An estimated seven out of every 10 deaths in Barbados are linked to a non-communicable disease (NCD).
The connection between NCDs and complications associated with COVID-19 is also well established as this opportunistic virus thrives on NCDs, weakening an already compromised system.
Although the high incidence of non-communicable diseases in Barbados did not start with COVID-19, the pandemic has revealed holes in the system to address them. The situation also puts to the test traditions and behaviours surrounding NCD triggers
For the island, this presents a multi-pronged challenge to its public health assets.
Barbados has long been keeping a close eye on what has been recognised as a high incidence of NCDs including hypertension, diabetes, cardiovascular diseases (diseases that affect the heart and blood vessels), cancers and pulmonary diseases.
To that has recently been added a fifth category: mental health disease. Once included, the numbers rise and, along with them, the cost of healthcare.
These statistics, though staggering, fuel the current COVID-19 pandemic caused by the SARS-CoV-2 virus. In addition to the mortality figures, most of the severe cases of COVID-19 comprise patients with NCDs.
Health professionals all agree that uncoupling this vicious bond requires new approaches and behaviours to recreate a stronger foundation to tackle other health crises.
Several theories look at the root causes of NCDs in Barbados and the wider Caribbean. These theories examine why there are high levels of NCDs especially among persons of African descent. Among them is a theory linked to the experience of the trans-Atlantic trade in African slaves.
Professor Emeritus of the University of the West Indies, a medical doctor and founding member of the Chronic Disease Research Centre (CDRC), Sir Henry Fraser, explores what is known as the “Thrifty Gene” theory.
This theory suggests that any enslaved person surviving the horrendous, food scarce journey from Africa to the Caribbean, most likely had a slow metabolism gene, “which meant that their descendants would have inherited those thrifty genes to a large extent.”
Sir Henry sums up the phenomenon: “People got little food or bad food, and diarrhoea was very common, vomiting would have been very common.
“(This)results not just the loss of fluid, but also the loss of electrolytes, sodium and potassium … the people who survived the slave trade were people who could conserve salt, and therefore, would have passed to their descendants, to a significant degree, to conserve salt.”
Beyond the gene research, Sir Henry and the Deputy Director of the Barbados Museum, Dr. Kevin Farmer cite the living conditions of enslaved people and their restrictive diets consisting mostly of starch, salt, and sugar.
Sir Henry also explains the persistence of ancestral beliefs which include “the traditional concept that fat is good. Fat is healthy, and part of that goes back 300 years to Africa.”
The Barbadian historian surmises that malaria made people thin and listless. “Fatness,” he says, was the opposite and depicted good health.
“So, in Africa, where there was not a glut of food, it was a hunter-gathering community for many, many centuries … fatness was valued.”
This generational foundation, he suggests, can create the framework for high rates of NCDs once the risk factors exist.
In 2015, the then Ministry of Health, National Insurance and Social Security; the National CNCD Commission Barbados; the Pan-American Health Organization (PAHO); the Chronic Disease Research Centre and the World Health Organization (WHO) highlighted this worrying trend in a “Health of the Nation” survey.
Despite these numbers, the Advisor for Non-Communicable Disease and Mental Health, PAHO/WHO Office for Barbados and the Eastern Caribbean Countries, Dr Patrice Lawrence-Williams primarily focuses on the NCD mortality rates. “We know NCDs constitute about 70% of all the deaths in the region and out of this 70% of deaths, cardiovascular disease alone constitutes 80% of these deaths.”
Along with mortality rates is the age of death. Anywhere between 30 and 69 counts as “premature.”
To reduce the rates means reducing the triggers or risk factors associated with NCDs. Dr Lawrence-Williams identifies these preventable risk factors as “unhealthy diets, (lack) of physical activity, (see special segment on Childhood Obesity) tobacco use, harmful use of alcohol and most recently, air pollution.”
As troubling as it looks, it magnifies under the lens of the COVID-19 pandemic.
Dr Arthur Phillips, Senior Medical Officer for NCDs in the island’s Ministry of Health and Wellness saw first-hand the effect of COVID-19 on the Barbadian NCD population.
“The people with NCDs are at an increased risk for having severe COVID and for having negative outcomes, including death should they be infected … particularly if the NCDs are uncontrolled,” he said.
Dr Lawrence-Williams also knows that the virus can easily attack an already compromised system. “Most persons with NCDs are immunocompromised, that is, the immune system is not functioning optimally, and this affects their ability to fight off diseases.”
Joycelyn Lynch recognises the effects of severe COVID-19 all too well. She describes herself as “big, but a real teddy bear.”
Looking back now, Joycelyn sees her recovery from COVID-19 as a miracle. Regrettably, her husband was not so fortunate. Together they went into isolation, but only Joycelyn walked out.
Joycelyn is 60. As a younger woman, her lifestyle led to weight gain, followed by hypertension in her early 30s.
In January 2021, she had a pulmonary embolism. After returning home from the hospital, she later contracted COVID-19, and her health deteriorated quickly.
