factors is shown in Figure 6.

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 6. Factors contributing to health inequalities (adapted from Labonte model) 10

Whilst each of the chronic disease areas outlined have their own specific pathway of pathogenesis,
all are associated with a common series of risk factors. The US Centers for Disease Control and
Prevention have outlined four major risk factors common to the leading chronic diseases, as shown
in Figure 7.

Figure 7. Major risk factors for chronic diseases

10 Office for Health Improvement and Disparities. Health disparities and health inequalities: applying All Our Health. 2022. Available: https://www.gov.uk/govern-
ment/publications/health-disparities-and-health-inequalities-applying-all-our-health/health-disparities-and-health-inequalities-applying-all-our-health

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

These four risk factors or behaviours can often cluster, with socioeconomic status being the stron-
gest predictor of engaging in multiple risk behaviours11. In Bermuda, there is a lack of robust pop-
ulation-wide data that links the prevalence of these risk factors with socioeconomic data. There is
evidently a requirement for further evidence-based policies to address these risk factors, particular-
ly for the most deprived, who are likely to be at greatest risk. There is also a role for the healthcare
system to develop pathways to prevent ill-health exacerbating underlying inequalities by ensuring
that those with chronic conditions have high-quality management to enable their continued partici-
pation in the workforce. The four stages of the prevention model, as shown in Figure 8, can be used
to achieve both aims.

Figure 8. The Four Stages of Prevention

Finally, there is a need for Bermuda to link health information with socioeconomic data at the indi-
vidual level to build a robust understanding of health inequalities. The Universal Health Coverage
Programme looks set to prioritise this, with the National Digital Health Strategy prioritising equity as
one of its design principles. The aim is to develop a national patient record that integrates all health
information related to a person and allows individuals to access and add personal health content
and manage privacy and access rights of their record via a ‘patient portal’.

11 Meader, N., King, K., Moe-Byrne, T. et al. A systematic review on the clustering and co-occurrence of multiple risk behaviours. BMC Public Health. 2016;16,657.
https://doi.org/10.1186/s12889-016-3373-6

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Variation in access to healthcare

The healthcare system plays a major role in preventing and effectively managing health conditions,
particularly chronic diseases that require ongoing clinical management with a focus on long-term
outcomes. High-quality chronic disease management is predominantly community based and is
characterised by collaboration between general/family practice, medical specialists, and allied
health professionals. Therefore, equitable access to healthcare is a prerequisite to addressing
health inequalities driven by unequal social determinants of health and health behaviours.

Bermuda’s healthcare system financing is based on insurance, a mandatory employment benefit for
employees working more than fifteen hours per week. Those aged 65 years and older can access
the government’s FutureCare scheme and may be entitled to a government subsidy12 to help with
affordability. FutureCare scheme is not as generous as other major medical insurance schemes. It
requires significant levels of co-payments to access many benefits.

Availability of health insurance is thus tied to employment status, Bermudian status, and previous
pattern of residency. This limits access to healthcare for the unemployed population or those aged
65 years and older without access to affordable health insurance. The 2016 census identified 8%
of the population as uninsured, with a further 17% only having basic coverage13. Worsening unem-
ployment during COVID-19 has led to revised estimates of 12% of the population being uninsured
and a further 23% having only basic cover or unaffordable insurance premiums.

As previously discussed, the demographic features of the uninsured population are associated with
wider deprivation. The Black population represented 77% of those without health insurance, with a
social gradient being associated with employment status and level of education. The details are in
the supplementary document.

Co-payments are also likely to play an important barrier in patients accessing healthcare, with out-
of-pocket payments for both healthcare visits and associated products’ costs (medicines, medical
equipment, spectacles etc.) preventing patients from seeking care until conditions are more serious.

The Bermuda National Cancer Control Plan suggests that inequalities could be preventing patients
seeking early diagnosis of cancer, which is potentially linked to barriers to accessing healthcare
such as lack of insurance and co-payments. Cancer diagnosed earlier (stages 0 and I) are associ-
ated with better outcomes than those diagnosed later (stages III and IV). However, the distribution
of early and late diagnoses are not equally distributed, with white patients constituting a greater
proportion of early diagnoses and Black patients a greater proportion of late diagnoses (Figure 9)14.

12 Known as the Certificate of Entitlement

13 Department of Statistics. Population and Housing Census. 2016. Available: https://www.gov.bm/sites/default/files/2016%20Census%20Report.pdf

14 Bermuda Cancer and Health Centre. Bermuda National Cancer Control Plan. 2022. Available: https://www.cancer.bm/Uploaded%20Files/annual%20re-
port/2021/bermuda%20nccp_national%20cancer%20assessment_2022%20(2).pdf

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 9. Cancer diagnoses, excluding non-melanoma skin cancer, by stage at diagnosis and race, Bermuda
National Cancer Control Plan

This example of later cancer diagnoses may be an indicator for delayed and emergency presenta-
tion amongst a broader range of health conditions. As well as resulting in poorer outcomes for pa-
tients (including premature mortality), there is also an impact on the healthcare system. Conditions
that have progressed to severe complications are more likely to require hospital treatment than if
managed earlier (e.g., a heart attack versus well-controlled hypertension). Given that Bermuda Hos-
pitals Board (BHB) is primarily funded through the Mutual Reinsurance Fund, which comes from
everyone’s insurance premium, and BHB is obliged to treat emergency cases, the lack of access to
community chronic disease management may paradoxically cost insurance policyholders more than
if everyone could access high-quality primary care through a system of universal health coverage.

The overall picture of Bermuda’s healthcare system is one that exacerbates pre-existing inequali-
ties. The Inverse Care Law is a core characteristic feature of the healthcare system, in which those
with greatest health needs have the least access to healthcare. The Universal Health programme is
a crucial opportunity to start to address this inequality in access to care. The National Digital Health
Strategy’s stakeholder engagement has identified the perception of worsening access to care due
to inequalities:

“The disparities are increasing. If you’re underinsured or uninsured, it’s very

tough to get the treatments that you want”15

However, further investigation is required to understand the detailed impact of inequalities on pa-
tients accessing healthcare and its ultimate impact on health outcomes. Again, this will require bet-
ter linking health information, especially insurance data, with socioeconomic data at the individual
level to build this picture. It would also require constructing indices of deprivation that can consis-
tently measure the scale of inequalities and the progress towards reducing these.

15 Quote from the National Digital Health Strategy’s series of insight interviews with healthcare professionals conducted by the University of Edinburgh

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Vulnerable Groups and Inequalities

In addition to broad disparities across society, specific groups are particularly at risk of poorer health
outcomes relating to inequalities. This section will briefly outline the impact of health inequalities in
these groups and the requirement to meet their specific needs in future health policy.

People with Disabilities. People with disabilities are more likely to die at younger ages, have worse
health, and experience more restrictions in everyday functioning. Disability can be a significant barrier
to work (or at least work without suitable adjustments). In 2016, 1174 of the working-age population
was unable to work due to disability16. Work is an important factor in promoting health and this could
compound existing health inequalities due to disability. The Human Rights Act 1981 outlines that
disability should not be a reason for disqualification from work if it is possible to modify employment
circumstances without causing unreasonable hardship to the employer or prospective employer. In
2020-2021, 782 people with a disability received financial assistance (47% of the total receiving fi-
nancial assistance)17. 

Unfortunately, there is a lack of robust population-wide data on disability, resulting in no robust calcu-
lations of disability prevalence or detailed information on the type of disability to help plan services. It
would be beneficial for Ageing and Disability Services to collect these types of data and to link them
with broader socioeconomic and health data to understand the impact of health inequalities on peo-
ple with disabilities with more granularity.

Homeless Population. The 2016 Population and Housing Census defines non-sheltered popula-
tions as those with no fixed abode and who do not stay in adult shelters. The 2016 census found that
138 people were homeless, of which 93% were black, 88% were male, and 50% had no academic
qualification. Whilst a 2022 report has found that rates of homelessness have increased by over 600%
in the past 21 years (from 30 cases in 2000 to 274 in 2022)18. The discrepancy may be due to the 2022
report’s methodology being more conducive to the homeless population identifying themselves.
A lack of resources (such as having no fixed address) can make it difficult for the homeless popula-
tion to access employment, healthcare, and other social services. According to the 2022 survey, the
homeless population had a high proportion of riskier health behaviour, with over 9 in 10 consuming
alcohol, tobacco, or other substances and close to 3 in 10 believing that their use of substances had
impacted their ability to secure stable housing. The COVID-19 pandemic resulted in further difficulties
for many homeless persons, with over half stating a negative impact on employment, income, and
social/emotional well-being.

Migrants. Migration status is an important determinant of health. In 2016, 19,332 foreign-born peo-
ple were living in Bermuda, with the non-Bermudian population making up 25% of the workforce19.
Bermuda’s migrant workforce falls into two broad socioeconomic groups: those on relatively high sal-
aries working in international business and those on lower salaries working in low-skilled manual jobs,
in many cases within the hospitality industry. Local data on migrant health remains scanty, but global
data would suggest that migrant workers are more likely to suffer occupational accidents compared
to non-migrant workers.20. Further work is required to understand migrant health, particularly the dif-
ferences between high-income and lower-income migrants. This work can then be used to consider
migrant health in future policy will be important to mitigate health inequalities in Bermuda.

16 Department of Statistics. Population and Housing Census. 2016. Available: https://www.gov.bm/sites/default/files/2016%20Census%20Report.pdf

17 Government of Bermuda. Department of Financial Assistance. Annual report 2020/2021 Available at: https://cloudfront.bernews.com/wp-content/up-
loads/2022/05/DFA-Annual-Report-2020-21.pdf

18 Catalyst Consulting Limited. Toward Ending Homelessness in Bermuda: Quantitative Research Full Report “Empowering the Most Vulnerable”. 2022. Available:
https://ccbdapp.files.wordpress.com/2022/07/toward-ending-homelessness-in-bermuda-quantitative-research-report-full-report-july-18-2022.pdf

19 Department of Statistics. Bermuda Digest of Statistics 2021. Available: https://www.gov.bm/sites/default/files/2021_Digest_of_Statistics.pdf

20 European Agency for Safety and Health at Work. Literature Study on Migrant Workers. 2009. Available: https://ec.europa.eu/migrant-integration/sites/default/
files/2008-08/docl_1357_31847427.pdf

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

COVID-19 and Inequalities

The COVID-19 pandemic has exacerbated inequalities worldwide, not just health inequalities, but
also socioeconomic inequalities, given the impact of the pandemic on travel and trade. In 2020,
Bermuda saw a 6.9% contraction in GDP followed by 5.4% growth in 2021(adjusted)21. A GDP of
$6.3 billion in 2021 remained below pre-pandemic levels of $6.5 billion. Economic sectors with
higher proportions of lower-salaried workers, such as tourism, saw a sustained drop in economic
activity. For example, “accommodation and food service” contracted by $430m (60.3%) in 202021.
This drop in economic activity will impact the wider social determinants of health due to changes
in employment patterns, educational opportunities, and a disruption of psycho-social factors such
as social networks. The Bermuda Foundation’s Vital Signs® report has highlighted some of the fi-
nancial impacts of the COVID-19 pandemic on people, with 40% of respondents accessing saving
to meet financial obligations and with financial insecurity being cited as the leading reason for not
feeling prepared to handle the second wave of the pandemic22.

