T&T is now ex­pe­ri­enc­ing the ‘sec­ond wave’ of this COVID-19 pan­dem­ic and while in the month of Au­gust, we wit­nessed num­bers in­creas­ing ex­po­nen­tial­ly, we were be­ing told that this def­i­nite up­ward tra­jec­to­ry of the virus was in keep­ing with the so-called ‘Log phase’ of the virus. The con­cern then was how high and how long this steep part of the curve will ex­ist. The ma­jor thrust of break­ing the trans­mis­sion of this virus was placed square­ly on the re­spon­si­bil­i­ty of the pub­lic to ad­here to all safe­ty pro­to­cols.

I had pre­vi­ous­ly stat­ed in an ar­ti­cle of 1/6/20 in this news­pa­per that the MOH had done a sat­is­fac­to­ry job in han­dling the pan­dem­ic. I write in an at­tempt to re­view my own state­ment.

One of the most strik­ing find­ings com­ing out of the col­lect­ed da­ta so far is the rise in num­bers in the younger age groups. This was the group that dom­i­nat­ed the min­gling, the par­ty­ing and the flout­ing of the reg­u­la­tions, par­tic­u­lar­ly the non-wear­ing of masks. The most alarm­ing find­ing is that there are al­most dai­ly deaths, with a to­tal of 75 at this time, high­est in the el­der­ly and in those with co-mor­bidi­ties. Ques­tion is, how did these el­der­ly pa­tients con­tract the virus? Were they al­so min­gling in pub­lic spaces or did the young ones take it home to them? Here­in lies a point I was labour­ing amongst those I knew—that the young ones will con­tract the virus, be­come asymp­to­matic car­ri­ers, take it to their old­er folks, and the lat­ter will be the ones to suc­cumb.

There was a think­ing by the par­ty­ing folks that the virus was gone and that they were safe to min­gle, to par­ty both in their own homes and else­where, beach­es in par­tic­u­lar. The ra­tio­nale em­ployed was that they all knew each oth­er, were fam­i­ly and they were all safe.

We must have failed in reach­ing the good sense of these delin­quents. The mes­sage seemed to have been lost some­where. My own ob­ser­va­tion is that the MOH slipped. I make ref­er­ence to my ar­ti­cle of the 1/6/20 in this news­pa­per where I wrote, “My fear that the pub­lic will start to let down their guard as they mis­in­ter­pret and mis­un­der­stand that the ap­par­ent re­duc­tion in the num­ber of new cas­es in­di­cates we are safer now. This false sense of safe­ty can cost us dear­ly. Now is the time for the MOH to in­ten­si­fy their mass ed­u­ca­tion pro­grammes, em­pha­sis­ing it’s not the ma­jor­i­ty do­ing the right thing who will win but that it takes on­ly one per­son to do the wrong thing”.

I stat­ed then that the pop­u­la­tion need­ed to be bom­bard­ed by ed­u­ca­tion­al videos demon­strat­ing the sim­ple cor­rect tech­niques of wear­ing the masks and wash­ing the hands. Again, we had the time.

But, in this qui­et phase, how much pre-plan­ning was be­ing done? Just how pro-ac­tive were we? We nev­er heard about not “if” but “when” the sec­ond phase comes. The talk was fever­ish and about elec­tions. We were so bom­bard­ed by the cam­paign ads, ad nau­se­um.

Prime time news hour was hi­jacked by the pol­i­tics while Rome was go­ing to go on fire! For sure, much went astray dur­ing the elec­tions, whether some want to ad­mit it or not. Cau­tion was thrown to the winds even by those who should be ex­em­plars! Thank­ful­ly, there were many of us guid­ed by good sense. This ‘qui­et’ pe­ri­od should have been for us to step up with our pub­lic health ed­u­ca­tion ads and ramp up our com­mu­ni­ty test­ing.

Of the lack of ad­e­quate test­ing at that phase, we have no in­for­ma­tion on what ex­ist­ed in the com­mu­ni­ty. Pub­lic health ed­u­ca­tion pro­grammes are few and in­ad­e­quate as it re­lates to COVID-19. They need to be im­proved in fre­quen­cy, graph­ics and con­tent and the pub­lic needs to be bom­bard­ed by mass ed­u­ca­tion pro­grammes. There should be more colour­ful fly­ers and posters and while some are fund­ing bill boards with po­lit­i­cal pro­pa­gan­da meant for a few, it would be more na­tion­al­is­tic if these bill­boards bore mes­sages to the ef­fect of ‘Mask Up!’.

This method has changed many trends in the mor­bid­i­ty and mor­tal­i­ty of chron­ic dis­eases in de­vel­oped coun­tries in ear­li­er years. I am shocked at how lit­tle our young peo­ple un­der­stand about this con­di­tion. The MOH has a chal­lenge to reach this group.

