Dr. C. V. Alert, MB BS, DM. (Family Medicine), FCCFP.
Family Physician.
Fellow, Caribbean College of Family Physicians.
The Family Physician in the Caribbean, part of the team of Primary Health Care workers, serves on the front-lines in battling not one but two pandemics, an chronic non-communicable (NCD) pandemic that has been around for a few decades and now a Covid-19 pandemic, the new ‘Sherriff in town’. The NCD pandemic exposed many deficiencies in the ability of local health services to battle these epidemics. Even though Caribbean Heads of Government and Ministers of Health met in Trinidad in 2007 and chartered the “Declaration of Port-of-Spain: Uniting to Stop the Epidemic of NCDs”, there is little evidence, fifteen years later, that Caribbean Health services have ‘united’ or that the epidemic is slowing down. And, on top of the NCD pandemic, an infectious disease pandemic, uninvited, has visited Caribbean shores.
As far as the NCDs are concerned, there are some specific tasks that the Caribbean Physicians can contribute to the overall battle against these pandemics. The purpose of this is to reduce the number of vulnerable individuals, as both the NCDs and Covid-19 target these persons for severe illness and death.
Screening.
It is generally easier to treat the ncds, and stall their progression, if detected early and intervention initiated.
In the absence of National Screening programs, screening for cardiovascular risk factors can be performed by family physicians that function on the front lines of health care. Many of these risk factors are ‘silent’ until complications arise; screening offers an opportunity for early diagnosis, early intervention and to retard disease progression. Country specific statistics, such as the Health of the Nation (HotN) study in Barbados, and the STEPS program in some other Caribbean Islands, suggest that at least sixty percent of adults have at least one chronic illness, and many have multiple chronic illnesses. Not uncommonly, the patient with diabetes may also be obese, have hypertension and a dyslipidemia, in addition to chronic kidney disease. Some cardiovascular risk factors, like nonalcoholic fatty liver disease and obstructive sleep apnea, are rarely diagnosed. The family physician has to be fairly adept at screening for, and then managing, all these conditions. Cardiovascular disease is still the leading cause of death in these individuals, so management has to go way beyond just managing the blood sugar or the blood pressure.
Over the last two decades or so, there have been a number of advances internationally in the diagnosis and effective treatment of the NCDs that should be adopted by Caribbean Family Physicians, as one way of improving the primary care management of some cardiovascular/metabolic conditions.
Immunizations.
The experience of the covid-19 pandemic serves to remind us of the importance of immunizations. Perhaps unfortunately, many patients (and their health care providers) have come along in an era of chronic diseases, which followed the era of infectious diseases/malnutrition. In the infectious disease era, immunizations, sanitation and antibiotics were important pillars in fighting off disease, but in the chronic disease era immunizations, especially for adults, were gradually forgotten. When covid-19 suddenly appeared many adults, with no history of keeping up with immunization schedules and also bombarded by conspiracy theories, were at best ambivalent about ‘taking the shot’. Unfortunately, many of them suffered after declining to got any covid vaccinations.
Generally speaking, an (uncontrolled) NCD lowers a person’s immunity, and makes him/her more susceptible to an infectious disease. Thus covid-19 had its most devastating effects on those with NCDs. Covid-19 serves as a grim reminder to re-establish adult immunization schedules, particularly in the elderly and those with chronic diseases. When two health pandemics, each with the ability to kill millions of people, meet, it is prudent to attempt to protect the most vulnerable of our communities,
With the WHO projecting that we are likely to have severe infectious disease outbreaks with increasing frequency in coming years, it is necessary to re-establish vaccine confidence in our adult population. The Family Physician can play a positive role in this regard.
It may be an appropriate time to revisit adult immunization schedules, even at a National level, while maintaining schedules in children and adolescents.
New Medical Technologies.
Nowadays we invite our patients to do self monitoring of their diets, weights, blood sugars and blood pressures: some guidelines utilize this patient data to diagnose diseases like diabetes and hypertension. Such activity can only supplement the role of the family physician, who should screen all adult patients, and any others who fall in high risk groups like overweight/obesity or a family history of a cardiovascular disease or event.
Current technology, on Smart-phones, Smart Watches, or a multitude of downloadable APPS, can allow patients, and their Family Physicians, to follow a multitude of health parameters. Continuous glucose monitoring, and ‘smart’ insulin pumps, along with parameters such as Time in Range (TIR), can ‘overtake’ parameters such as the HbA1c, in monitoring the progress of the diabetic patient.
Pulses, blood pressures, ECGs, step counts, total sedentary time, calories burned, oxygen saturation, calories consumed and many more allow real-time monitoring of the patient, or could be downloaded directly into the patient’s electronic health record (EHR).
These innovations are all available to the patient in primary care, whereas previously such patient monitoring was perhaps reserved for a patient in Tertiary Care, especially if that patient was critically ill and/or resided in an intensive care unit (ICU).
So this represents a paradigm shift, where the Family Physician 2.0 has to select the appropriate information to ‘guide’ his/her patient to accept appropriate health choices. This explosion of patient data available to physicians also supports the introduction of the EHR. The old ‘pen and paper’ record, for so long the tool used by physicians to record patient information, grew bulkier over time, the ink often faded, the paper disintegrated, and it was a tedious process of sharing information with other members of the medical team. Some information was ‘hidden’ by doctors’ handwriting, and some information was confined to the deep recesses of hospital or clinic basements. This often made retrieval, and subsequent research efforts, an almost impossible task. The EHR allows some of these limitations to be overcome. It is not surprising that the term ‘meta-analysis’, where data from different sources is pooled to generate large sample sizes and hence strengthen the confidence in which research conclusions could be based, is now quite common in the medical literature. This provides a potential avenue in which Caribbean Primary Care can be done; to date this has just been a ‘bucket list’ item.
This can lead to the day when we have Caribbean primary care research data, which may allow us to generate cost-effective solutions to our own problems. These are some of the tools needed by Caribbean Family Physician 2.0
Summary.
As the world negotiates current realities, and prepares for the future, the Caribbean Family Physician 2.0 has to equip himself/herself to function optimally in this ‘whole new world’. Sometimes the Family Physician is the only source of medical attention, in an era of a growing number of medical specialities and medical innovations. An appropriately trained Caribbean Family Physician can play a leading role in tackling Caribbean Health problems. The preparation has to start today, for the challenges of today and tomorrow.