Work is ongoing to understand the full economic, health and social impacts of the COVID-19 pan-
demic. However, reports from other high-income nations (e.g., the UK) have found that the risk
presented by COVID-19 correlated with socioeconomic position. This risk ultimately resulted in dis-
parities in hospitalisations and deaths based on pre-existing health inequalities. COVID-19 risks and
inequalities were linked to:

• Infection Risk
• Those in lower socioeconomic groups had a heightened risk of exposure due to:

• overcrowded housing

• use of public transports

• job roles not amenable to working from home23.

• Severe disease and mortality.

• Age-standardised COVID-19 mortality rates have been 3-4 times higher in the most
deprived areas compared to the least deprived24

• Ethnic minorities experience higher all-cause mortality rates and mortality rates from
COVID-1925

• People with disability were particularly at risk, with 6 out of 10 deaths in England in
the first wave being those who reported a disability26.

21 Department of Statistics. Annual Gross Domestic Product 2021 Highlights. 2022. Available: https://www.gov.bm/sites/default/files/GDP-2021-annual-publi-
cation.pdf

22 Bermuda Foundation. Bermuda Vital Signs® Special COVID-19 Pandemic Edition. 2022. Available: https://www.bermudacommunityfoundation.org/Portals/0/
Uploads/Documents/BCF%20Covid%20Special%20Report%202022%20final1.pdf

23 Beale S, Braithwaite I, Navaratnam AM et al. Deprivation and exposure to public activities during the COVID-19 pandemic in England and Wales. J Epidemiol
Community Health. 2022;76(4):319-326. https://doi.org/10.1136/jech-2021-217076

24 The Health Foundation. The continuing impact of COVID-19 on health and inequalities. 2022. Available: https://www.health.org.uk/publications/long-reads/
the-continuing-impact-of-covid-19-on-health-and-inequalities#:~:text=Inequalities%20in%20COVID%2D19%20mortality%20by%20deprivation&text=Be-
tween%20July%20and%20December%202021,in%20the%20least%20deprived%20areas.

25 Public Health England. Disparities in the risk and outcomes of COVID-19. 2020. Available: https://assets.publishing.service.gov.uk/government/uploads/
system/uploads/attachment_data/file/908434/Disparities_in_the_risk_and_outcomes_of_COVID_August_2020_update.pdf

26 Office for National Statistics. Updated estimates of coronavirus (COVID-19) related deaths by disability status, England: 24 January to 20 November 2020.
2022. https://www.ons.gov.uk/peoplepopulationandcommunity/birthsdeathsandmarriages/deaths/articles/coronaviruscovid19relateddeathsbydisabilitysta-
tusenglandandwales/24januaryto20november2020

17
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Public Health Measures

• Those in lower socioeconomic groups were disproportionately impacted by public
health measures necessary to control COVID-19, such as children missing face-
to-face education with impacts including lost learning, poor mental health, and a
reduction in safeguarding referrals27. This worsens the economic outlook as adults
missed work as a result of shelter in place, lack of childcare for school closures and
caring responsibilities for isolating or quarantining relatives.

However, the overall picture of COVID-19 and inequalities remain complex, with individual, social,
economic, biological, and behavioural risk overlapping and interacting28.

Inequalities were also associated with the uptake of COVID-19 vaccination, with the most deprived
being the least likely not to be fully vaccinated. This pattern has been seen across the world, includ-
ing Bermuda. The Government of Bermuda’s Pandemic Administration System collected detailed
information on vaccination uptake, which could be linked to socioeconomic indicators such as cen-
sus district and race.

Figure 10 shows that, in general, the lowest rates of COVID-19 vaccination were found in the census
districts with the highest markers of socioeconomic deprivation (Figure 1). The Ministry of Health
responded to this unmet need by setting up vaccination pop-up clinics in previously underserved
areas, including St David’s Island.

Figure 10. Distribution of persons vaccinated for COVID-19 through December 2021 using data from Gov-
ernment of Bermuda Pandemic Administration System via Locus Limited

27 Viner R, Russell S, Saulle R et al. School closures during social lockdown and mental health, health behaviors, and well-being among children and adolescents
during the first COVID-19 wave: a systematic review. JAMA Pediatr. 2022;176(4):400–409. https://doi.org/10.1001/jamapediatrics.2021.5840

28 Department of Health and Social Care. Chapter 2: Disparities in Technical report on the COVID-19 pandemic in the UK. 2023. Available: https://www.gov.uk/
government/publications/technical-report-on-the-covid-19-pandemic-in-the-uk/chapter-2-disparities#important-factors-in-the-covid-19-pandemic

18
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Despite efforts to address COVID-19 vaccination inequalities, data from the vaccination programme
has shown a gap in the uptake of booster vaccinations between those who are black, Asian, and
mixed-race, and those who are white or did not report their race (Figure 11). This differential in
booster uptake may continue to present a differential effect of COVID-19 by racial and socioeco-
nomic groups across society.

White and race not declared

Black, Asian and Mix race

Figure 11. Vaccination uptake by race through December 2021 using data from Government of Bermuda
Pandemic Administration System

An analysis of the preliminary mortality data from 2020-2021, indicated that Black persons were
disproportionately affected, accounting for 9 out of every 10 COVID-19-related deaths.

Considerable uncertainty remains about the impact of COVID-19 on health, including health in-
equalities. Further work will be required to understand the pandemic's epidemiological, social, and
economic consequences, which may impact future health policy and healthcare services planning.

19
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Health Inequalities: Implications for Bermuda

Bermuda is characterised as a society with significant socioeconomic inequalities, including income,
employment prospects and educational attainment. There is overlap between these socioeconomic
factors and racial inequalities, with the non-white population appearing to be more disadvantaged.

Bermuda’s health inequalities exist within this wider societal context. However, due to the current
health information infrastructure, it has been difficult to map health inequalities onto societal in-
equalities in a consistent or precise manner. Improving this underlying health information system
will be a key constituent in addressing health inequalities and looks set to be a priority for the up-
coming National Digital Health Strategy within the Universal Health coverage programme.

From the available information, health inequalities appear to track wider societal factors. Socio-
economic disparities are driving unequal social determinants for health, particularly for the most
vulnerable groups in society, whilst the current healthcare system is exacerbating these inequalities
through the Inverse Care Law. Those with the greatest health needs appear to have the least access
to the healthcare system. Substantial numbers of the population are either uninsured or have ac-
cess only to basic health insurance benefits. The fact that insurance is linked to employment-status
may mean that those with health problems that are significant enough to remove them from the
labour-force suffer a double burden as they may lose access to their insurance benefits.

At system-level, health inequalities may be driving additional healthcare costs, as people with signif-
icant health needs are unable to access cost-effective chronic disease management in primary care,
instead relying on more expensive episodic emergency treatments that are ultimately ineffective
for long-term health outcomes. A lack of upstream chronic disease management may have a detri-
mental impact on Bermuda’s workforce, and ultimately, the economy. Chronic diseases, particularly
mental health and musculoskeletal disorders are a leading reason for workforce absences across
high-income countries, particularly in manual occupations. Therefore, addressing health inequali-
ties should become a priority for employers, and occupational health a priority for the healthcare
system.

Bermuda now stands at a crossroads with enormous opportunities for tackling health inequalities.
COVID-19 has identified Bermuda’s vulnerabilities. The Bermuda Health Strategy 2022-2028 and
Universal Health Coverage programme present a chance for Bermuda to reform its health system
to become fairer, more effective, and better value for money for all who live in Bermuda. The oppor-
tunity is ours to grasp to ensure Bermuda can achieve “healthy people in healthy communities”!29

“Inequality in health is the worst inequality of all. There is no more serious inequality than knowing
that you’ll die sooner because you’re badly off”30

Frank Dobson, UK Secretary of State for Health 1997-1999

29 Ministry of Health. Bermuda Health Strategy 2022-2027. 2022. Available: https://www.healthstrategy.bm/

30 Hansard. Health Inequalities. Volume 672: debated on Wednesday 4 March 2020. Available: https://hansard.parliament.uk/com-
mons/2020-03-04/debates/F45AA8C2-154A-497D-88E4-80304A4714ED/HealthInequalities

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Supplementary Data Appendix to the Chief Medical

Officer’s Annual Report 2023
This supplementary appendix contains the underlying data to the Chief Medical Officer’s Annual Report
2023: A Post-Pandemic Focus on Health Inequalities. It is based on the format developed by the Pan Amer-
ican Health Organization’s Caribbean Sub-Regional Center, which has been adapted for Bermuda’s needs.

GEOGRAPHY
Figure 1: Map of Bermuda
Description: Bermuda is a small archipelago situated in the northern Atlantic Ocean. It is comprised
of seven main islands and over 100 smaller islands. The main land area is approximately 21 square
miles and densely populated.

