A healthy balance
Compounding threats are intensifying health burdens in the Caribbean region, but, as seen with COVID-19, a unified response is not just words – it works. Interview with Joy St John, executive director, Caribbean Public Health Agency
What are the health burdens facing poorer countries as the COVID-19 pandemic has intensified?
The ultimate burden is non-communicable diseases. The burden of NCDs was already big in the Caribbean – many of our countries have the highest per capita levels of illness and death in the Americas, and very often those people were picked off by COVID-19.
Small island developing states are generally under-resourced with the specific skill set for clinical management. Severe cases need very specialised management, as does public health management. So we have a cadre of health workers who are quite extended, and that increases their mental health and clinical risk profile.
A third burden is the unfortunate brain drain of medical professionals, especially specialists. This will become a greater burden, because everything was under-resourced and diverted towards COVID-19. We’re not seeing the correct management of preventive and health-promotive services including regular immunisations. So we’ve got people with uncontrolled NCDs turning up with issues apart from COVID-19, and COVID-19 also caused some NCD issues
How have these health burdens from COVID-19 been intensified by the compounding threat of climate change?
Yes, we still had our fair share of climate-related severe weather. Flooding, but not as many hurricanes. And, in the middle of this, not climate related, we had a massive volcano eruption that affected St. Vincent and neighbouring countries, especially Barbados because the ash fall effect.
We saw the impact of climate change on vector-borne diseases, specifically dengue. Because they’ve similar symptoms, there would have been some mixed-up diagnoses: is it dengue or is it COVID-19? We have not had any reports of any unlucky persons having both diseases at the same time, but there’s different treatments for them.
Climate change and health impacts don’t go away. One of those impacts is the mental health fallout when people feel overburdened. There’s always a silver lining, though: there has been more focus on mental health, and understanding and acceptance that a mental health challenge is not a person’s fault. That is really important.
But yes, we’ve seen those impacts. We did have some issues where actual health services had to be stopped or suspended for a short while because of severe flooding and so on, and so they couldn’t respond to the COVID-19 impact.
What kind of a strain does slowing global economic growth put on people’s health and the healthcare system?
To their lasting credit, the Caribbean Community’s heads of government did everything they could to preserve life in the first stages of the pandemic. Remember tourism is our business and tourism stopped, so we as a region did not have the revenue to match the significant outlay on those critical care services that in some cases had to be built from scratch and in others expanded. This was a pandemic where you had to learn the trick of balancing lives and livelihoods. First it was lives, and now that we are dealing with variants that don’t have as severe impacts as earlier variants had, the scales are tipping with member states opening up for tourism. The Caribbean Public Health Agency has provided support to the tourism sector for a safe return to work and also developed protocols and guidelines for special aspects of tourism and cruise tourism. So economies are the focus now.
But the ordinary person in the street was not spared. People lost jobs because businesses closed. People saw their incomes reduced because only one member in the household was working. With schools closed, someone has to look after the children, so that also had impacts on the economy. But as things are opening up, as safely as they can, we’re seeing a return to equilibrium, rather than just focusing on lives or the economy. The equilibrium offers maximum benefit to both lives and livelihoods.
Why is regional cooperation such an important instrument in overcoming health challenges?
In the Caribbean we are lucky that we have political and other constructs provided by the Caribbean Community. The heads of government function as a quasi cabinet: each has a reponsibility – one health, one the CARICOM single market and economy. And I specifically mention the single market and economy because they have been working even during the pandemic to see an improvement for all, because the whole idea is for regional development rather than one country. It is not perfect, but it is the best way for making sure things work. If your neighbour’s tourism product is somehow hampered, people think your product is hampered as well. So from a perspective of making sure the customer is happy, it makes sense for the islands and the coastal territories to work together and to have a long-term goal for improving many things at the same time.
The other thing about Caribbean unity is that it’s a multisectoral mix here, and one of the best ways for individual sectors to thrive is if there is an overall plan that supports all of them. The COVID-19 response was for me a massive success because the heads of government mandated health in all policies, in all sectors, to get to a point where the pandemic was manageable and allowed for economic activity alongside this virus. So Caribbean unity is not just words. It works.
What are the signs that the tourism-dependent Caribbean is safely open for international visitors?
First, yes, it is safe. Let me talk about some economic indices from the Caribbean Development Bank. We have a projection that there will be growth in the region of 9% – but that is predicated on Guyana, whose wealth is most definitely from the petroleum industry. Nevertheless there has been a successful return to tourism arrivals, in some cases as good as or better than the 2019 pre-COVID levels.
