Public health officials appeared before a Joint Select Committee (JSC) on Social Services and Public Administration two weeks ago. The stated purpose of the conclave: ‘An enquiry into Trinidad and Tobago’s response to the prevalence of non-communicable diseases (with specific focus on diabetes, cardiological diseases and cancer)’-Trinidad Express, Nov. 16, 2023.

CMO Dr Roshan Parasram was, appropriately, the chief spokesperson for the public health group. The bullet points drawn from his remarks were: • Lifestyle choices. Poor lifestyle choices, such as use of tobacco, alcohol, and poor diet and exercise regimes, continue to be the primary cause of persons developing non-communicable diseases (NCDs).

• NCDs and bedspace. The NCD problem must be dealt with now, since further delay in doing so would make the recent increase in bedspace inadequate.

• Collaborative programmes.

The Ministry of Health was collaborating with other ministries-Education, Sport, and Agriculture-on programmes aimed at encouraging lifestyle change.

• Targeting children. Most importantly, primary and secondary school children would be targeted: ‘Children will drive the change’referencing a 2011 PAHO survey indicating a 27 per cent obesity prevalence in childhood.

No rational person would contend that a focus on behavioural health is not critical in the prevention and control of NCDs. The CMO was embracing the opportunity to provide greater detail, elaborating the policies and action plans to be employed in addressing this behavioural risk factor.

As readers may recall from previous articles in the print media, that strategy was first articulated by Minister of Health Terrence Deyalsingh on World Health Day 2019: the launch of the TT Moves initiative. It was repeated as a fullpage message in the daily newspapers on World Health Day earlier this year (April 7, 2023), in which he acknowledged that the Ministry of Health ‘has been concentrating our efforts and resources on the promotion of health, as opposed to only health care’.

Before addressing some of the more worrisome aspects of these most recent elaborations of the Ministry of Health’s behavioural thrust re: the NCDs, it would be remiss of me not to advise the ministry’s principal decision-makers to tread cautiously on pronouncements about health care, since the term is interpreted by John Public to mean the healthcare system, whose main task is to provide healthcare services demanded by the population.

The Ministry of Health, in its 2017 publication ‘National Strategic Plan for the Prevention and Control of Non-Communicable Diseases: T&T 2017-2021’, outlined (in the preamble preceding specification of policies and action plans) multiple areas of under-performance in public health services-a super-important arm of the health care system, which, as deduced in this very document, has led to lower life expectancy in T&T when compared to Caribbean neighbours, and unacceptably high morbidity and mortality rates when challenged, as occurred in the recent Covid pandemic.

Turning to the current strategy by the Ministry of Health to concentrate its efforts and resources on health promotion in the attack on NCDs, there are three main areas of concern: 1. Length of time.

The benefits of this strategy will be long in coming to fruition; changing behaviour will not happen overnight. That children are projected to drive the change is remindful of the phrase ‘the future of the nation is in your schoolbags’; the future of health in our twin-island state will be driven by children. There is much chatter currently on ‘acculturation’ of the nation’s children, so one more item has been put on that plate. All such notions, believe it or not, are driven by the actions of adults; in this case, the development of a new culture and attitude towards a healthy diet.

For starters, one year ago, in November 2022, adults in the Nutrition and Metabolism Division of the Ministry of Health, along with FAO support, completed the draft: National Nutrition Guidelines for Food Offered to Children in Schools. I am not aware that the projected next step-public consultation with stakeholders, e.g., ministries of education, agriculture, cafeteria owners, etc.,-is under way, or has already been taken. Suffice it to say that the acculturation of children as agents of change in this behavioural strategy is still in the cocoon stage; adults have much work to do. The call for action ‘now’ by the CMO using this approach seems distant.

2. Improve public health services for better prevention and control.

Given the foregoing happenstance, the immediate focus of the Ministry of Health should be on addressing other modifiable risk factors, namely: apply strategies and action plans to improve public health and primary care services that have been chronically found to be wanting. There is a time-tested rationale for the moniker ‘prevention and control’ when discussing NCDs. The principal weapon of this war is a two-edged sword. For any meaningful success in reducing morbidity and mortality, both sides of the blade must be employed. A focus on prevention must not be at the expense of the modifiable and non-modifiable elements of the NCDs. The policies and action plans for moving forward with such bilateral foci are enshrined in the Ministry of Health’s 2017 document on NCDs. Not much has changed; the ball just needs to be picked up and wiped off.

3. Address inequity in health services.

Finally, failure to adequately provide basic public health and primary care services has led to worsening inequity in the overall health system. In T&T, as elsewhere, persons of lower socio-economic status have a higher incidence of obesity, diabetes and cardiovascular disease, but lesser access to quality care, the combination leading to escalation of their health issues to more complex and costly conditions.

Kenwyn Nicholls