DEMOGRAPHY

Population Projections
Table 1: Registered births and deaths, 2011-2021
(SOURCE: Department of Statistics1)

Live Births Deaths

Year
Total Total
2011 670 429
2012 648 422
2013 648 471
2014 574 480
2015 583 478
2016 591 492
2017 576 481
2018 530 535
2019 525 535
2020 541 566
2021 494 727

1 Department of Statistics, Government of Bermuda. Digest of Statistics 2021. Available: https://www.gov.bm/sites/default/files/2021_Digest_of_Statistics.pdf

21
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 2: Bermuda Population 1950-2050

(SOURCE: Department of Statistics)
NB: Data Limitations2

67,000
CENSUS PROJECTED
62,000

57,000

52,000
Population

47,000

42,000

37,000

32,000
═
0
1950 1960 1970 1980 1990 2000 2010 2020 2030 2040 2050
Year
Sources: Population and Housing Censuses and Population Projections

Figure 3: Projected population 2016-2050

(SOURCE: Department of Statistics)
NB: Data Limitations as per footnote 2

66,000
64,000
62,000
60,000
Population

58,000
56,000
54,000
52,000
50,0000 ═
2016 2018 2020 2022 2024 2026 2028 2030 2032 2034 2036 2038 2040 2042 2044 2046 2048 2050
Year
Source: Population and housing censuses projections

2 Limitations of Projections. Population projections are not predictions or forecasts. They are illustrations of how the structure, size and characteristics of Ber-
muda’s population would change if certain assumptions on fertility, mortality and migration are held true over the projection period. While the assumptions are
based upon an assessment of short–term and long–term demographic trends, there is no certainty that any of the assumptions will be realised. The projections
do not take into account future non–demographic factors (e.g. major government policy decisions, economic factors, natural disasters, etc.) which may diminish
the accuracy of the projections. Historically, Bermuda’s projections are updated after each population and housing census so that new information about demo-
graphic trends can be included. The age–sex structure in this population projections report was based on self–reported data collected in the 2016 Population
and Housing Census.
Scope of the Projections. This population projection series is for Bermuda as a whole from July 1, 2016 until July 1, 2050. Projections are less reliable the
further into the future they are because assumptions are less likely to hold true.
Net Migration. It was assumed that net migration would be zero each year over the projection period due to a lack of comprehensive migration data.
Birth and Death Data. The projection input file contains recorded births and deaths up to 2020.

22
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Life Expectancy
Table 2: Average life expectancy at birth, 2010-2026
(SOURCE: Department of Statistics3)
Mid-year Life expectancy at birth
2010 75.9
2011 81.3
2012 81.9
2013 80.7
2014 80.9
2015 81.1
2016 81.9
2017 82.4
2018 82.6
2019 82.7
2020 82.8
2021 82.9
2022 83.0
2023 83.2
2024 83.3
2025 83.4
2026 83.5

Table 3: Life expectancy at birth, 1960-2016

(SOURCE: Department of Statistics4)
Year Male Female
1960 70.6 65.1
1970 66.9 73.9
1980 68.7 76.1
1991 70.0 78.3
2000 75.3 80.6
2010 75.9 83.6
2016 78.6 85.3

3 Department of Statistics, Government of Bermuda. Bermuda’s Population Projections 2016-2026. Available: https://www.gov.bm/sites/default/files/Bermu-
da-Population-Projections-2016-2026.pdf

4 Department of Statistics, Government of Bermuda. Bermuda’s Population Projections 2016-2026. Available: https://www.gov.bm/sites/default/files/Bermu-
da-Population-Projections-2016-2026.pdf

23
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 4: Population pyramid with 2016 census population and 2016 projected population
(SOURCE: Department of Statistics)
NB: Data Limitations as per footnote 2

Ethnicity
Table 4: Population by ethnic group, 2016
(SOURCE: Department of Statistics5)
Ethnic Group Population Percentage of Total Population
Black 33339 52%
White 19466 31%
Asian 2592 4%
Mixed 5780 9%
Other 2553 4%
Not Stated 49 0%

5 Department of Statistics, Government of Bermuda. Digest of Statistics 2021. Available: https://www.gov.bm/sites/default/files/2021_Digest_of_Statistics.pdf

24
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 5: Percentage of population who identify as Black by census district, 2016

(SOURCE: Department of Statistics6)

Child and Maternal Health Vital Indicators

Table 5: Basic Demographic Indicators - Child and Maternal Mortality (SOURCE: ESU)
No data displayed due to the reporting of small numbers to protect privacy.

Years
Indicator 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
available
Maternal
0 0 0 0 0 0 0 0 0 0 0 0 12
Mortality Ratio
Under-5
2.6 1.5 1.5 4.6 5.2 3.4 3.4 0.0 1.9 1.9 0.0 0.0 12
Mortality Rate
Infant Mortality
1.3 0.0 1.5 1.5 3.5 3.4 3.4 0.0 1.9 1.9 0.0 0.0 12
Rate
Post Neonatal
1.3 0.0 0.0 1.5 3.5 0.0 0.0 0.0 1.9 0.0 0.0 0.0 12
Mortality Rate
Neonatal
0.0 0.0 1.5 0.0 0.0 3.4 3.4 0.0 0.0 1.9 0.0 0.0 12
Mortality Rate
Stillbirth Rate 3.9 3.0 3.1 4.6 3.5 3.4 1.7 0.0 9.4 0.0 1.9 0.0 12

6 Department of Statistics, Government of Bermuda. 2016 Bermuda Census Maps. Available: https://www.gov.bm/2016-bermuda-census-maps

25
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Years
Indicator 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
available
# of maternal
0 0 0 0 0 0 0 0 0 0 0 0 12
deaths
# of under 5
2 1 1 3 3 2 2 0 1 1 0 0 12
deaths
# of infant
1 0 1 1 2 2 2 0 1 1 0 0 12
deaths
# of
postneonatal 1 0 0 1 2 0 0 0 1 0 0 0 12
deaths
# of neonatal
0 0 1 0 0 2 2 0 0 1 0 0 12
deaths
# of stillbirths 3 2 2 3 2 2 1 0 5 0 1 0 12
# of births 769 670 648 648 574 583 591 576 530 525 540 494 12
perinatal
3.9 3.0 4.6 4.6 3.5 6.9 5.1 0.0 9.4 1.9 1.9 0.0
mortality rate

Definitions Source

Maternal WHO The maternal mortality ratio (MMR) is defined as the number of maternal deaths during
Mortality Ratio a given time period per 100,000 live births during the same time period. (WHO)

Under-5 WHO The quotient between the number of deaths in children under 5 year of age in a given
Mortality Rate year and the number of live births in that year, for a given country, territory, or geographic
area, expressed per 1,000 live births.

Infant Mortality PAHO The quotient between the total deaths of children under one year of age residing in
Rate a certain country, territory or geographical area, during a specific calendar year, and
the number of live births in the same population and year, expressed per thousand live
births .

Post Neonatal PAHO The quotient between deaths between 28 and 364 days of life of live births residing in a
Mortality Rate certain country, territory or geographical area, for a specific calendar year, and the total
number of live births for the same population and year. It is expressed per thousand live
births.

Neonatal PAHO The quotient between the deaths of live births residing in a certain country, territory or
Mortality Rate geographical area before reaching 28 days of life, in a specific calendar year and the
total number of live births for the same population and year, reported by the health
authority. correspondent. It is expressed per thousand live births.

Stillbirth Rate WHO The stillbirth rate (SBR) is defined as the number of babies born with no signs of life at
28 weeks or more of gestation, per 1,000 total births.

26
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

SOCIO-ECONOMIC PROFILE

Economics and Employment

Table 6: Vital Economic Statistics
Indicator Details Comment
GDP per capita $114,090 7
4th highest globally
Cost of living - Highest cost of living
globally8,9

Table 7: Sector Contribution to GDP

Sector % Contribution to
GDP
International business 27.5%
Real estate 15.2%
Insurance and financial services 14.3%
Tourism 2.2%

Table 8: Major occupation groups, 2021

(SOURCE: Department of Statistics10)

Occupation groups Population Percentage of Total Population

Professionals 6,496 21%
Senior Officials and Managers 6,150 20%
Service Workers and Shop and Market Sales Workers 5,851 19%
Clerks 4,602 15%
Technicians and Associate Professionals 2,751 9%
Craft and Related Trades Workers 2,544 8%
Plant and Machine Operators and Assemblers 1,191 4%
Elementary Occupations 956 3%
Skilled Agricultural and Fishery Workers 742 2%
Armed Forces 33 0%

7 The World Bank. GDP per capita (current US$) – Bermuda. Available: https://data.worldbank.org/indicator/NY.GDP.PCAP.CD?locations=BM

8 Fox D. Bermuda tops cost of living index. Royal Gazette. 2021. Available: https://www.royalgazette.com/year-in-review/article/20211231/bermuda-tops-cost-
of-living-index/

9 Numbero cost of living index https://www.numbeo.com/cost-of-living/rankings.jsp last assessed July 7, 2023

10 Department of Statistics, Government of Bermuda. Digest of Statistics 2021. Available: https://www.gov.bm/sites/default/files/2021_Digest_of_Statistics.pdf

27
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 6: Unemployment rate by census district, 2016

(SOURCE: Department of Statistics11)

Table 9: Median income from main job, 2020

(SOURCE: Department of Statistics12)

Population grouping Median annual income ($)

Total working population 64033.4

Gender
Male 66878.6
Female 60878.1

Bermudian Status
Bermudian 61041.7
Non-Bermudian 75890.1

Ethnicity
Black 58605.2
White 83644.4
Mixed/Other 55521.4

Highest Academic Qualification

No Formal Certificate 41114.1
High School Certificate 50186.5
Tech. / Voc./ Assoc. / Diploma 56934.8
Degree 93889.7

11 Department of Statistics, Government of Bermuda. 2016 Bermuda Census Maps. Available: https://www.gov.bm/2016-bermuda-census-maps [accessed 1st
January 2023].

12 Department of Statistics, Government of Bermuda. Labour Force Survey Report 2020. Available: https://www.gov.bm/sites/default/files/November%20
2020%20Labour%20Force%20Survey%20%20Report.pdf

28
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 7: Median annual personal gross income by census district, 2016

(SOURCE: Department of Statistics13)

Education
Table 10: Highest academic qualification in the 16+ population, 2016
(SOURCE: Department of Statistics14)
Academic qualification Population Percentage of Total Population
No Formal Certificate 7,283 13.6%
High School Certificate 18,764 35.0%
Tech./ Voc. / Assoc./ Diploma 11,940 22.3%
Degree 15,541 29.0%
Other 1 0.0%
Not Stated 84 0.2%

13 Department of Statistics, Government of Bermuda. 2016 Bermuda Census Maps. Available: https://www.gov.bm/2016-bermuda-census-maps

14 Department of Statistics, Government of Bermuda. Population and Housing Census 2016. Available: https://www.gov.bm/sites/default/files/2016%20Cen-
sus%20Report.pdf

29
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 8: Proportion of the 16-64 year old population with no academic

qualification by census district, 2016
(SOURCE: Department of Statistics15)

Housing
Figure 9: Average number of persons per bedroom by census district, 2016
(SOURCE: Department of Statistics16)

15 Department of Statistics, Government of Bermuda. 2016 Bermuda Census Maps. Available: https://www.gov.bm/2016-bermuda-census-maps

16 Department of Statistics, Government of Bermuda. 2016 Bermuda Census Maps. Available: https://www.gov.bm/2016-bermuda-census-maps [accessed 1st
January 2023].

