Wed, 2021-11-17 12:43 by Dr. Colin Alert
Is there a role for the trained Family Physician in the Caribbean? Perspectives of three senior family physicians from three islands.
Dr Colin Alert, MB BS, DM (Family Medicine, UWI), FCCFP. Barbados;
Dr. Sonia Roache-Barker, MB BS (UWI-London), FCCFP Trinidad and Tobago; and
Dr. Pauline Williams-Green, MD, DM (Family Medicine, UWI), MA (Distance Education), FCCFP. Jamaica.
November 13, 2021
Covid-19 has exacerbated the weaknesses in the health care sector as the Caribbean states have been rocked by wave after wave of Covid-19 cases. This has increased the need for front-line personnel to do testing, contact tracing, quarantine of suspected cases and triage of the infected persons. Initially these activities were confined to the public health practitioners but long-standing shortages in personnel resulted in them being overwhelmed. Inadequate resources required for the tasks caused frustration and delays in managing this new threat.
Family physicians provide significant interface with the population by providing information, education and first contact care. As we await the fourth wave of Covid-19 infections, it should be clear to policy makers that public health practitioners alone cannot tackle this pandemic. Family physicians are well placed to offer testing, promote behavior change to reduce transmission of the infection and manage mild to moderate disease.
Along with the the pandemic of Covid-19 has come a pandemic of misinformation about the cause, the transmission and strategies to manage the disease. Social media has played havoc with the Caribbean States’ attempts to educate and influence their populations to reduce transmission through mask wearing, sanitization, and social distancing. The message of the States could have been strengthened if public health practitioners and family physicians had worked together to give the same, coherent messages. Caribbean populations trust their primary care doctors who often fill the role of family doctors.
The Covid-19 pandemic has compounded the non-communicable disease (NCD) pandemic by competing for very scarce resources. While there is an ongoing major challenge to tackle the NCDs, along comes the covid pandemic. Primary care systems that struggled to deal with the chronic non-communicable diseases now had to deal with an acute communicable disease epidemic as well. Sir George Alleyne, then head of PAHO, the Pan American Health Organization, pointed out to Caribbean Heads of Government in 2005, the morbidity and mortality rates from the NCDs in the Caribbean were many times higher (sometimes by as much as 5-10 fold) than in “first world” countries. Although this speech was probably the prelude to the conference in Trinidad in September 2008: “Uniting to stop the epidemic of the Chronic Diseases”, in fact well over a decade later there is little evidence that any Caribbean country have lived up to the declarations that the governments all endorsed at this conference, or even managed to make any significant effort to improve national primary care services.
The long term (‘international’) ambition, of requiring all medical practitioners to complete some level of post internship (post graduation) training before being allowed to operate independent medical practice, as a means of upgrading the level of primary care in the country, never materialized. Many Caribbean governments simply ignored the family medicine graduates, even while acknowledging that the in-country situation with the NCDs required a cadre of individuals with the clinical skills to tackle the health issues associated with the NCDs. Reliance on individuals trained in public health, with whom the government chose to fill the primary care clinics, did not have a positive impact on the NCD epidemic. The programs in Public Health do not have a clinical component, while the NCDs create a tsunami of clinical issues.
Thus Covid-19 exacerbated the divide between the practitioners of public health and family medicine but created the imperative for both disciplines to work together. What is the point of post graduate programs in Family Medicine (FM) offered by The University of the West Indies and also our fight for FM to be treated as a medical specialty when our specialty position has no particular advantages. In Barbados, the Family Medicine graduate is treated like an ‘outside child’. In Jamaica the DM in Family Medicine attracts the same remuneration as a general practitioner just leaving medical school just with undergraduate qualifications. In Trinidad and Tobago, the concept of a FM graduate as a Registrar/Consultant in the ambulatory care department is an alien one: these posts may be reserved for Public Health Practitioners.
There are no career options in the public system in most of the islands for the Family Medicine graduate. Certification in Public Health, such as the Masters in Public Health (MPH) are given the carrots, and get the highest posts versus the Masters in Family Medicine (MSc) and the doctorate in Family Medicine (DM), are given the stick. More than one decade after the Faculty in Barbados was producing trained graduates in Family Medicine, the Government has failed to provide a job ladder for this category of specially trained health care professional.
As an example, on the UWI Cave Hill Faculty of Medical Sciences website, under the Public Health Program the following career options are offered: Public : Chief Medical Officer, Medical Officer of Health, Chief Public Health Nurse, Health Disaster Coordinator, Environmental Health Officer; Private: Health Advocate, Research Project Manager, Health and Lifestyle Consultant. There are no career options listed, in the public or the private sector, when UWI Family Medicine program, available at four UWI campuses in Bahamas, Barbados, Jamaica, and Trinidad & Tobago, is sourced on the internet.
The role of the FM Specialist operating in a Medical Home/Health Centre Ambulatory Care setting is not even being envisaged –although it could herald in an enhanced and revolutionary model of care that could benefit patients enormously and ultimately impact the NCD epidemic positively. Revolutionizing family medicine in the public sector does not mean the death of public health- since both disciplines have their role to play. There is, at least in theory, the recognition that effective primary care can be an effective antidote to perennial rising exorbitant costs associated with Tertiary Medicine.
In Jamaica the race to achieve Covid-19 “herd immunity” by vaccination of 60 to 70 per cent of the population was lost because of the dependence on public health actors. The Government now concedes that private players – who in the main are family medicine practitioners – must be engaged in order to overcome vaccine hesitancy. Many family physicians routinely give vaccines to their patients. They are a more credible source of information and are more accessible and convenient to the population.
In conclusion, we call upon the Caricom Health Desk, our Ministries of Health (and Wellness), our Faculties of Medical Science, our family medicine organizations such as the Caribbean College of Family Physicians (CCFP) and affiliated medical associations to join our call to Caribbean states to recognize, promote and support family practitioners in joining forces with their public health colleagues. The simultaneous pandemics: Covid-19, the NCDs and the Covid-19 misinformation and the need for rapid vaccine roll-out programs, must be met head-on by both groups of practitioners. The pandemics remind us that “United we must stand, or divided we will continue to fall”.