“How can you mend a broken heart,
How can you stop the rain from falling down,
How can you stop the sun from shining,
What makes the world go round”
– The Bee Gees, song released in 1978
It is said that “an ounce of prevention is better, and likely to be both cheaper and healthier, than a pound of cure”. This is a partial response to comments made by Dr Dawn Scantlebury, head of the cardiology service at the Queen Elizabeth Hospital (QEH), and head of the Heart and Stroke Foundation of Barbados (HSFB) in a newspaper article on Wednesday. Her comments address the national health picture from the point of view of hospital (or tertiary) care. I am not in a position to challenge most of her comments, and in fact, I agree with many of her conclusions. But I am willing to share some thoughts about primary care, mainly the polyclinics in Barbados.
One reason I am not in a position to challenge her comments is that, since 2012, we have not had a published annual Chief Medical Officer’s (CMO) report detailing statistics about healthcare and health services in Barbados. Certainly, the CMOs between 1976 and 2012 made this information available, but this access suddenly ceased after 2012, for reasons not publicly announced. It is unclear whether we will ever get the statistics of the last dozen years, and/or whether we will be afforded any sort of analytic data on our health situation in the years to come. Most of our data we get in snippets when one of our local health officials makes a public statement, or we read articles in the international media, or from multilateral health organisations like WHO and PAHO, that highlight some aspect of health in Barbados [I had the misfortune of quoting the QEH CEO on figures given for new cases of chronic kidney disease two weeks previously in a newspaper article, only to be ‘corrected’ by a hospital nephrologist who suggested that the situation was twice as bad as that I described).
Just around 2012, the Ministry of Health and Wellness were quick to announce to the public of Barbados the introduction of computerised electronic health records in many (if not all) of the public health clinics, including the QEH and the polyclinics. One interpretation of this was that we (the general public) would have ongoing access to activities in our health services, and analysis of such data would (or could) lead to rationalising public health services, hopefully leading to improvement in the provision of healthcare nationally. Patient information could be moved electronically between primary and tertiary care, thus facilitating a smoother patient flow. Instead, based on a patchwork of anecdotal data, our health services seem to be getting worse. And we are getting less, not more, information.
As Dr Scantlebury pointed out, the hospital is seeking to employ 300 new staff, including 43 clinical specialists. This is likely to send our national healthcare bill, which, compared to 1980, one of the earliest years in which an annual report on the nation’s health was produced, rose by approximately 850 per cent, while the population growth in the same period was approximately 24 per cent. While I am no financial expert, it is difficult to see this level of rising expenditure being sustained.
Instead, our polyclinics seem to be suffering from being under-resourced, both in terms of staff and equipment, and quite a few patrons are dissatisfied with the services offered (or not offered), the length of time it takes to get an appointment, and the chronic shortages of pharmaceuticals. This dissatisfaction has brought out some angry individuals.
About two weeks ago, in the USA, there was a high-profile assassination when a senior official of their health insurance industry was shot dead in broad daylight. The public response seemed to focus on the unacceptable service being offered by the medical insurance companies, who seemed to put ‘profit before people’, and much sympathy was extended to the alleged shooter. It is not clear whether this episode will cause any change in the behaviour of the health insurance companies there. We have had in Barbados over the last few months incidents where polyclinic staff were threatened or actually beaten by ‘patrons’ dissatisfied with the service being offered (or denied) at the polyclinic. The Ministry of Health’s response has been offers to improve the security, rather than to focus on the dissatisfaction of the patrons with the service. I hope we don’t wait until someone is killed or seriously injured before this is addressed.
While public service announcements from the ministry suggest that only people with medical emergencies go to the Accident and Emergency Department (A&E), the lack of an effective health information campaign to educate the general public on what conditions constitute a medical emergency, and the not infrequent reports of persons who were apparently well collapsing and dying suddenly elevate many a non-emergency condition to that of an apparent medical emergency. It is not a coincidence that, in the absence of “Health Promotion and Disease Prevention”, one of the pillars on which national health should be built, we see a proliferation of private emergency clinics, and we have an avalanche of patrons flocking to these emergency clinics and the A&E Department. If many of these are really medical emergencies, this is further testimony of the current inability of our primary care services to preserve health and prevent disease. Perhaps one day we will have the hard data to confirm (or refute) this theory . . .