30
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

MORTALITY
Figure 10: Number of deaths 2010-2021
(SOURCE: ESU)
800
700
Nummber of Deaths

600
368
500
238
400 226 268 263
220 220 234 216 237
300 219 178
200 359
266 267 272 328
100 255 210 244 251 244 247 244
0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Year

Male Female

Figure 11: Age-standardised all-cause mortality rates per 100,000 population 2010-2021
with 3 year rolling average trend line
(SOURCE: ESU)
700
Age-standardised rate per 100,000

600

500
population

400

300

200

100

0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Year

Total Total 3 year rolling average Male

Male 3 year rolling average Female Female 3 year rolling average

31
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 12: Age-standardised potential years of life lost per 100,000 population OECD
Comparison aged 0-75 2020. NB: *Age-standardisation using OECD standard population
(SOURCE: ESU and OECD)
14000
Age-standardised* rate per 100,000 people

12000

10000

8000

6000

4000

2000

d
A

el
Slo y

ia
ia

UK

a
ain
a
Lit co

h R ca

a
lic
Co nia
ia

Au s
d

re
an

ni

lan
ali
ud
US
an

tv

ra
Ne str
e c a Ri

ub

lan
i

ve
ex

Sp
to

Ko
La

rm

str
rm

s
hu

Ice
Au
ep

I
er
M

Es

st

Ge

of
Be

th

ic
bl
pu
Cz

Re
Country or Territory

Figure 13: Age-standardised potential years of life lost per 100,000 population aged 0-75
2010-2021 with 3 year rolling average trend line
(SOURCE: ESU)

10000
Age-standardised rate per 100,000 population

9000
8000
7000
6000
5000
4000
3000
2000
1000
0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Year

Total Total 3 year rolling average Male

Male 3 year rolling average Female Female 3 year rolling average

32
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 14: Leading 10 causes of mortality: combined total for 2010-2019 by ICD group
(SOURCE: ESU)

2.4% 2.1% 3.2%

2.9%
5.4%

33.3%
6.1%

7.3%

9.9%

27.4%

Circulatory Neoplasms
Mental And Behav ioural/Nerv ous Endocrine, Nutritional And Metabolic
Respiratory External
Digestive Genitourinary
Infectious And Parasitic Other

Table 11: Leading 10 causes of mortality 2010-2019 by ICD group

(SOURCE: ESU)

Combined 2010-2019
Rank & ICD Group 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 Total
1.Circulatory 29.4% 34.7% 35.6% 34.5% 38.0% 36.9% 33.2% 31.0% 29.1% 31.4% 33.3%

2.Neoplasms 28.4% 26.1% 29.6% 28.6% 30.8% 26.8% 28.2% 25.9% 25.7% 24.8% 27.4%

3.Mental and Behavioural/

5.4% 5.6% 6.5% 8.6% 9.8% 9.6% 12.0% 13.2% 12.9% 13.2% 9.9%
Nervous

4.Endocrine, Nutritional
5.2% 11.0% 8.8% 7.1% 5.2% 7.0% 5.8% 5.9% 7.7% 10.1% 7.3%
and Metabolic

5.Respiratory 11.6% 6.1% 6.2% 5.5% 4.4% 4.9% 5.4% 4.3% 6.6% 5.7% 6.1%

6.External 6.4% 6.3% 4.8% 4.2% 5.2% 5.1% 5.2% 6.9% 6.6% 3.7% 5.4%

7.Digestive 5.4% 2.1% 1.8% 2.9% 1.9% 1.8% 2.4% 4.3% 2.7% 3.3% 2.9%

8.Genitourinary 3.1% 3.0% 1.4% 2.1% 2.1% 1.6% 2.6% 3.1% 2.2% 3.1% 2.4%

9.Infectious and Parasitic 2.1% 2.3% 2.3% 2.3% 1.5% 2.7% 1.2% 2.4% 2.2% 1.8% 2.1%

10.Unknown 1.4% 2.1% 0.9% 1.1% 0.0% 0.8% 1.0% 0.6% 1.3% 1.5% 1.1%

11.Blood and Immunity 0.4% 0.0% 0.2% 1.5% 0.4% 1.0% 1.0% 1.0% 1.3% 0.7% 0.8%
12.Musculoskeletal and
0.2% 0.5% 0.7% 0.4% 0.6% 0.8% 0.4% 0.8% 0.5% 0.2% 0.5%
Nervous System
13.Perinatal 0.4% 0.2% 0.5% 0.4% 0.2% 0.6% 0.4% 0.0% 0.5% 0.2% 0.3%

14.Skin and Subcutaneous 0.4% 0.0% 0.5% 0.2% 0.0% 0.2% 0.6% 0.6% 0.5% 0.0% 0.3%

15. Congenital 0.2% 0.0% 0.2% 0.6% 0.0% 0.0% 0.6% 0.0% 0.2% 0.4% 0.2%

33
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 15: Age-standardised mortality rates for leading causes of mortality per 100,000 population 2010-2019
with 3 year rolling average trend line (SOURCE: ESU)

140

120
Age-standardised rate per 100,000 population

100

80

60

40

20

0
2010 2011 2012 2013 2014 2015 2016 2017 2018 2019
Year
Neoplams/Cancer Neoplams/Cancer 3 year rolling average
Ischaemic Heart Disease Ischaemic Heart Disease 3 year rolling average
External Causes External Causes 3 year rolling av erage
Mental and Behavioural/Nervous Mental and Behavioural/Nervous 3 year rolling average
Diabetes Diabetes 3 year rolling average
Respiratory Respiratory 3 year rolling average
Cerebrovascular Disease Cerebrovascular Disease 3 year rolling av erage
Communicable Diseases Communicable Diseases 3 year rolling average

34
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

MORBIDITY

Communicable Diseases
Table 12: Number of annual cases of Vaccine-preventable diseases
(notified to ESU 2010-2022)
(SOURCE: ESU)
Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Disease
Chicken pox (varicella) 43 20 13 27 25 28 15 22 10 17 10 9 9
Congenital Rubella 0 0 0 0 0 0 0 0 0 0 0 0 0
COVID-19 … … … … … … … … 612 6055
Diphtheria 0 0 0 0 0 0 0 0 0 0 0 0 0
Influenza 11 25 37 29 38 20 75 154 93 145 186 68 110
Measles 0 0 0 0 0 0 0 0 0 0 0 0 0
Meningitis (due to H.
0 0 0 0 0 0 0 0 0 0 0 0 0
influenzae)
Meningitis (due to S.
.. … … … 0 0 0 0 1 0 0 0 0
pneumoniae)
Meningococcal
infection (due to 0 0 0 1 0 0 0 0 0 0 0 0 0
Neisseria meningitidis)
Mumps 2 3 0 0 0 0 0 0 0 2 0 0 0
Pertussis (whooping
0 1 3 0 0 3 0 2 2 2 8 0 0
cough)
Pneumonia (due to H.
0 0 0 0 0 0 0 0 1 6 2 0 0
influenzae)
Pneumonia (due to S.
.. … … … 5 6 2 6 5 11 4 12 1
pneumoniae)
Respiratory syncytial
11 38 34 9 8 24 43 19 66 56 104
virus (RSV)
Rubella (German
0 0 0 0 0 0 0 0 0 0 0 0 0
measles)
Tetanus (excl.
0 0 0 0 0 0 0 0 0 0 0 0 1
neonatal)
Tetanus (neonatal) 0 0 0 0 0 0 0 0 0 0 0 0 0
Tuberculosis (extra-
0 0 1 0 0 0 0 1 0 0 0 0 1
pulmonary)*
Tuberculosis
1 1 2 0 0 1 1 2 2 2 2 2 2
(pulmonary)*

Table 13: Number of annual cases of Vector-borne diseases (notified to ESU 2010-2022)
(SOURCE: ESU)
Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Disease
Chikungunya* .. … … … 3 0 1 0 0 0 0 0 0
Dengue Fever* 2 1 0 0 1 0 0 0 0 2 0 0 0
Leptospirosis 0 0 0 0 0 0 0 0 0 0 0 0 0
Malaria* 0 2 0 0 2 1 2 1 2 1 0 0 0
Zika* .. … … … … … 5 1 0 1 0 0 0

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Table 14: Number of annual cases of Food and water-borne diseases

(notified to ESU 2010-2022)
(SOURCE: ESU)

Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Disease
Campylobacter 19 19 30 27 17 17 11 20 21 41 66 62 37
Ciguatera 0 0 0 0 0 0 10 1 15 5 0 1 0
Cryptosporidium .. … … … 0 0 0 4 5 4 4 2 8
Giardia .. … … … 0 1 1 9 9 7 5 5 4
Listeria .. … … … 0 0 1 1 0 1 0 1 0
Norovirus 2 3 19 1 1 2 7 1 2 6 3 5 9
Rotavirus 8 13 3 6 3 6 7 16 18 15 9 8 7
Salmonellosis 40 14 60 61 95 70 71 56 65 73 38 44 42
Shigellosis 3 3 4 2 1 1 0 1 1 3 1 3 1
Typhoid and para- 0 0 0 0 0 0 0 0 0 0 0 0 0
typhoid fevers

Table 15: Number of annual cases of other diseases of public health interest
(notified to ESU 2010-2022)
(SOURCE: ESU)
Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Disease
Hepatitis A 0 0 0 0 0 0 0 0 0 0 0 0 0
Hepatitis B 1 0 2 1 8 5 4 8 6 2 3 2 0
Hepatitis C 28 14 13 18 8 8 6 8 8 7 1 1 0
Leprosy (Hansen's
0 0 0 0 0 0 0 0 0 0 0 0 0
Disease)*
Rabies (in humans) 0 0 0 0 0 0 0 0 0 0 0 0 0

Table 16: Number of annual cases of Sexually Transmitted Infections

(notified to ESU 2010-2022)
(SOURCE: ESU)
Year 2010 2011 2012 2013 2014 2015 2016 2017 2018 2019 2020 2021 2022

Disease
Chlamydia 431 332 380 322 312 356 416 334 384 357 262 216 207
Genital herpes 40 30 61 70 72 92 181 78 46 70 47 45 62
Gonorrhoea 31 68 65 40 25 27 14 47 61 22 22 23 20
HIV 11 8 6 7 7 5 6 0 5 3 4 5 3
Syphilis 3 1 10 11 7 8 2 3 3 6 3 4 2

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

COVID-19
Figure 16: Cases of COVID-19 by Epidemiological Week (notified to ESU 2020-2022)
(SOURCE: ESU)
1600

1400

1200
Number of new cases

1000

800

600

400

200

0
1 5 9 1317212529333741454953 4 8 1216202428323640444852 4 8 1216202428323640444852
2020 2021 2022
Epidemiological Week