Like Joycelyn, asthmatic, Salem Collector contracted severe COVID-19, and he, too, lost a close family member – his mother. Doctors diagnosed Salem with asthma at the age of seven. It was so severe, he spent two weeks on the children’s ward.
Later at age 23, Salem added another NCD – hypertension. He was handling both until he contracted COVID-19. Then asthma became an issue again. “Most persons with NCDs are immunocompromised, that is, the immune system is not functioning optimally, and this affects their ability to fight off diseases,” Dr Lawrence-Williams said.
This vicious cycle also strengthens risk factors associated with the non-communicables. Take, for example, lockdowns. In Barbados, the Ministry of Health used them as a protective measure. However, experts have suggested that they helped bolster two risk factors associated with NCDs – physical inactivity and unhealthy eating habits.
Communications Officer of the Healthy Caribbean Coalition and Public Health Consultant Sheena Warner-Edwards agrees with this assertion.
“They’re literally not moving except from the kitchen to the couch and from the couch to the bedroom … I do know some people stopped activity because of their fear of going outside to do anything – they do not want to catch the COVID-19 virus.”
Beyond the reduction of physical activity and increased snacking, Dr Lawrence-Williams points to the effects of ‘long COVID’.
“Once that virus comes into the system, it is going to trigger inflammatory responses within the body, and that is going to set up a set of biological processes. What we are seeing, she says “is a ‘long COVID’ impact post-acute infection, and NCDs is one of the diseases that can happen post COVID”.
Joycelyn and Salem both agree with this. In Salem’s case, COVID-19 brought back his asthma. “My lungs were collapsing, and I couldn’t breathe at all, and my saturation levels were like 60%,” he said.
While at the isolation centre, Salem stayed on oxygen “all day and all night.” After three weeks, the doctors reduced his oxygen but still transferred him to the General Hospital.
“While I was in Harrison’s Point (isolation centre”, I developed some blood clots on my lungs.” Following his week-long hospital stay, doctors still prescribed oxygen for him to take at home.
In Joycelyn’s case, she developed an additional NCD. “In the aftermath of contracting COVID-19, I’m now a diabetic,” she declared.
In addition to the effects of ‘long COVID’ is the change in the way persons manage NCDs.
The postponement of specialised clinics and appointments occurred during COVID-19 shutdowns. In some cases, persons felt too vulnerable to attend.
“The other thing that we saw particularly at the beginning of COVID in Barbados was issues, both on the provider side and on the side of the public, where individuals were less likely to go for care because they were concerned that they may be exposed while they’re waiting in the waiting area,” explained Dr Phillips.
“Some health care providers, who thought of themselves as vulnerable, may have closed their practices or reduced their practices.”
Dr Francine Browman-Jones, the Acting Senior Medical Officer at the Winston Scott Polyclinic, one of the largest 24-hour polyclinics in Barbados, observes that a good cross-section of Barbadian society is being affected by these issues.
“We (the Polyclinic) are situated in the centre of town, and that’s where you have the densest population, so we really have a very large catchment base,” she says.
“What percentage of our client base has NCDs? If we look at NCDs, being asthma, hypertension, diabetes, cancer, or some combination of those, I would have to give you an average of probably 70% … it’s quite high.”
To deal with COVID-19 and manage the high client base of NCD patients, changes had to occur. Dr Browman-Jones adds that “in our NCD clinics, nurses play a large part in education. These were the same nurses that were out doing vaccines … so when you have maybe one or just two Clinical Medical Officers in the clinic, you really cannot see appointments. We definitely couldn’t do that focusing that we wanted to do.”
Furthermore, Dr Browman-Jones noticed that Barbadians do not generally have a “health seeking” tradition.
They tend to visit polyclinics only when something goes wrong. Add COVID to that thinking, and people have more reason to not venture to appointments.
Along with that belief, Dr Browman-Jones notices that some clients find it difficult to manage their diseases alone.
“This continues to be an Achilles heel for us because persons don’t accept responsibility for (addressing issues to do with) their disease. Persons at this point in time still would prefer to be supported on their NCD journey.”
The COVID-19 pandemic also adds another layer of decision-making for persons with NCDs. Vaccine acceptance is crucial. It is an added layer against dying from complications due to COVID-19.
The main question, many ask, is why would someone with an NCD not want to take a vaccine to reduce vulnerability to severe effects and death from COVID-19?
There are many reasons being offered in Barbados. There are concerns, for example, related to exposure to the virus at the vaccine centres. There have also been questions about the tolerance levels of the immune system and vaccine compatibility with medications.
Joycelyn spoke with doctors at the Isolation Centre before deciding to take the vaccine. “I asked if I’d be able to take the vaccine, and they said, ‘yes’, any time after October.
“So, I said, ‘alright’ but then I didn’t believe them. So, when I went back to my GP in September, I asked him a question, and he said, ‘yes’, they are right, you could take it.”
Salem, now fully vaccinated, also had some reservations at first. “My concern with the vaccine first was back when we only had AstraZeneca,” he says. “There were some concerns that AstraZeneca was giving you blood clots.
