#BTColumn – Condolences are not enough

Disclaimer: The views and opinions expressed by this author are their own and do not represent the official position of the Barbados TODAY. 

by Dr. Colin V. Alert

About one year ago, while we waited with some trepidation for the arrival of the new coronavirus named COVID-19, our health decision-makers told us of their planned strategy. The strategy involved ‘flattening the curve’: attempting to totally banish patients with COVID-19 from our tertiary health care institutions, allowing the medical staff to focus on their ‘usual’ patients, primarily the patients with the chronic non-communicable diseases, the NCDs.

Now, one year later, and still keeping patients affected by COVID-19 out of our tertiary health care institution, we have reached a point where the hospital is overwhelmed by inpatients, particularly on the wards that house patients affected by complications of one or more of the NCDs.

Not only are hospital wards bursting at the seams, but hospital staff is so overwhelmed that routine clinics and appointments are being cancelled, sometimes indefinitely, leaving patients without medical care or attention. Primary care clinics have also been cancelled as staff members are being diverted to COVID-19 related activities. Routine care and assessment of the NCD patients has been abandoned.

But we do  know  that chronic diseases left undiagnosed, or without the appropriate follow-up care can create worse problems for the patients: for example permanent damage to brains (‘strokes’), hearts (‘heart attacks and heart failure’), eyes (‘blindness’), and kidneys (‘chronic kidney disease, necessitating dialysis or the rare renal transplant’). And these are just some of the problems, negatively affecting the health and happiness of our patients and their families.

There are also patients who were ‘encouraged’ to delay seeking medical attention even when available: ‘stay home’, as any open medical clinics may be filled with persons who were potential COVID spreaders. This has lead to delayed or missed diagnosis(es), and ultimately leading to a sicker patient and a likely poorer outcome.

The proposed plan for dealing with COVID-19 unfortunately did not adequately consider the status of our NCD patients at the start of this pandemic. The Health of the Nation (Barbados) Study, published in 2015, showed that more than half of our adult patients with one or more of these NCDs did not have their diseases controlled adequately. At that point in time Barbados had an average of a heart attack a day, and three stokes every two days.

Monthly, 40 patients died from one of these conditions, and in 2017 the then government was forced to spend over BDS$19m, or about 13 per cent of the hospital budget, just to treat patient who had developed chronic kidney disease (and many of them died shortly after diagnosis anyway).

In 2018, an unfortunate reduction in the allocation of funds on the National Formulary to treat the NCDs caused further (and in some patients major) disruptions in their medications. This was likely to cause severe blows to our NCD patients, and ‘set them up’ for disease progression, and in some cases even death. This was the landscape that awaited the arrival of COVID-19.

Those who did not die were left with chronic disabilities, dependant on their families and medical care for day-to-day living and even survival.  The COVID-19 protocols disrupted this severely.

The COVID-19 public health messages rightly pointed out those patients with these NCDs, also called co-morbidities, were at increased risk for poor outcomes should they come in contact with the virus. The messages failed to stress the importance of continued care and the importance of controlling the disease(s) in the first place.

The messages stressed the importance of patients taking their medications, without acknowledging that many medications were in short (or at least erratic) supply. Going out for fresh fruit and vegetables brought you into contact with strangers: stock your homes for the long run with preserved foods (that are generally high in salt anyway). While the doctors stressed the importance of exercise, the NCD patients were told to stay inside with windows and doors tightly locked.

When clinics were postponed or cancelled, their chronic diseases worsened, ultimately leading sicker patients, some of whom ended up in hospital as a last resort.  These individuals with poorer health then became ‘red meat’ for the COVID-19 virus: we are now seeing a surge in the number of patients with NCDs succumbing to the virus. [And this is on top of the deaths of these NCD patients not affected by COVID-19].

Our COVID-19 communication team gives us updates on the national COVID-19 dashboard every few days.  Good. No equivalent level of attention is being paid to the NCDs. Bad.  Not only is there no communication team, but the Ministry of Health has not produced a Chief Medical Officer’s (CMO’s) annual report since 2012. [This is equivalent to the Auditor General reporting that some Ministries and Departments have not submitted their financial reports for a number of years]. So data on the national health picture has to be assembled piecemeal.

Ideally studying the data generated by this pandemic can help us understand the effects of delayed or missed care, and may help us prepare for future pandemics, but we are not even sure that adequate attention is being paid to this data collection for our NCD patients.

So the focus on “COVID, COVID, COVID” has still left our elderly patients with the NCDs, those more likely to comply with the social distancing/hand-washing/mask-wearing protocols, of poor outcomes and even death.  The focus on COVID-19, and the neglect of the NCD patients, is unfortunately very bad news. Now our NCD patients are being struck down by COVID-19, as well as the complications of uncontrolled NCDs. We must not abandon these patients. Extending condolences to the families is not enough.

Dr. Colin V. Alert, MB BS, DM. is a family physician and associate UWI family medicine lecturer