Figure 17: Admissions to Hospital with a positive COVID-19 test in the past 28 days by
Epidemiological Week (notified to ESU 2020-2022)
(SOURCE: ESU)
50

45

40
Number of Hospitalisations

35

30

25

20

15

10

0
1 5 9 1317212529333741454953 4 8 1216202428323640444852 4 8 1216202428323640444852
2020 2021 2022
Epidemiological Week

37
 Number of COVID-19 Vaccine Doses Adminstered Number of Deaths

0
5
10
15
20
25

0
1000
2000
3000
4000
5000
6000
2020-12-27 - 2021-01-02
2021-01-24 - 2021-01-30
2021-02-21 - 2021-02-27
2021-03-21 - 2021-03-27
2021-04-18 - 2021-04-24

2020
2021-05-16 - 2021-05-22
2021-06-13 - 2021-06-19
2021-07-11 - 2021-07-17
2021-08-08 - 2021-08-14
2021-09-05 - 2021-09-11
2021-10-03 - 2021-10-09
2021-10-31 - 2021-11-06
2021-11-28 - 2021-12-04
2021-12-26 - 2022-01-01

38
Week
2022-01-23 - 2022-01-29

2021
2022-02-20 - 2022-02-26
(SOURCE: ESU)

2022-03-20 - 2022-03-26
2022-04-17 - 2022-04-23

Epidemiological Week
2022-05-15 - 2022-05-21
(notified to ESU 2020-2022)

2022-06-12 - 2022-06-18
2022-07-10 - 2022-07-16
2022-08-07 - 2022-08-13
2022-09-04 - 2022-09-10
27th December 2021 – 31st December 2022
2022-10-02 - 2022-10-08
2022-10-30 - 2022-11-05
2022

2022-11-27 - 2022-12-03
2022-12-25 - 2022-12-31
Figure 19: Weekly COVID-19 vaccines doses given (split by dose)

(SOURCE: Government of Bermuda’s Pandemic Administration System)

Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

1 5 9 1317212529333741454953 4 8 1216202428323640444852 4 8 1216202428323640444852

Dose1
Dose2
Dose3
Dose4
Dose5
Figure 18: Deaths with a positive COVID-19 test in the past 28 days by Epidemiological Week
 COVID-19 Vaccines Cumulative Doses
Count

10000
20000
30000
40000
50000
60000

0
2020-12-27 - 2021-01-…
2021-01-24 - 2021-01-…
2021-02-21 - 2021-02-…
2021-03-21 - 2021-03-…
2021-04-18 - 2021-04-…
2021-05-16 - 2021-05-…
2021-06-13 - 2021-06-…
2021-07-11 - 2021-07-…
2021-08-08 - 2021-08-…
2021-09-05 - 2021-09-…
2021-10-03 - 2021-10-…
2021-10-31 - 2021-11-…
2021-11-28 - 2021-12-…

39
2021-12-26 - 2022-01-…
Week 2022-01-23 - 2022-01-…
2022-02-20 - 2022-02-…
2022-03-20 - 2022-03-…
2022-04-17 - 2022-04-…
2022-05-15 - 2022-05-…
2022-06-12 - 2022-06-…
2022-07-10 - 2022-07-…
2022-08-07 - 2022-08-…
27th December 2021 – 31st December 2022

2022-09-04 - 2022-09-…
2022-10-02 - 2022-10-…
2022-10-30 - 2022-11-…
Figure 21: COVID-19 vaccines coverage by age and gender

2022-11-27 - 2022-12-…
2022-12-25 - 2022-12-…
(SOURCE: Government of Bermuda’s Pandemic Administration System)
(SOURCE: Government of Bermuda’s Pandemic Administration System)
Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 20: Weekly COVID-19 vaccines cumulative doses given (split by dose)

Dose5
Dose4
Dose3
Dose2
Dose1
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 22: Spatial distribution of vaccinated persons, December 2021

(SOURCE: Locus Limited)
(using data from Government of Bermuda’s Pandemic Administration System and 2016 census)

Figure 23: Spatial distribution of vaccinated persons, December 2021

(SOURCE: Government of Bermuda’s Pandemic Administration System)

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Non-Communicable Diseases
Table 17: Total insurance claims for leading causes of adult physical disease burden
(SOURCE: Bermuda Health Council’s Cost and Utilisation Data)
Total Number of Claims
2021
Rank Diagnosis FY16-17 FY17-18 FY18-19 FY19-20 FY20-21
1 Diabetes 45979 36198 37579 34248 43930
2 Cancer 15245 35975 44248 33835 33520
3 Low Back Pain 12711 19797 19332 18263 17159
4 Chronic Kidney Disease 31971 21399 20344 15817 16673
5 Gynaecological disease 4498 1027 3014 6651 10875
6 Heart Disease 2662 4916 5240 5873 7165
7 Obesity 8325 10506 7374 5746 5956
8 Skin Disease 2265 3226 2967 3171 4440
Headache include
9 3234 1537 2284 1809 3552
migraine
10 Stroke 4884 6134 8037 5621 3417
11 Asthma/COPD 4124 4429 4149 3298 2977
12 Hypertension 8194 6847 7996 7366 2258
13 Other Musculoskeletal 11890 7187 9450 6380 1872
14 COVID-19 1043
Upper respiratory tract
15 3532 4537 3853 3637 973
infection
16 Arthrosis 1245 906 796 600 352
17 Hearing Loss 211 177 185 301 165
18 Falls 66 104 34 34 145

Table 18: Total insurance claims paid for leading causes of adult physical disease burden
(SOURCE: Bermuda Health Council’s Cost and Utilisation Data)

Total Paid for Claimed Services

2021
Rank Diagnosis FY16-17 FY17-18 FY18-19 FY19-20 FY20-21
1 Cancer $6,050,441.95 $12,502,938.40 $16,309,391.90 $14,060,613.70 $12,137,916.00
2 Chronic Kidney $16,029,180.10 $6,421,700.60 $4,421,724.09 $5,352,591.47 $5,158,559.66
Disease
3 Diabetes $6,334,446.66 $3,627,838.91 $3,322,119.57 $3,252,003.50 $3,517,748.74
4 Heart Disease $1,350,058.16 $2,809,861.44 $3,267,365.42 $4,277,101.83 $3,393,479.02
5 Low Back Pain $2,444,214.39 $2,429,714.49 $2,632,211.46 $2,255,246.84 $1,722,873.15
6 Gynaecological $563,686.78 $160,719.59 $500,405.64 $570,828.61 $1,299,290.75
disease
7 Other $2,615,459.28 $1,739,127.95 $2,237,460.16 $1,618,515.07 $987,761.64
Musculoskeletal
8 Stroke $2,193,628.84 $2,018,009.62 $2,222,567.97 $2,310,114.37 $834,999.36
9 Obesity $770,225.44 $919,085.43 $655,415.04 $684,203.25 $653,694.35
10 Headache $860,455.24 $214,560.02 $383,637.90 $420,193.67 $519,177.59
include migraine
11 Skin Disease $302,235.22 $348,103.78 $331,928.13 $413,847.07 $513,589.43

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

12 Asthma/COPD $1,091,652.30 $952,157.07 $679,273.92 $467,734.81 $373,584.32

13 Hypertension $754,866.61 $574,063.64 $773,134.23 $668,391.59 $217,081.38
14 COVID-19 $106,630.89
15 Upper respiratory $375,013.37 $506,791.45 $407,398.90 $368,858.74 $77,023.66
tract infection
16 Hearing Loss $115,881.03 $64,349.24 $95,893.15 $91,871.85 $52,472.08
17 Arthrosis $131,896.98 $60,414.51 $73,365.90 $51,386.63 $32,527.90
(Osteoarthritis)
18 Falls $21,573.67 $4,797.75 $2,123.37 $8,825.52 $12,843.50

Table 19: Total insurance claims for leading causes of adult mental health burden
(SOURCE: Bermuda Health Council’s Cost and Utilisation Data)
Note: *Data has been removed due to the reporting of small numbers to protect privacy
Total Claims
2021
Rank Diagnosis FY16-17 FY17-18 FY18-19 FY19-20 FY20-21
1 Panic/anxiety 745 1682 1680 2841 6687
2 Other disorders 5071 5241 7463 6626 4789
3 Adjustment 1549 2557 3383 4216 3816
disorder
4 Depression 1913 2484 3042 2880 3399
disorder
5 Schizophrenia 1448 2374 1922 2189 2268
6 Bipolar disorder 517 1686 2178 2309 1218
7 ADD/ADHD 83 493 629 905 703
8 Drug disorder 816 1363 2054 2179 443
9 PTSD * 93 153 156 382
10 Eating disorder * 216 289 273 307

Table 20: Total insurance claims paid for leading causes of adult mental health burden
(SOURCE: Bermuda Health Council’s Cost and Utilisation Data)
Note: *Data has been removed due to the reporting of small numbers to protect privacy

2021 Total Paid for Claimed Services

Rank Diagnosis FY16-17 FY17-18 FY18-19 FY19-20 FY20-21
1 Dementia $14,015.73 $1,055,130.09 $1,584,011.70 $1,625,890.43 $1,261,520.63
2 Panic/anxiety $100,611.01 $174,554.27 $220,090.76 $420,189.88 $953,141.45
3 Schizophrenia $547,241.70 $619,222.60 $1,218,834.25 $994,972.62 $797,803.60
4 Other $743,375.68 $721,740.84 $2,739,687.52 $1,014,521.41 $608,294.73
disorders
5 Depression $340,986.63 $269,406.21 $426,913.55 $409,100.59 $588,457.77
disorder
6 Adjustment $182,025.80 $284,567.02 $434,003.72 $490,816.11 $475,927.30
disorder
7 Bipolar $152,492.10 $336,742.71 $424,775.44 $371,763.51 $306,523.96
disorder
8 Eating disorder * $32,492.85 $41,474.68 $37,217.29 $159,482.12
9 PTSD * $11,061.16 $22,014.40 $34,759.35 $104,766.67
10 Drug disorder $496,420.90 $355,511.28 $530,738.50 $526,986.49 $98,546.20

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Table 21: Total insurance claims for leading causes of paediatric physical disease burden
(SOURCE: Bermuda Health Council’s Cost and Utilisation Data)
Note: *Data has been removed due to the reporting of small numbers to protect privacy