Another challenge with the polyclinic staffing is this: many of the doctors who are attached to the polyclinics are UWI trained, with the UWI undergraduate medical course being very heavily hospital medicine focused. The one-year internship period after graduation is also hospital-biased. There are many differences between hospital medicine and non-hospital medicine. The Ministry of Health, in employing these doctors to work in the polyclinics, encourages them to gain additional training in public health, the Masters of Public Health or MPH degree, a course that emphasises statistics and epidemiology, but not clinical medicine. The patrons that attend the polyclinics have clinical problems, unearthed by the NCD (and now also the COVID) pandemic. Obesity, for example, is associated with over 200 clinical problems, and may require cardiologists, nephrologists, dermatologists, gynaecologists, obstetricians, mental health specialists, internists and others: our polyclinics are rarely staffed with any of these specialists. But these are the health problems that the polyclinic attendees present with. So many of these doctors are not sufficiently trained, and/or lack experience, to manage any of the many clinical problems faced on a daily basis. On the other hand, UWI also offers a postgraduate course in family medicine, which is a clinically-based programme, which also includes a mental health component, and some other Caribbean countries (but not Barbados) have tried to build up the clinical expertise in their polyclinics (or health centres) by requiring their doctors to be trained in family medicine. Outside of the Caribbean, many places are now requiring physicians who wish to work as independent medical practitioners (IMPs) – GPs in our scenario – to complete training in family medicine before being allowed to practise.
Our last major study of national health, the Health of the Nation (HotN) study, was published in 2015. This study, of 1 234 adults aged 25 years and above, identified many ‘weak areas’ in our national health. For example, 66 per cent of persons interviewed were overweight or obese, as noted above conditions that put these individuals at risk for a large variety of medical problems. Many of these people had been diagnosed with diabetes and/or hypertension, but the study also found that large numbers – 43 per cent of people with diabetes or hypertension – who were offered treatment did not have their condition controlled. Uncontrolled diabetes and hypertension leads to heart attacks and strokes, here averaging one and one and a half each day. These conditions fill our A&E Department, our hospital wards, and even our cemeteries. But these are also conditions that are initially seen and treated in primary care: our primary care clinics are unable to adequately manage large numbers of patients with these conditions.
In the foreword to the HotN study, our current CMO (who at that time was the senior medical officer of health, with special responsibility for the NCDs) stated: “The HotN results will provide vital information to assist governmental agencies, civil society and the private sector in the creation of a robust policy and programme environment for the prevention and control of NCDs in Barbados.” Ten years later we are still awaiting this ‘robust policy’: meanwhile people are suffering and dying. At a January 2025 edition of “Ask the World Bank series”, a World Bank executive noted that “a lack of urgent policy implementation could escalate a dual crisis of health and economic instability in the Caribbean”.
At this same forum, Dr Heather Armstrong, the head of chronic disease and injury at the Caribbean Public Health Agency (CARPHA) raised the call to increase healthcare investments, particularly in prevention, to improve NCD outcomes and boost economic performance. She said: “Prioritising prevention provides a significant opportunity to lower healthcare expenses while enhancing national productivity.”
As the Bee Gees suggested in 1978 with their song How can you mend a broken heart, if your starting point is ‘a broken heart’, it may be very difficult to stop ‘the rain from falling down’. It is easier to preserve a good heart, than to fix a damaged one. It is easier to preserve good health, than to ‘offer a patch’ to fix a damaged product.
So while Dr Scantlebury is calling for increased resources to be channelled to the QEH, I am calling for increased resources to be channelled to primary care offices. While she is calling for 43 clinical specialists to be employed at the QEH, I am calling for a number of family medicine specialists to be employed in primary care. We do have a large study that has identified ‘weak areas’ in primary care; we do not have a similar study of tertiary care here, but a number of anecdotal stories, phone calls to the radio call-in programmes, or an occasional video clip, generally suggest dissatisfaction with tertiary care, particularly the prolonged waiting periods in the A&E Department and the prolonged times spent in the A&E Department waiting to be transferred to the wards, once hospital admission has been confirmed. Our primary care clinics can benefit from additional staff, and additional resources, to reduce the workload on the A&E Department, and on our hospital wards. Our primary healthcare centres must be offered an opportunity to practise “Health Promotion and Disease Prevention”. As I stated in the first line of this article: “An ounce of prevention is better and likely to be both cheaper and healthier, than a pound of cure.”
Family physician Dr Colin Alert, founder-director of the Wellness Clinic, is a former researcher with the George Alleyne Chronic Disease Research Centre of the University of the West Indies.
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