Improving stroke care in TT

DR VEDAVID MANICK

I CONGRATULATE Dr Shane Gieowarsingh who was featured in a recent article on endovascular thrombectomy in the print media. His vision and passion to reduce the morbidity and mortality among stroke victims in Trinidad is admirable and I wish him all success in such efforts. This article also served to further re-enforce how far behind we are in providing world class healthcare in Trinidad and Tobago within the public heath sector.

The number one cause of death in our country is cardiovascular (heart disease), yet the gold standard for an acute myocardial infarction (heart attack) in the emergency setting angiography and percutaneous coronary intervention is unavailable to the public sector patients. Thankfully at least through the external patient programme this service is available. However in many cases it is several weeks to months too late in reversing the morbidity and mortality of patients.

Cerebrovascular accidents or strokes are among the top five causes of mortality in TT, and certainly debilitates many who do not die, yet we struggle in terms of providing specialist stroke care to our public sector population.

Stroke care in the acute setting as Dr Gieowarsingh’s service aims to provide is essential in reducing the loss of functionality of a patient but regretfully is not available in the public sector and is out of reach to many who cannot afford. It is however essential, because the devastating impact of a stroke is that it removes a patient’s independence and places that burden on the family.

For example, a person who suffers a devastating stroke which leaves them paralysed, bed bound, unable to swallow or speak, is now very dependent on the caregivers. These caregivers are usually members of the family who do the basic needs of daily living for that person: cleaning, feeding, turning, moving around and many others. This is no easy task and many caregivers tend to “burn out” in the process.

If the stroke victim was the sole breadwinner of the family, the responsibilities of financial sustenance shifts to the caregivers, who are already burdened with taking care of a dependent loved one. The added needs of the home is well out of the reach of the disability grant of $1,700 a month or public assistance grant of $1,100 a month which the social services of this country only grant if the total household income is less than the established poverty line.

No other grants, I have been told, are provided to such people or family once they receive a family income that exceeds the poverty line, even in situations like these. And thus begins the downward spiral of healthcare and poverty as the patient develops complications of dependency and debilitations such as bed sores, infections, aspiration and poor nutrition while the caregivers face depression and poor lifestyle choices. The overall cost of such a decline no doubt far exceeds the cost of having an efficient stroke service and overall functional health sector.

I know many public officials have and will advocate that prevention is better than cure and that there is need for more focus on primary care rather than developing specialty services. Primary care is essential in preventing people developing strokes and heart attacks. But the reality remains that our primary healthcare service continues to fail us miserably with absent policies to promote a healthy lifestyle, lack of health education, promotion of personal responsibility and suboptimal community care.

Thus in the current scenario, there is need to lift the standard of our care, both primary and tertiary, to where it ought to be. Among ways this can be done include:

* The reinforcement of our primary care service by creating policies that promote a healthy lifestyle, improve the cost of living healthily and educating our population to make informed choices with regard to healthcare.

* The review of the health centres to ensure they are well staffed by passionate health personnel who will screen and reinforce a healthy lifestyle and manage chronic conditions with the aim of secondary prevention.

* Reduce the arrival time of patients with strokes to an equipped hospital.

* Ensure that there is adequate staffing to allow for patients with suspected strokes to be seen and referred to have imaging and intervention within the necessary timeframe.

* A functional CT and MRI service at all public hospitals which will allow for emergency scans.

* The establishment of acute stroke centres in the public sector to allow for early intervention.

* The addressing of the dire need for rehabilitative medicine in our public sector to provide patients with a disability an opportunity to regain some independence and thus limit the debilitation to themselves and their caregivers.

* A reorganisation of our social services which includes developing policies with heart so that patients and families who really need that support get it.

It is my hope that these humble recommendations will reach someone with the capacity to institute such changes and hence lift the quality of healthcare the public sector can provide to our population.