The MOH has to be com­mend­ed for leg­is­lat­ing the use of masks. It sent the sig­nal that the MOH was se­ri­ous in its fight against this virus.

Our cul­ture at times seem to bor­der on in­dis­ci­pline and law­less­ness. As such, many need the heavy hand of the law, and it is very un­for­tu­nate that manda­to­ry wear­ing of masks was not le­galised pri­or to the elec­tions in an­tic­i­pat­ing the cul­ture of some here. But, we all know well, the heavy politi­cis­ing of the pan­dem­ic pre-elec­tions could in no way ex­tend to com­mon sup­port for such a mea­sure.

Sim­i­lar­ly, an­nounc­ing the clo­sure of beach­es and bars on a Sat­ur­day to take ef­fect on a Mon­day morn­ing, shows we do not un­der­stand the cul­ture here. Clear­ly, the virus was at bay and would have been re­leased on Mon­day! Hikes in gas prices take im­me­di­ate ef­fect on bud­get day. Fu­ture de­ci­sions must fac­tor in this as­pect. The dan­ger is with the delin­quent few.

HOTBED OF UN­CER­TAIN­TY

Since mid-Au­gust, we have not been pro­vid­ed with an ac­cu­rate dai­ly fig­ure for num­ber of cas­es re­port­ed on that spe­cif­ic day. In­stead, the fig­ure giv­en to the pub­lic can in­clude cas­es that go as far back as days to over a week. How­ev­er, the MOH Epi­demi­ol­o­gist seems to have this dai­ly fig­ure and right­ly so, yet, we are not privy to it. In­deed, this rais­es a hot bed of un­cer­tain­ty and doubt in the con­cerned pub­lic’s mind. Is there some­thing we are not sup­posed to know or on­ly know it when time­ly? Ef­fec­tive dis­sem­i­na­tion of in­for­ma­tion to the pub­lic is im­por­tant and in­deed, it is our right to know.

The MOH de­ci­sion to have home care of those asymp­to­matic to mild cas­es and fur­ther, de­liv­er pulse oxime­ters to them and have cas­es in­volved in mon­i­tor ing the course of their own con­di­tion is al­so very com­mend­able.

In ear­ly years, when neb­u­lis­ers were be­ing pre­scribed for asth­mat­ics at home, this was as­so­ci­at­ed with an in­crease in mor­tal­i­ty for the sim­ple rea­son that pa­tients over re­lied on their neb­u­liz­er and pre­sent­ed at a de­layed time to the A&E.

The ma­jor pit­fall that comes with home care of COVID-19 cas­es is re­ly­ing on their symp­toms, es­pe­cial­ly the ab­sence of dys­p­noea or a feel­ing of dif­fi­cul­ty in breath­ing. I wish to em­pha­sise a clin­i­cal point raised on the me­dia up­date. There ex­ists a dis­crep­an­cy or a marked dis­con­nect be­tween low lev­els of oxy­gen in the blood (hy­pox­emia) and rel­a­tive­ly ab­sent or mild symp­toms of SOB. This so called ‘Hap­py or Silent Hy­pox­emia’ phe­nom­e­non can re­sult in rapid de­te­ri­o­ra­tion of a pa­tient and death. There­fore, pa­tients need to be vig­i­lant in this re­gard and in those pa­tients at home equipped with pulse oxime­ters, re­ly­ing on symp­toms alone is not best prac­tice. Pa­tients are hope­ful­ly be­ing giv­en a fly­er ex­plain­ing this phe­nom­e­non when be­ing giv­en the oxime­ter. In fact, a ma­jor sign to note is any in­crease in the res­pi­ra­to­ry rate (Tachyp­noea ) that can be an in­valu­able sig­nal of im­pend­ing com­pro­mised lung func­tion.

While the par­al­lel health sys­tem seems to now have sat­is­fac­to­ry ca­pac­i­ty with the new dis­charg­ing guide­lines, screen­ing at the com­mu­ni­ty lev­el is poor and no one can be sat­is­fied with our TEST­ING ca­pa­bil­i­ties at this time.

TEST­ING MUST BE A PRI­OR­I­TY

With­out rapid anti­gen test­ing in the com­mu­ni­ty, we can nev­er know the bur­den of our spread and to say num­bers are drop­ping, will leave un­cer­tain­ty and doubt while pro­pelling some delin­quents. Fi­nal­ly, af­ter weeks of lengthy de­lays, there seems to be some progress in han­dling the back­log of cas­es wait­ing on re­port­ing. We are told the prob­lem is not in test­ing but in re­port­ing.