2021 Total Paid for Claimed Services

Rank Diagnosis FY16-17 FY17-18 FY18-19 FY19-20 FY20-21
1 Ear Nose and Throat Conditions 794 1226 1468 1201 1205
2 Upper respiratory tract infection 2777 4897 4475 5115 922
3 Asthma/COPD 237 489 507 482 205
4 Diabetes 162 80 147 178 146
5 Cancer 72 92 61 140 123
6 Obesity 192 105 136 234 64
7 COVID-19   41
8 Epilepsy 59 113 77 74 28
9 Gastroenteritis 235 119 146 77 27
10 Lower respiratory tract infection * * * * *

Table 22: Total insurance claims paid for leading causes of paediatric physical disease burden
(SOURCE: Bermuda Health Council’s Cost and Utilisation Data)
Note: *Data has been removed due to the reporting of small numbers to protect privacy
Total Paid for Claimed Services
2021
Rank Diagnosis FY16-17 FY17-18 FY18-19 FY19-20 FY20-21
1 Ear Nose and Throat Conditions $111,743.06 $130,235.68 $169,105.15 $164,770.57 $129,977.84
2 Upper respiratory tract infection $197,279.69 $355,759.38 $338,191.87 $423,746.60 $64,098.90
3 Cancer $152,869.83 $44,077.06 $46,312.71 $100,400.25 $49,001.72
4 Asthma/COPD $30,160.87 $48,903.56 $60,608.82 $45,544.82 $18,934.53
5 Diabetes $23,184.38 $12,792.02 $23,240.08 $25,527.51 $13,312.57
6 Obesity $17,501.82 $11,318.40 $13,407.38 $25,084.48 $7,858.40
7 Epilepsy $9,881.81 $77,040.64 $18,293.17 $14,434.46 $4,957.52
8 Gastroenteritis $54,249.78 $34,550.76 $23,187.11 $14,643.55 $3,208.08
9 COVID-19   $2,583.70
10 Lower respiratory tract infection * * * * *

Table 23: Total insurance claims for leading causes of paediatric mental health burden
(SOURCE: Bermuda Health Council’s Cost and Utilisation Data)
Note: *Data has been removed due to the reporting of small numbers to protect privacy
Total Claims
2021
Rank Service FY16-17 FY17-18 FY18-19 FY19-20 FY20-21
1 Other disorders 1563 3820 4672 4654 3163
2 Panic/anxiety 219 484 1166 1327 2108
3 ADD/ADHD 138 331 457 649 899
4 Autistic disorder 31 95 231 441 512
5 Adjustment disorder 296 754 702 556 418
6 Eating disorder   17 159 160 231
7 Depression disorder 128 189 322 293 195

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

8 Dementia   * 12 139 194

9 OCD   * 27 10 110
10 Phobias * 16 27 66 57

Table 24: Total insurance claims paid for leading causes of paediatric mental health burden
(SOURCE: Bermuda Health Council’s Cost and Utilisation Data)
Note: *Data has been removed due to the reporting of small numbers to protect privacy
Total Paid for Claimed Services
2021 Rank Service FY16-17 FY17-18 FY18-19 FY19-20 FY20-21
1 Other disorders $197803.8 $363,205.59 $501,834.95 $481,119.51 $319,340.10
2 Panic/anxiety $29,784.51 $66,625.10 $201,069.48 $196,824.36 $290,239.15
3 ADD/ADHD $20,451.67 $118,307.17 $161,335.60 $124,198.29 $134,422.43
4 Eating disorder   $2,505.00 $54,460.83 $55,169.41 $95,804.82
5 Autistic disorder $2,799.70 $43,791.42 $72,801.19 $114,070.21 $74,913.13
6 Adjustment disorder $35,791.00 $86,055.15 $85,779.53 $61,924.38 $50,099.00
7 Depression disorder $20,744.67 $20,432.63 $45,775.96 $35,395.97 $24,543.34
8 Dementia   * $1,135.00 $16,450.00 $23,753.00
9 Gender disorder17     $570.00 $2,029.75 $22,549.35
10 OCD   * $7,648.40 $1,500.00 $13,315.00

Table 25: Annual percentage coverage of Routine Immunisations for Children

(SOURCE: Department of Health – Extended Programme of Immunisations)

% Coverage by Year
Vaccine 2018 2019 2020 2021
Rotavirus, 1st dose 87 93 89 86
Rotavirus, last dose 75 87 83 101
DTP-containing vaccine, 1st dose 91 100 93 96
DTP-containing vaccine, 2nd dose 92 100 93 102
DTP-containing vaccine, 3rd dose 95 98 89 108
Diphtheria-containing vaccine, 4th dose (1st booster) 76 90 84 88
Diphtheria-containing vaccine, 5th dose (2nd booster) 64 77 65 65
Diphtheria-containing vaccine, 6th dose (3rd booster) 67 91 85 ND
Tetanus-containing vaccine, 4th dose (1st booster) 76 90 84 88
Tetanus-containing vaccine, 5th dose (2nd booster) 64 69 65 65
Tetanus-containing vaccine, 6th dose (3rd booster) 67 91 85 No data
Pertussis-containing vaccine, 4th dose (1st booster) 76 90 84 88
Hib3 95 96 87 71
Polio, 1st dose 91 100 93 96
Polio, 2nd dose 92 101 93 102
Polio, 3rd dose 95 98 89 108

17 Bermuda’s insurance claim data is based on coding using previous versions of ICD, which used the term ‘gender disorder’. The authors note that ICD-11 has
revised language on gender-identity health to reflect modern understanding of sexual health and gender identity. Further information can be found at: WHO.
Gender incongruence and transgender health in the ICD. Not dated (accessed 20th February 2023). Available: https://www.who.int/standards/classifications/
frequently-asked-questions/gender-incongruence-and-transgender-health-in-the-icd

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Polio, 4th dose 76 90 84 88

Pneumococcal conjugate vaccine, 1st dose 90 99 94 94
Pneumococcal conjugate vaccine, 2nd dose 91 97 91 102
Pneumococcal conjugate vaccine, final dose 94 96 92 105
HepB3 78 97 89 100
Measles-containing vaccine, 1st dose 87 108 99 92
Measles-containing vaccine, 2nd dose 70 102 74 65
Rubella-containing vaccine, 1st dose 87 108 99 92
Varicella 98 98 89 108
HPV Female (final dose) No consistent data available 52
HPV Male (final dose) No consistent data available 52

National Tumour Registry Data

Figure 24: Number of new cancer registrations 2012-2021
(SOURCE: Bermuda National Tumour Registry, Bermuda Hospitals Board)
Note: Data includes all carcinomas (invasive, in-situ and skin)

500
450
400
Number of New Cases

350
300
250
200
150
100
50
0
2012 2013 2014 2015 2016 2017 2018 2019 2020 2021
Year

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 25: Number of new cancer registrations and age-specific incidence rates (per
100,000), 2010-2019
(SOURCE: Bermuda Cancer and Health Centre18).
Note: Non-melanoma skin cancer and in-situ carcinoma excluded

300 2500
250 2000

Incidence rate per 100,000

200
1500
Number of new cases

150
1000
100
50 5 00

0 0
0- 5- 10- 15 - 20- 25 - 30- 35 - 40- 45 - 50- 55- 60- 65 - 70- 75 - 80- 85 +
Age at diagnosis

Male cases Female cases Male rate Female rate

Figure 26: Ten most common cancers among females by site 2012-2021
(SOURCE: Bermuda National Tumour Registry, Bermuda Hospitals Board)
Note: Data excludes non-melanoma skin cancers

18%

2%
2% 38%

5%

5%

5%

6%
13%
9%

Breast Invasive Cervix and CIN III Colon/Rectum

Melanoma Endometrium Lung
Blood/Bone Marrow Ovary Bladder
Other

18 Bermuda Cancer and Health Centre. Bermuda National Cancer Control Plan 2024-2030. Bermuda, April 2023 (Forthcoming).

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 27: Ten most common cancers among males by site 2012-2021
(SOURCE: Bermuda National Tumour Registry, Bermuda Hospitals Board)
Note: Data excludes non-melanoma skin cancers

18%

2% 34%
2%
3%

6%

6%

7% 12%
10%

Prostate Colon/Rectum Lung Melanoma

Blood/Bone Marrow Bladder Unknown Primary Kidney
Pancreas Other

Figure 28: Cancer cases per 1,000 population 2012-2021 mapped by postcode19
(SOURCE: Bermuda National Tumour Registry, Bermuda Hospitals Board)
Note: Bottom panels’ numbers refer to cancer cases per 1,000 population in each postcode
Data excludes non-melanoma skin cancers

19 The numerator data is taken from all cancers (excluding non-melanoma skin cancers) 2012-2021, whilst the denominator data is 10 x 2016 census data per
census district. Whilst the denominator data does not reflect the exact underlying population per census district per year, the degree of variation is likely to be
within an acceptable margin of error.

47
 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 29: Cancer Cases 2017-2019 by Stage at Diagnosis and Race

(excluding non-melanoma skin cancer)
SOURCE: Bermuda National Cancer Control Plan20

HEALTH RISK FACTORS

Tobacco
Table 26: Quantity of cigarettes consumed in the past month among those who
currently smoke, 2021
(SOURCE: Department for National Drug Control21)
Cigarettes consumed in the past month Number of smokers Percentage of smokers
1 to 5 297 5.6%
6 to 10 459 8.7%
11 to 20 (Half - 1 Pack) 804 15.3%
2 - 3 Packs 1185 22.5%
4 - 5 Packs 367 7.0%
More than 5 Packs 2082 39.6%

Table 27: Cigarette use by gender, 2021

(SOURCE: Department for National Drug Control22)
Cigarette use Male Female
Lifetime use of cigarettes 59.3% 45.7%
Used cigarettes in the past year 17.5% 6.9%
Current use of cigarettes 14.0% 5.7%

20 Bermuda Cancer and Health Centre. Bermuda National Cancer Control Plan. 2022. Available: https://www.cancer.bm/Uploaded%20Files/annual%20re-
port/2021/bermuda%20nccp_national%20cancer%20assessment_2022%20(2).pdf

21 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

22 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Table 28: Cigarette use by age, 2021

(SOURCE: Department for National Drug Control23)
Age Cigarette use by age
16-24 4.7%
25-34 10.9%
35-44 13.8%
45-54 12.5%
55-64 16.1%
65-74 5.3%
75-84 3.8%
85+ 6.3%

Table 29: Estimates of global smoking prevalence by age range, 2020

(SOURCE: WHO24)
Age Global smoking prevalence
15-24 14.2%
25-34 21.7%
35-44 26.3%
45-54 28.5%
55-64 26.8%
65-74 22.7%
75-84 18.0%
85+ 12.7%