Second, more people are back in jobs. There is money flowing. It’s not perfect and it’s not where it was before. But part of the reason they’re coming back is the other part of your question – because indices show that it’s safer in the Caribbean. In terms of numbers of cases and deaths for the Americas, this region is doing very well. And it’s not by happenstance – the tourism and health programme developed specific regional public goods aimed at ensuring it’s not just that the hotel says it’s safe, but there are standards to which the hotels are working. And the Healthier Safer Tourism Award, developed by CARPHA, links to standards in seven areas, including COVID-19, vector control, food safety and water safety. So a tourist knows if they come to the Caribbean it’s not just that we have low COVID-19 numbers but also we make sure systems are working. We’re working towards immunisation for our tourism sector. So to answer your question, yes.
What challenges remain?
The challenge of making sure we catch the next thing that’s coming, early, before it actually gets here, so we can prepare. Because of climate change, we’re going to have more and more diseases. We must keep working with all our public health partners – not just the Pan-American Health Organization, the US Centers for Disease Control, the Public Health Agency of Canada, the UK Health Security Agency and the French and Dutch public health agencies with interests in the Caribbean. So we are working to keep up with the evolution of the International Health Regulations, to make sure the weaknesses exposed by COVID-19 are addressed.
Another challenge is kick-starting the work that was put off, folding the COVID-19 systems into pre-existing health systems and strengthening health systems as a result. Much good came with COVID-19: increased testing capacity, and the ability to work together in real time, because the chief medical officers worked together, the heads of government worked together, the ministers of health worked together, strengthening the bonds of health and also working with other sectors more seamlessly. So how do we kick-start that and fold in the good and bad lessons learned so you don’t go back to the pre-existing systems?
Yet another challenge is how we stop that brain drain. How do we ensure those people who can deal with infection prevention and control and intensive care are in the region in enough numbers to deal with what can come our way? How do we balance our health needs with the need to promote tourism? We don’t have our tourists separated from us – we live and work where the tourists are. We have to keep those brains that can crunch the science of something new and prepare for it.
And we need access to medications, access to treatments, access to vaccines, because even with COVAX and the ACT-A Accelerator there’s still an issue of access – nowhere as bad as the 2019 H1N1 pandemic but still significant enough that we’re concerned about the equity of availabiility of what people will need. We need to find a way to strengthen our health diplomacy, to strengthen our ability to have a seat at the table so we are remembered when things start to go wrong, and we are counted when these new products and medicines are being shared.
What are your views on the World Health Organization’s pandemic preparedness treaty?
I mentioned the evolution and maybe revolution in the International Health Regulations because there are clearly issues that need to be addressed. The member states are involved through their Geneva-based missions – there aren’t many but I’m hoping they’re involved – and through the CARICOM representatives on the executive board. The UN system, of which WHO is a partner organisation, is staying true to its way of interacting with the world when it has new things. But one thing that came out of this pandemic was that not everybody who needed to know got to know officially. I would like to see this process address that and have a way of ensuring that regional organisations that are not in the UN system have at last some note coming from their regional organisation to let them know the process and the outcomes. CARPHA is not allowed to be at the World Health Assembly unless we become a member of one of the member state delegations.
How can G7 leaders at their Elmau Summit best help SIDS with their health and related challenges?
Let me start with climate change. In the Paris Agreement there is a big section on climate change and health. I would like true attention to be paid to that, and not lip service, because when you link climate change and health effectively you’re going to help the member states more. That means money has to come to climate change and health initiatives.
Second, I would like the understanding that SIDS, even though collectively not a huge number, are here and part of your lives because this is where you like your relaxation, and everyone needs to relax. Some attention needs to be paid to the SIDS, not just the CARICOM ones, from the health perspective, and from the economic perspective.
That leads me to the third. I would like to see changes in how the world economy is structured, especially when it comes to debt, access to funding and access to commodities that may be hurt by the supply chain issues of the war in Ukraine. There needs to be a rewrite of who get access to include SIDS.
Fourth, going back to COVID-19, we need to continue to have access to medicines and treatments. We need to have access that is affordable, and available when we need it. We also need access to vaccines, and I’m hoping there will be some attention paid to vaccines for omicron because infection with omicron, it appears, does not give immunity against infection of the other variants. So there needs to be some vaccines for at least special or more vulnerable groups.
Stepping away from health a little bit, looking at the economy, because all the economies were hit, I think the whole world order needs to change. We saw some amazing changes with sanctions against Russia in a short time, so changing how debt is looked at and access to certain things is entirely possible.