How does that help? The trend was al­ways that the so called 2nd wave re­bounds hard­er. Now, is the re­al test. The num­bers were al­ways known to be go­ing to rise. We cre­at­ed new beds. We added ex­tra staff. But, did we an­tic­i­pate that with added num­bers meant in­creased sam­ples for test­ing and there­fore, in­crease staff at the TPHL?

Long be­fore the min­is­ter stat­ed re­peat­ed­ly the hitch was not at CARPHA, the lat­ter had al­ready put out a state­ment that they had no out­stand­ing sam­ples to test. The usu­al very con­fi­dent min­is­ter had to open­ly apol­o­gise to pa­tients for lengthy de­lays in them ac­quir­ing their test re­sult. Sam­ples from To­ba­go had to be sent to Trinidad and sam­ples from SWRHA were be­ing sent to as far as San­gre Grande and Port-of-Spain.

The de­cen­tral­iz­ing of test­ing ser­vices, set­ting up new test­ing sites and ma­chines were be­ing told to us since March. As much as there must be a process such as ac­quir­ing the ap­pro­pri­ate test­ing kits, (de­mand-sup­ply chain), val­i­dat­ing ma­chines, train­ing staff etc, it does seem an un­usu­al­ly lengthy pe­ri­od of time get­ting this as­pect of the sys­tem go­ing. The in­ter­val of swab­bing a sus­pect case and ac­cess­ing that re­port is a crit­i­cal pe­ri­od. The Min­is­ter of Health should fo­cus more on pro­vid­ing up­dates on pro­cure­ment de­tails, staff re­cruit­ment and de­ploy­ment, and plans to avoid a 3rd and 4th wave, and in­deed, nit­pick­ing those busi­ness­es that can in fact func­tion rather than pre­sent­ing clin­i­cal de­tails or oth­er so­cial ills. We are hap­py To­ba­go and SWRHA are now seem­ing­ly com­ing on stream with their own test­ing ca­pa­bil­i­ties.

DEATHS AND CO-MO­PRBIDI­TIES

The num­bers of deaths are be­ing pre­sent­ed and this is a crit­i­cal part of pub­lic in­for­ma­tion.

But, to qual­i­fy it by ref­er­enc­ing the fig­ure to the glob­al pro­ject­ed fig­ure gives us no com­fort.

It sounds too clin­i­cal and al­most harsh and jus­ti­fi­able.

Any death in this small com­mu­ni­ty of ours is a most dis­tress­ing and heart­break­ing oc­cur­rence and no one will like to feel their dear one’s pass­ing was ac­cept­able as we are still be­low the glob­al trend. This calls for much sen­si­tiv­i­ty in pre­sen­ta­tion. Per­son­al­ly, I find the num­ber of deaths very con­cern­ing, of ones dy­ing at home and some en route to the hos­pi­tal.

I was shock­ing to hear of pa­tients dy­ing be­cause they pulled off their oxy­gen masks. Hy­pox­ic pa­tients are con­fused but it is hoped that they are be­ing prop­er­ly cared for med­ical­ly. We need to know how many have re­quired ven­ti­la­tors, and of those, how many died.

I make ref­er­ence to my pre­vi­ous ar­ti­cle again, where I stat­ed the con­cept of Med­ical Con­fi­den­tial­i­ty need­ed to be re­vis­it­ed. As a med­ical pro­fes­sion­al my­self of over 40 years stand­ing, am very much con­scious of this term. By re­peat­ed­ly stat­ing ‘2 were el­der­ly men with co-mor­bidi­ties ‘ etc, tells lit­tle of worth.

By stat­ing the co-mor­bid­i­ty, eg the pa­tient was Di­a­bet­ic or Hy­per­ten­sive can serve as a mes­sage to those Di­a­bet­ics and Hy­per­ten­sives in the pub­lic do­main, to tight­en their con­trol of these con­di­tions, fur­ther lim­it their where­abouts and in­crease their safe­ty pro­to­cols. A Di­a­bet­ic or Hy­per­ten­sive who con­trols their con­di­tion more tight­ly will be bet­ter able to sur­vive the in­fec­tion.

It is be­ing sug­gest­ed that apart from pre­sent­ing the Glob­al, and Lo­cal Epi­demi­ol­o­gy, we must in­clude the Re­gion­al. We must in­volve our­selves in the Re­gion­al COVID-19 epi­demi­o­log­i­cal find­ings as this can on­ly be a fur­ther learn­ing ex­er­cise.

The in­ten­tion here is not to point fin­gers at loop holes but to sup­port good ini­tia­tives as laid out by the MOH while ex­press­ing some con­cerns. COVID-19 is every­one’s busi­ness.

DR C SINANAN-MA­HABIR,

For­mer Se­nior Chest Con­sul­tant/TB Per­son­nel,

Cau­ra Hos­pi­tal