Table 30: Current cigarette use by ethnic group, 2021

(SOURCE: Department for National Drug Control25)
Ethnic group Current smoker
Black or African 10.6%
White 7.4%
Portuguese 7.6%
Asian 12.9%
Mixed (Black & White, Black & Other, White & Other) 16.7%
Other 0.0%

23 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

24 World Health Organisation. WHO global report on trends in prevalence of tobacco use 2000-2025, fourth edition. Available: https://www.who.int/publica-
tions/i/item/9789240039322

25 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Table 31: Current cigarette use by highest academic qualification, 2021

(SOURCE: Department for National Drug Control26)

Highest Academic Qualification Current smoker

None 9.9%
School Leaving Certificate/High School Diploma 13.1%
Technical/Vocational Certificate (Bermuda College) 7.9%
Associate's Degree 13.1%
Bachelor's Degree 7.7%
Master's Degree 3.9%
Doctorate Degree 13.7%
Professional Designation (With or Without Any Prior Academic Qualification) 6.9%
Other 25.7%

Table 32: Current cigarette use by employment status, 2021

(SOURCE: Department for National Drug Control27)

Employment status Current smoker

Employed/Self-Employed, working 1-39 hours per week 9.7%
Employed/Self-Employed, working 40 or more hours per week 12.3%
Not employed, looking for work 22.3%
Not employed, NOT looking for work (e.g. housewife, student, other) 3.6%
Retired 4.6%
Disabled, not able to work 22.3%
Not Stated 0.0%

Table 33: Smoking prevalence by country

(SOURCE: Department for National Drug Control28)

Country/Territory Year Age Smoking prevalence

Bermuda 2021 16+ 9.7%
England 29
2021 18+ 13.3%
USA 2019 18+ 22.8%
Canada 2017 15+ 15.1%
Barbados 2006 18+ 9.1%
St Helena 30
2021 18+ 22.2%
Global 31
2020 15+ 22.3%

26 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

27 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

28 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf. .

29 UK Office for National Statistics. Adult smoking habits in the UK – Office for National Statistics. 2022. Available: https://www.ons.gov.uk/peoplepopulationand-
community/healthandsocialcare/healthandlifeexpectancies/bulletins/adultsmokinghabitsingreatbritain/2021

30 St Helena Government. St Helena Joint Strategic Needs Assessment. 2022. Available: https://www.sainthelena.gov.sh/wp-content/uploads/2022/10/Sum-
mary-of-St-Helenas-Joint-Strategic-Needs-Assessment-2022-JSNA.pdf

31 World Health Organization. Tobacco. 2022. Available: https://www.who.int/news-room/fact-sheets/detail/tobacco]

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Alcohol
Table 34: Problematic drinking behaviour prevalence, 2021
(SOURCE: Department for National Drug Control32)

Problematic drinking behaviour Prevalence

When you wake up in the morning after having drunk the night before, have you ever expe-
rienced not remembering part of what happened? 14.0%
Have you felt like decreasing the amount of alcohol you drink? 13.5%
Have you lost friends or partners because of alcohol? 4.5%
Do you drink more than you want, without noticing? 3.8%
Have you had trouble with your partner because of alcohol? 3.5%
Does it bother you that you are criticised for the way you drink? 2.1%
Did you have to drink alcohol in the morning? 0.7%

Table 35: Alcohol use by gender, 202133

Alcohol use Male Female
Lifetime use of alcohol 93.2% 89.1%
Used alcohol in the past year 74.0% 64.2%
Current use of alcohol 60.9% 47.7%

Table 36: Alcohol use by ethnic group, 2021

(SOURCE: Department for National Drug Control34)
Ethnic group Current drinker
Black or African 44.2%
White 69.0%
Portuguese 58.0%
Asian 41.0%
Mixed (Black & White, Black & Other, White & Other) 60.2%
Other 55.7%

Table 37: Alcohol use by highest academic qualification, 2021

(Department for National Drug Control35)
Highest Academic Qualification Current drinker
None 22.2%
School Leaving Certificate/High School Diploma 51.1%
Technical/Vocational Certificate (Bermuda College) 46.7%
Associate's Degree 59.4%

32 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

33 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

34 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf..

35 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Bachelor's Degree 65.0%

Master's Degree 60.1%
Doctorate Degree 62.7%
Professional Designation (With or Without Any Prior Academic Qualification) 76.9%
Other 16.7%

Table 38: Alcohol use by employment status, 2021

(Department for National Drug Control36)
Employment status Current drinker
Employed/Self-Employed, working 1-39 hours per week 53.1%
Employed/Self-Employed, working 40 or more hours per week 65.1%
Not employed, looking for work 54.0%
Not employed, NOT looking for work (e.g. housewife, student, other) 48.3%
Retired 39.4%
Disabled, not able to work 28.1%

Table 39: Alcohol use by country, 2021

(SOURCE: Department for National Drug Control37)
Country/Territory Age Alcohol consumption prevalence
Bermuda 16+ 54.0%
USA 18+ 54.9%
Canada 15+ 78.2%
Barbados 18+ 36.2%

Excess Weight

Table 40: Percentage of 5-year-olds that are overweight

(SOURCE: Department of Health38)
School year 14-15 15-16 16-17 17-18 18-19 19-20 20-21
Total Population 716 703 599 716 563 516 259
Percentage of students 97% 99% 99% 84% 98% 87% 99%
screened (697) (697) (593) (600) (553) (451) (257)
Percentage of screened who 22% 22% 25% 32% 31% 28% 33%
are overweight BMI >25 (156) (154) (149) (191) (174) (127) (86)

36 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

37 Department for National Drug Control, Government of Bermuda. 2021 National Household Survey. Available: https://www.gov.bm/sites/default/files/Nation-
al_Household_Survey_2021_Report_FINAL.pdf.

38 Department of Health, Government of Bermuda. Child Health Obesity Data. Unpublished. Please note: the 2020/21 data did not include all schools and there-
fore may not be representative.

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Table 41: BMI by gender, 202339

BMI Male Female
BMI ≥ 25 (overweight including obesity) 71.3% 71.7%
BMI 25-30 (overweight) 37.4% 36.1%
BMI ≥ 30 (obese) 33.9% 35.6%

Table 42: BMI by age range, 202340

Age range BMI ≥ 25 BMI 25-30 BMI ≥ 30
(overweight including obesity) (overweight) (obese)
18-34 73.3% 44.4% 28.9%
35-64 75.2% 36.8% 38.4%
65+ 61.8% 33.7% 28.1%

Table 43: BMI by ethnic group, 202341

Ethnic group BMI ≥ 25 BMI 25-30 BMI ≥ 30
(overweight including obesity) (overweight) (obese)
Black 75.0% 38.2% 36.8%
White 62.2% 31.9% 30.3%
Mixed and Other 80.4% 41.3% 39.1%

Table 44: BMI by income, 202342

Income group BMI ≥ 25 BMI 25-30 BMI ≥ 30
(overweight including obesity) (overweight) (obese)
< $75,000 70.5% 35.6% 34.9%
$75,000-$150,000 72.8% 33.17% 39.7%
> $150,000 76.1% 41.3% 34.8%

Table 45: Percentage of adults that are overweight and obese by comparator areas
(SOURCES: See table’s footnotes)
Country/Territory Year Overweight Obese
Bermuda 2023 37% 35%
England43 2021 38% 26%
USA 44
2018 31% 42%
Global 45
2016 39% 13%

39 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

40 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

41 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

42 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

43 Baker C. Obesity statistics. Available: https://researchbriefings.files.parliament.uk/documents/SN03336/SN03336.pdf

44 US Department of Health and Human Services. Overweight & Obesity Statistics. Available: https://www.niddk.nih.gov/health-information/health-statistics/
overweight-obesity#:~:text=the%20above%20table-,Nearly%201%20in%203%20adults%20(30.7%25)%20are%20overweight.,obesity%20(including%20
severe%20obesity).

45 World Health Organization. Obesity and overweight. Available: https://www.who.int/news-room/fact-sheets/detail/obesity-and-overweight

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 30: Histogram of BMI Distribution in Bermuda’s Population46

Males Females

Nutrition: fruit and vegetable intake

Table 46: Fruit and vegetable intake by gender, 202347

Fruit and vegetable intake Male Female
5+ fruit and vegetables daily 24.8% 33.8%

Table 47: Fruit and vegetable intake by age range, 202348

Age range 5+ fruit and vegetables daily
18-34 33.3%
35-64 31.0%
65+ 25.3%

Table 48: Fruit and vegetable intake by ethnic group, 202349

Ethnic group 5+ fruit and vegetables daily
Black 30.2%
White 34.1%
Mixed and 20.0%
Other

46 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

47 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

48 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

49 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Table 49: Fruit and vegetable intake by income, 202350

Income group 5+ fruits and vegetables daily
< $75,000 26.1%
$75,000-$100,000 31.2%
> $150,000 33.7%

Physical activity
Table 50: Physical activity by age range, 202351
Age range Meet WHO guidelines for physical activity Insufficient physical activity
18-34 87.2% 12.8%
35-64 78.6% 21.4%
65+ 75.0% 25.0%

Table 51: Physical activity by ethnic group, 202352

Ethnic group Meet WHO guidelines for physical activity Insufficient physical activity
Black 71.5% 28.5%
White 87.3% 12.7%
Mixed and Other 91.3% 8.7%

Table 52: Physical activity by income, 202353

Income group Meet WHO guidelines for physical activity Insufficient physical activity
< $75,000 72.2% 27.8%
$75,000-$150,000 83.3% 16.7%
> $100,000 84.4% 15.6%

Table 53: Insufficient physical activity by comparison area (SOURCE: WHO54)

Country/Territory Insufficient physical activity
Bermuda 21.2%
Barbados 42.9%
Canada 28.6%
UK 35.9%
USA 40.0%
High-income countries 36.8%
Global 27.5%

50 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

51 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

52 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

53 Department of Health, Government of Bermuda. Bermuda Omnibus Pulse Survey January 2023. Unpublished. Narrative Research Bermuda.

