Dr Mandreker Bahall, Specialist Medical Officer (Internal Medicine/Cardiology) & Consultant, department of Medicine SFGH.

We continue with Dr Mandreker Bahall’s look at this country’s COVID-19 situation and how the country can move forward.

What led to the rise in COVID -19 cases?

This may have resulted from:

• The open borders along the coastline.

• The COVID-19 Variant B 117 strain (UK)—Variant B 117 was first found in a local sample on January 21, 2021.

• The Brazilian strain—COVID-19 Variant of Concern P1 (Brazilian Variant) was first found in a local sample on the April 19, 2021.

• Non-compliance to public health regulations (social distance, sanitise and wear face masks).

• Lack of an enabling environment to ensure compliance with public health regulations.

• Breaking the law to fulfil basic needs.

• “Festive occasions” gatherings

• Caring for COVID patients in private homes.

• Resource constraints—unable to purchase appropriate masks etc

How do we curb the spread of the virus strategically?

Overall, there must be a change in mindset and policy direction. People and not virus must be the focus and our prime concern. The public health model or the social ecological model (SEM) must be utilised to curb the virus spread. The public health model or the SEM as used by Shanghai is the way to go.

1.Regionalisation. Delegate responsibility to regions and subunits. This must be well coordinated throughout the country supported by volunteers. Make units as semi-bubble units.

Community services (information centres, support centres, relief coordinators, medical support and call in centres) must be ramped up. Utilise education units in education/ training to teach children. National and subnational measures must be in place for COVID-19 crisis.

2. Healthy environment. The environment must be structured in such a way that supports “preventing viral spread.” It must be mandatory for service providers to make their places comfortable yet COVID free. Patients that are already suffering must not be allowed to suffer more. People must be able to acquire services in comfortable “units,” avoid long lines for purchasing items, paying bills, collecting prescriptions, medication etc. (A unit is any department or service that is open for public or private use). Units must be certified for use by the regional authority if they fulfil the required public health criteria.

Some such strategies that were developed and/ or utilised by service providers within Trinidad and Tobago include delivery, curbside pick-up, development of a website/ online platform (eg social media page) / telecommunication, using online cashless/ contact-free payment options. Local government bodies must upgrade their roles to ensure public health adherence of road usage, garbage disposal, wastewater treatment and drainage systems and all service centres.

3. Societal measures. This include reporting systems, quarantine reinforcement, customs, security and legislative support, educational support, teleworking —work environments etc.

4. Epidemiological data. Disease surveillance, carriers, cases and deaths on virus must be replaced with pandemic statistics. Pandemic statistics must include trends in joblessness/ reduced income, education, poverty, social, economic and psychological indicators. This will help all stakeholders to re-focus based on the patients Bio-pshychosocial need. The Shanghai experience did just that. They utilised the social ecological model (SEM) addressing the needs of the people through individual, community, organisational and societal levels.

5. Ongoing measuring and monitoring.

This must be done to identify and address gaps in the system. Monitoring must be used to help not to criminalise people. This would require more public health inspectors not police inspectors. More love not lash, more encouragement not punishment. All service units have to be certified for business by the Public Health department. Adhering to COVID guidelines requires incentives, education and proper leadership.

The management of COVID positive patients at home or private places where potential spread can get outer-hand has to be very closely monitored and deficiencies addressed. Home care should be avoided as soon as is possible unless patients have adequate social and clinical support.

The public health environment with its age-old deficiencies puts a greater challenge for us in our attempt to eradicate the COVID-19 virus in the midst of resource constraints. But the cost of tertiary care will be even more. We need to spend more money in public health environmental infrastructure than a vast amount in tertiary care (a major recommendation of the Health Sector Reform Programme (HSRP) started in 1994). Since then with the support of the Inter-American Development Bank (IADB) there was to be holistic care of the patient by instituting quality health care (efficiency, effectiveness, equity, customer centeredness, safety and timeliness). This will be an ideal opportunity to revisit the objective of the HSRP.