“So, when I went back for my check-up in June, I asked (the doctor) if I could take the vaccine. She said I don’t have to fear the blood clots because I’m already on blood thinner medication. She told me to take both doses, and I did, and I’m now fully vaccinated.”
However, outside of those understandable concerns, patients with NCDs essentially have no problem getting vaccinated.
Dr Phillips estimates that numerous Barbadians with underlining conditions have taken the jab. “I think the message has definitely gone out that persons with NCDs are vulnerable, and they should look to have onboard all of the preventive measures possible, including vaccination,” he says.
He explains that medical personnel in the Ministry of Health try to address fears surrounding vaccinations and provide information. “We’re trying to provide a supportive environment that incentivises persons to do the right thing but still allows them to have the choice to do what they want,” Dr Phillips adds.
Now to put a price tag to alleviate all these challenges is yet another formidable task.
Chief Economic Advisor to the Prime Minister of Barbados, Ambassador Dr Clyde Mascoll, stated: “The coronavirus pandemic knocked the Barbados economy back 24 years. The economy is worse off now than it was after the 9/11 terrorist attacks in 2001 and the global financial meltdown of 2008.”
In Barbados, the research is still out on the cost of the pandemic. However, Senior Health Officer (NCD), Dr Phillips, outlines some potential direct expenses such as the length of stay for a person with severe COVID which runs between 10 and 14 days.
Further, there are direct costs associated with the vaccines, additional staff and infection prevention measures like test kits, swabs, and sanitisation.
Indirectly, Dr Phillips highlights several costs. “There are issues around productivity, because they’re (COVID-19 patients) away from work, and then the costs in terms of all the infection prevention and control measures.
“Every workplace now has a thermometer. They’re buying alcohol. They’re sanitising more often. They may have hired workers to do these things specifically. It has changed the cost structure of business and life in Barbados.”
So, what does this all mean for the future of the country? Specifically, how is the pandemic forcing a hard look at the NCD problem?
It all comes down to what the experts propose – “prevention, prevention, prevention!” Yet taking the long and arduous path to create new behaviours does not happen overnight.
Dr Phillips sees the need to expand beyond the “treatment” solution. “The reality is that a lot of our resources are still focused on treatment as opposed to prevention,” he says. “So yes, you would say, okay, 80% of the money that we’re spending is on NCDs, but that’s on dialysis, that’s on amputations, that’s on eye surgery. That’s on the medication to control diabetes and hypertension and so on.
“How much of that is on educating people, empowering them to manage their health? How much of that is on creating a supportive environment, so it’s easier for people to eat healthy food?”
Dr Phillips also looks at the allocation of resources to NCDs. Even though the numbers are high, there is only one administrative “post” specific to NCDs.
“The HIV programme has 80 people, Environmental protection has 150 persons, and the Family Heath programme has 100 people,” he says.
Despite the discouraging numbers, there is broad recognition that the way forward is to use community-focused educational prevention programmes backed by governmental policies.
Dr Lawrence-Williams, among others, sees the importance of targeted behavioural change and joining Ministries of Health to specific non-governmental NCD organisations to fill in the gaps.
“We are proud to have also collaborated with the Diabetes Association by providing the capacity building for a program that was previously face to face,” she declares. “Now we’re implementing the online version to cater to the COVID response. There are strategies at PAHO that we’re starting to implement with countries that focus on self-management; self-management has to be a key player.”
Warner-Edwards points to prevention policies. “I see them as low hanging fruit. I think Barbados, as well as some of the other Caribbean countries do see it like that as well … at least we are having a conversation,” she says.
“There was a time when there was no conversation. So, we’re having a conversation, and we’re putting in place those next steps, move to the policy, the legislative bit that is so required to keep our people healthy, strong, living longer and without the NCDs,” she adds.
Speaking for her medical colleagues from one of the busiest polyclinics in Barbados, Dr Browman-Jones believes it is a “whole behaviour change, a whole mindset change. It’s a cultural change.”
“Education, education, education. But it can’t just be blurred, because that goes in one ear and out the other, we have to try a multi-pronged approach, we have to have the supporting structure, we have to tie small changes to success that people can actually understand,” she argues.
“As long as they don’t see it being beneficial to them. They’re not going to want to change.”
Incremental changes are the right steps on the footpath of behavioural change, and it took the COVID-19 pandemic to bring it to the forefront, the experts suggest.
Working to reduce NCDs will make it less burdensome when the next health crisis comes along.
COVID-19 survivor Salem is taking that to heart. He now happily brags that he is back on the path to better health.
“I started back on my dieting; I started back on my exercising; I’m walking three days a week on evenings, so it’s helping, it’s helping me,” he says.
Joycelyn is planning a trip to England once fully vaccinated, and she is making other life changes too.
“I have changed my diet. You know, I go to the beach more regular now. I’m eating more fruits and more vegetables,” she says.
“I just changed my lifestyle, and it’s made me stronger in looking at life. You know, you have to have a different outlook. You know the phrase, ‘here today and gone tomorrow?’ You’re here today and gone tonight. So, I try and abide by the rules and think positive.”
It’s a creed increasingly being adopted by an entire nation.