Inertia, Insanity or Incompetence? A look at our response to the NCD pandemic.

Dr. C. V. Alert, MB BS, DM. FCCFP.

Family Physician.

In 2005, Sir George Alleyne, then Director of WHO/PAHO, pointed out to Caribbean Heads of Government (and Caribbean people) that the morbidity and mortality rates from the NCDs in Caribbean countries were many times higher than, for example, the USA and the UK.

At a 2008 Conference on Port-of-Spain, Trinidad, Caricom Prime Ministers and Ministers of Health “United to stop the epidemic of the NCD in Caribbean Countries”, and proposed a series of measures towards achieving this goal.

Now, almost two decades later, the NCD epidemic continues, while the covid-19 pandemic has largely shifted attention, and importantly scarce resources, away from the NCDs. Unfortunately, the NCDs did not emigrate overseas.

The reasons for the high morbidity and mortality rates are multi-factorial, but certainly treatment costs must feature high on this list, with Caribbean countries all belonging to the group of middle to low income countries. This suggests that the old adage: “An ounce of prevention is a lot cheaper than a pound of cure”, should govern our resource allocation, but Caribbean Health Decision makers have diverted many resources to high cost tertiary care, at the expanse of Health Promotion and Disease Prevention.

Table 1: Affects of Intensive treatment on the development of diabetic microvascular and macrovascular complications from some large studies

Study(Patients on intensive therapy)	UKPD (3676)	ADVANCE (1140)	ACCORD (10251)	VADT (1791)
Mean duration of T2DM (years)	0	8	10	11.5
Mean HbA1c (%)	7.1	7.3	8.5	9.1
Baseline FBG (mmol/l)	8.3	8.5	9.7	11.4
Mean age (years)	53	66	62	60
Microvascular complications	Decreased	Decreased	+	–
Macrovascular complications.	Decreased	–	Increased	–

Taking Diabetes mellitus as one example of a disease that is rampant on our shores, data from a number of large studies shows that the progression to diabetic complications can be slowed by intervention in the newly diagnosed diabetic (UKPDS) or shortly after diagnosis (ADVANCE), while aggressive intervention in patients with long standing diabetes, such as the ACCORD and the VADT studies, is fraught with danger. But our decision makers, who claim to follow the science (at least when talking about covid-19 restrictions), have not implemented national screening programs for the NCDs so that early intervention can become a reality.

It is also noticeable that recent guidelines for the treatment of diabetes have included options for patients for whom cost of treatment is a limiting factor: this applies to large numbers of our patients, who often rely on free medications from the National Drug Formularies. Since the newer anti-diabetic drug classes are multiple times more expensive than the older drug classes, it is hearting to know that these new guidelines still offer evidence-based guidelines that ‘middle to low’ income countries should adopt.

The outpouring of Caribbean medical graduates from medical faculties in four UWI Campuses, and a sprinkling of candidates from a few off-shore medical schools, suggests that Caribbean patients should have access to improved medical care. Our limited health statistics suggest otherwise. Clinical inertia may be part of the explanation.

Clinical inertia – one definition: a failure to initiate treatment in a timely manner in people whose health is likely to improve as a result of this treatment. We have no National Screening programs, even though clinical data suggest that the best impact on diabetic outcomes, including legacy effects, comes with early intensive interventions. The fact that clinical audits, such as the 2015 Health of the Nation (Barbados) 5, showed that 62% of diabetics on treatment were not achieving blood sugar targets, suggest that clinical inertia is ‘alive and kicking’ in many primary care settings that serve these clients. In fact, of the four major NCD risk factors – obesity, diabetes, hypertension and the dyslipidemias –obesity as a medical issue seems to be completely ignored, the status of dyslipidemia control is unknown, and both hypertension and diabetes are poorly managed in primary care. Surprise! Our hospitals are overflowing with persons who develop these conditions, while family, friends and work colleagues suffer.

Another definition of clinical inertia points to treatment targets. Clinical inertia: a failure to establish targets and to escalate treatment to achieve treatment goals. Current treatment protocols point to the need for an initial assessment of each individual’s cardiovascular risk, using cardiovascular risk assessment tables, such as CARDIOCAL. Once this risk is calculated, specific blood pressure, blood sugar, and LDL Cholesterol must be decided on, specific therapies initiated, and periodic assessments made to determine the patient’s progress towards achieving those targets, and/or the need for adjusting the therapeutic regimes.

The non-achieving of blood sugar targets in these patients could be described as inertia, but it also fits Einstein’s description of insanity: doing the same thing over and over yet expecting a different result. What about incompetence: inability to do something successfully? Achieving blood pressure and serum cholesterol targets also show up poorly on clinical audits, and in some individual patients’ poor control of all these parameters occur simultaneously.

The fingers of ‘blame’ for this unfortunate NCD situation can be pointed in many directions. Caribbean Heads of Government, and Ministries of Health, have failed to create the healthy environment that was envisioned at the 2008 conference. Caribbean persons, in large part, have failed to adopt healthy eating and exercise habits. The Ministries of Health have failed to introduce National Primary Prevention programs that (some of) their own national strategic plans champion. Some, (perhaps many) primary care physicians, fail to familiarize themselves with the appropriate tools and targets that are appearing with considerable frequency to optimize NCD patient management, and fail to ‘up-titrate’ the management of many of their patients. Our Health decision makers have failed to respond to their own national statistics that highlight the dire situation around the NCDs, even while our hospital beds and morgues become supersaturated with NCD patients (long before covid-19). By ‘defaulting’ to tertiary care, the NCDs are allowed to raid out national treasuries. Caricom Ministries of Health who have introduced EHR – Electronic Health Records – to allow rapid access to patient clinical information, have failed to use this data to optimize patient management.

So how can our management of many NCD patients be described? Inertia? Incompetence? Insanity? Whatever tern is used, it is hoped that going forward it should not be ‘business as usual’. We urgently need improved NCD management. The needs expressed at the 2008 conference by our Heads of Government and our Ministers of Health remain the same: we must unite to stop the epidemic of the NCDs.

References.

Stratton IM, Adler AI, Neil HA, et al. Association of glycaemia with macrovascular and microvascular complications of type 2 diabetes (UKPDS 35): prospective observational study. BMJ 2000;321:405-
The ADVANCE Collaborative Group: Intensive Blood Glucose Control and Vascular Outcomes in Patients with Type 2 Diabetes. N Engl J Med 2008; 358; 2560-2572
The Action to Control Cardiovascular Risk in Diabetes (ACCORD) Study Group. Effects of Intensive Glucose Lowering in Type 2 Diabetes. N Engl J Med 2008; 358
Abraira C, Colwell JA, Nuttall F, et al. Cardiovascular events and correlates in the Veterans Affairs Diabetes Feasibility Trial: Veterans Affairs Cooperative Study on Glycemic Control and Complications in Type II Diabetes. Arch Intern Med 1997;157:181-18
Unwin N, Rose AMC, George KS, Hambleton IR, Howitt C. The Barbados Health of the Nation Survey: Core Findings. Chronic Disease Research Centre, The University of the West Indies and the Barbados Ministry of Health: St Michael, Barbados, January 2015;