54 World Health Organisation. Global Health Observatory. Available: https://www.who.int/data/gho/data/indicators/indicator-details/GHO/prevalence-of-insuffi-

cient-physical-activity-among-adults-aged-18-years-(age-standardized-estimate)-(-)

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Air Pollution
Table 54: Annual air emissions from Tynes Bay waste to energy incinerator, 2020
(SOURCE: Department of Statistics55)
Component of Year
Air Pollution 2016 2017 2018 2019
NO2 (mg/ 274.4 242.9 322.7 353.3
Nm3)
SO2 (mg/Nm3) 36.5 43.8 1.7 69.4
Particulate 3.9 8.1 2.8 39.6
Matter (mg/
Nm3)

Table 55: European Directive limits on air pollution56

Component of
Air Pollution Limit
PM10 40 µg/m3 (annual mean); 50 µg/m3 (24 hour mean) not to be exceeded more
than 35 times a year.
PM2.5 20 µg/m3 (annual mean)
NO2 40 µg/m3 (annual mean); 200 µg/m3 (1 hour mean) not to be exceeded more
than 18 times a year
SO2 125 µg/m3 (24 hour mean) not to be exceeded more than 3 times a year; 350
µg/m3 (1 hour mean) not to be exceeded more than 24 times a year

HEALTH PERSONNEL
Table 56: Bermuda Health Workforces
(SOURCE: 2021 Labour Force Survey)
Occupation Number Bermudian Non-Bermudian % Non-Bermudian
Dentist 34 21 13 38.24%
Medical Laboratory Technician 38 20 18 47.37%
Medical Worker NEC 103 85 18 17.48%
Occupational Therapist 31 16 15 48.39%
Pharmacist 81 23 58 71.60%
Physician 160 70 90 56.25%
Physiotherapist 47 26 21 44.68%
Radiological Technician 44 24 20 45.45%
Registered Nurse 373 95 278 74.53%
Surgeon 10 4 6 60.00%
Total Human Health Workers 2046 1425 621 30.35%

55 Department of Statistics, Government of Bermuda. Environmental Statistics Compendium 2021. Available: https://www.gov.bm/sites/default/files/2021-En-
vironmental-Statistics-Compendium.PDF] Please note: The data is captured through isokinetic sampling over a two day period each year and is reported
normalised to 11% oxygen.

56 UK Department for Environment Food and Rural Affairs. UK AIR. National air quality objectives and European Directive limit and target values for the protection
of human health. Not dated. Available: https://uk-air.defra.gov.uk/assets/documents/Air_Quality_Objectives_Update.pdf [accessed 14th March 2023].

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

HEALTH SERVICES

Insurance Coverage
Table 57: Population by type of health insurance coverage, 2010 and 2016
(SOURCE: 2016 Census and Housing Report)
Number Percentage Percentage
Type of Health
Change
Insurance Coverage 2016 2010 2016 2010 2010-2016
Total 63,779 64,237^ 100 100
Major Health Coverage (Private or 46,084 50,759 72 84 -12
GEHI)
None 5,341 3,233 8 5 +3
Only Private Basic Coverage 4,015 1,349 6 2 +4
Only HIP 3,632 3,053 6 5 +1
Only FutureCare 3,244 1,965 5 3 +2
Insured – Type Unknown 1,389 * 2 * *
Not Stated 74 1,327

Notes: * represents <1%, ^includes 2,551 persons for whom there is no data

Figure 31: Percentage of population without health insurance coverage by census district
(SOURCE: 2016 Census and Housing Report)

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Table 58: Demographic Characteristics of Uninsured Population, 2010 and 2016

(SOURCE: 2016 Census and Housing Report)
Number
Percentage in Percentage Change
Demographic Characteristics
2010 2016 2016 2010-2016

Sex 3,233^ 5,341 100  

Male 1,911 3,000 56 +3
Female 1,322 2,341 44 -3
Age Groups (years) 3,233 5,341 100  
0 – 14 602 1,008 19 *
15- 29 897 1,286 24 -4
30-44 637 942 18 -2
45-64 210 564 11 +5
Median Age (years) 32 35    
Race 3,233 5,341 100  
Black 2,480 4,085 77 *
White 288 499 9 *
Mixed and Other 444 754 14 *
Not Stated 21 3    
Nativity 3,233 5,341 100  
Bermuda Born 2,786 4,601 86 *
Foreign Born 438 737 14 *
Not Stated 9 3    
Bermudian Status 3,233 5,341 100  
Bermudian Status 2,974 4,949 93 +1
Non-Bermudian 251 392 7 -1
Not Stated 8      
Highest Academic Qualification 2,596 4,254 100  
(16 years +)
No Formal Certificate 1,001 880 21 -18
High School Certificate 970 2,063 49 +11
Tech./Voc./Assoc./Diploma 338 845 20 +7
Degree 219 460 11 +2
Other 27 0 * -1
Not Stated 41 6    
Economic Activity (16 years +) 2,596 4,254 100  
Working 1,139 1,550 36 -8
Unemployed 755 1,354 32 +3
Economically Inactive 679 1,344 32 +6
Not Stated 23 6    

Notes: ^ excludes persons for whom there is no data

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Health Facilities
Figure 32: Map of Bermuda Health Facilities
(SOURCE: Bermuda Health Council Health Facility Data, December 2022)

Reasons for Hospitalisation

Figure 33: Reasons for Hospitalisation: Combined Total by ICD Code (2012-2021)
(SOURCE: BHB/ESU)

1.1% 0.8% 0.5% 0.3% 0.3% 0.2%

2.1%
2.4%
2.9%
5.4%
33.3%
6.1%

7.3%

9.9%

27.4%

Injury And Poisoning Circulatory

Pregnancy And Chil dbirth Diges tive
Res piratory Mus cul os keletal
Genitourinary Neoplasms (Cancer)
Infectious And Parasitic Mental And Behav ioural/Nerv ous
Endocrine, Nutritional, Metabolic And Immunity Ill-Defined
Skin Blood And Blood Forming
Perinatal

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Table 59: Reasons for Hospitalisation by ICD Code (2012-2021)

(SOURCE: BHB/ESU)

ICD Group 2012 2013 2014 2015 2016 2017 2018 2019 202057 2021
Injury And
21.8% 21.3% 21.2% 20.0% 19.8% 20.1% 19.8% 19.7% 15.2% 11.1%
Poisoning
Circulatory 12.5% 13.7% 13.6% 14.1% 14.4% 15.7% 15.8% 17.1% 17.8% 16.5%
Pregnancy And
12.6% 12.3% 11.1% 11.2% 10.9% 10.6% 9.9% 9.6% 12.3% 11.7%
Childbirth
Digestive 9.6% 9.6% 10.1% 9.5% 11.9% 10.8% 10.5% 10.4% 11.5% 12.7%

Respiratory 10.2% 8.9% 9.5% 9.7% 8.8% 8.5% 8.7% 8.8% 7.6% 10.4%

Musculoskeletal 6.3% 6.3% 6.7% 6.9% 6.8% 5.2% 5.4% 4.9% 4.2% 3.7%

Genitourinary 5.1% 4.7% 4.6% 6.2% 5.2% 5.5% 6.7% 5.4% 5.6% 5.9%
Neoplasms
5.9% 5.5% 6.3% 5.6% 5.4% 4.9% 4.9% 5.2% 5.1% 5.2%
(Cancer)
Infectious And
2.5% 2.6% 3.0% 4.0% 4.6% 4.8% 4.4% 5.8% 5.9% 4.9%
Parasitic
Mental &
Behavioural/ 3.7% 3.9% 3.2% 2.8% 3.3% 4.0% 4.1% 4.1% 4.9% 7.3%
Nervous
Endocrine,
Nutritional,
3.2% 3.5% 3.5% 3.2% 2.8% 3.8% 3.7% 3.2% 3.3% 3.7%
Metabolic And
Immunity
Ill-Defined 2.5% 3.4% 3.1% 2.7% 1.9% 2.1% 2.3% 2.5% 2.3% 3.1%

Skin 1.6% 1.9% 1.9% 1.7% 1.8% 2.0% 1.9% 1.7% 1.9% 2.2%
Blood And Blood
1.8% 1.7% 1.7% 1.9% 2.0% 1.6% 1.6% 1.4% 1.7% 1.6%
Forming
Perinatal 0.5% 0.5% 0.4% 0.4% 0.3% 0.3% 0.2% 0.2% 0.4% 0.1%
Congenital 0% 0% 0% 0% 0% 0% 0% 0% 0% 0%

57 NB: Changed from ICD 9 to ICD 10 in 2020.

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Health Spending
Table 60: Sources of Health Finance FY17-18
(SOURCE: 2019 Health Account Report)

Source Health Finance Amount ($000s) % of Total

Ministry of Health $161,080 21.9%
Department of Social Insurance $3,235 0.4%
Grants for provision of health services $2,363 0.3%
Public Sector Sub-Total $166,678 22.6%
Health Insurance $453,260 61.5%
Out-of-Pocket Expenditure $109,992 14.9%
Donations $6,696 0.9%
Private Sector Sub-Total $569,947 77.4%
Total Public & Private $736,625 100.0%

Table 61: Health Expenditure FY 17-18

(SOURCE: 2019 Health Account Report)
Health Expenditure Amount ($000s) % of Total
Ministry of Health HQ $11,479 1.6%
Department of Health $25,689 3.5%
Bermuda Hospitals Board $307,514 41.7%
Public Sector Sub-Total $344,681 46.8%
Local Practitioners – Physicians $57,656 7.8%
Local Practitioners – Dentists $31,820 4.3%
Other Health Providers, Services & Appliances $92,385 12.5%
Prescription drugs $44,597 6.1%
Overseas care $93,114 12.6%
Administration of health insurance, health policy and health programmes $72,374 9.8%
Private Sector Sub-Total $391,945 53.2%
Total Public & Private $736,625 100.0%

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

Figure 34: International comparison of health expenditure as share of GDP

(SOURCE: 2019 Health Accounts Report)

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 Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

COVID-19 and healthcare accessibility and availability

Figure 35: Effect of pandemic on accessibility and availability of healthcare
(SOURCE: Bermuda Vital Signs® Special COVID-19 Pandemic Edition in October 2022)

Rating on a 10 point scale

1 = much worse than before the pandemic
10 = much better than before the pandemic
45%
39%
40% 36%
34%
35% 32%
29% 28%
30%
25%
20%
15%
10%
5% 2% 1%
0%
Accessibility to healthcare serv ices Availability of healthcare services
Mean score: 5.1 Mean score 5.2

Bottom 4 Box (1-4) Middle 2 Box (5-6) Top 4 Box (7-10) Don't know/no opinion

Figure 36: Accessibility and availability of healthcare within the next year
(SOURCE: Bermuda Vital Signs® Special COVID-19 Pandemic Edition in October 2022)

60%

49% 48%
50%

40% 36%
34%

30%

20% 16%
13%
1 0%
1% 2%
0%
Accessibility to healthcare serv ices Availability of healthcare services

Worsen Stay the same Improve Don't know/No answer

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Chief Medical Officer’s Annual Report 2023: A Post-Pandemic Focus on Health Inequalities

64