Dr. C. Alert, MB BS, DM. FCCFP.
Family Physician.
“If you’re not getting older, you’re dead”. Tom Petty, musician, Grammy Award winner.
It was a bit of a wakeup call when, on September 19th 2023, the Queen Elizabeth Hospital, the only tertiary hospital on the island, issued a Public Service Advisory, advising all with non-life threatening conditions not to come to the Accident and Emergency (A&E) Department, but to seek medical attention elsewhere. The reason for this request was given as an increase in patient flow through the department in the previous four weeks, resulting in a backlog of patients waiting to be seen.
Just a few days previously, the (acting) Minister of Health and Wellness suggested that the waiting time patients experienced in the A&E Department was an average of 30 hours, perhaps in response to a circulating video highlighting a case where someone spent over 96 hours in the A&E Department before being seen. So if you have a life-threatening illness, pray that your life credit card has at least 30 hours left.
In was about two decades ago when the then Chief Medical Officer noted that the number of persons in Barbados over the age of 65 years would soon exceed 15%, the level at which a population is considered to be ageing, or at least elderly, and suggested that the Medical Services were being prepared for this surge in the elderly population. But are we really able to adequately cater to the medical needs of the elderly? In general terms, our health care services are ill-prepared to deal with prevention and wellness (in spite of the re-branding of the Ministry of Health to the Ministry of Health and Wellness), and are struggling to deal with accident and emergency situations.
Our epidemiologists ( medical statisticians) point to the high percentage of our population that, in the absence of disease prevention, actually have become ill, with chronic non-communicable diseases (NCDs) like hypertension, obesity, diabetes and hyper-cholesterolemia, all conditions whose complications include many of the same life-threatening complications (like heart attacks and strokes) that force persons to the A&E Department. Chronic kidney disease, another NCD complication, is taking a big chunk [in 2018 about $18M, roughly 10% of the hospital’s budget] of our total health budget, with little positive results. As the Health of the (Barbados) Nation 2015 study showed us, not only do we have high numbers of persons afflicted with one or more NCDs, but the study also showed that those persons whose disease(s) had previously been diagnosed were not being adequately managed. [The study also unearthed many persons whose disease was not previously diagnosed, are hence were walking around untreated and at risk for severe disease complications]. The NCDs and cancers tend to be more prevalent in elderly persons; hence the elderly tend to need more medical care, not less.
Even in the elderly with no diagnosed chronic disease, there tends to be more frail individuals: the medical components of ‘frail’ include low muscle strength, low physical activity, slowed walking speed, unintentional weight loss and low energy. Frail individuals are more prone to falls, incontinence and dementia, to generally be of poor health, and to need more medical attention.
Poor nutrition is an important contributor to fragility, and the elderly, who have to survive rapidly rising food prices on fixed incomes (pensions), are often prone to malnutrition, especially when family and/or community support is absent.
Even before covid-19, mental illnesses were considered to be widespread, undertreated and under-resourced. The covid-19 pandemic highlighted the need for increased resources to deal with mental health issues. Some persons became very ill, some lost jobs, some lost family members, and some were cut off from friends and family, all conditions that contribute to deteriorating mental health. Many countries actually were able to document rises in mental illnesses, but for a variety of reasons including stigma associated with mental illness and fear of appearing in public spaces, many persons here were afraid to come forward for treatment. Those with severe mental illnesses (pre covid-19) were also more likely to contract covid, and were more likely to become severely ill.
When the covid-19 virus came to our shores, as elsewhere, it tended to seek out those whose bodies were weakened by one or more chronic illnesses, or who were generally frail. Those with mental illnesses were often unwilling, or unable, to take care of their personal health, were often susceptible to disease. Ultimately, this put further stress on our health services.
Over the last few decades, our health services have been challenged by the NCD pandemic, unfortunately with growing emphasis being placed on (often expensive) pharmacotherapy rather than on disease prevention. Quantity of life has been given a higher priority rating than quality of life. As a result, persons are living longer, but not necessarily better, and there is increased need to treat a variety of conditions in the elderly, including NCDs, mental illnesses and life-threatening conditions. At the moment our need for chronic disease and mental health services is greater than our ability to build Emergency Departments which are then not appropriately resourced to treat our prevalent medical conditions.
The covid-19 pandemic disrupted our health services, allowing many physical and mental illnesses to incubate and fester. The A&E Department suddenly realised that it was being overwhelmed by a deluge of very sick persons. While covid-19 was unplanned, failing to aggressively manage the NCDs left us with a large population susceptible to being infected by the virus.
More covid-like epidemics are projected to arrive in the near future. The climate change pandemic is also likely to add to our misery. The elderly are vulnerable to a wide variety of chronic diseases and mental illnesses, and more so when the next infectious disease pandemic comes. As the notice from the A&E Department suggested, and as our response to the covid-19 pandemic suggests, our health services are increasingly focused on imminent death situations only. Our elderly are often described as those who built this proud nation: one day if good fortune holds we will all be elderly. Hopefully adequate and appropriate health care will be available.