Despite warnings from clinicians, Barbados held on to a too-short quarantine and test protocol when its borders opened last summer. Now, a new surge in COVID cases and deaths begs retrospective policy questions.
As Barbados battles a second wave more deadly than its first, its anti-COVID-19 efforts have come under fire. But could the hurdles being faced by the island be traced to past policy failures? And have these since been addressed?
I begin at the border, with Barbados being COVID-free as it officially opened to tourists in July 2020. When the primary concern should have been to prevent the importation of new cases, the decision was made to institute a too short two-day quarantine for incoming travellers, far below the then scientifically-established standard of two weeks.
The Barbados Association of Medical Practitioners (BAMP) expressed their concerns with this early on, stating “such an approach will fail to detect and quarantine (at least) 9 – 33% of travellers who contract COVID-19 between their initial test and arrival in Barbados”, with BAMP requesting instead that the isolation period be extended to seven days. Pre-prints published by the CDC also hint at how porous the borders remained, with their models indicating a risk reduction as low as 40% for shorter isolation periods.
Meanwhile, reports on how difficult it was to keep tourists in isolation flooded the region, raising questions about the ability to effectively curtail the movement of potentially infectious visitors. Still, authorities resisted change, insisting that two negative qPCR COVID tests – one prior to travel and a second at the exit of quarantine – were an adequate countermeasure.
But there was no scientific evidence of this, a fact that was reflected by the Pan American Health Organization’s guidelines for resuming non-essential international travel. PAHO’s position was that the focus should be on monitoring visitors for symptom development and tracking their locations, and that “conducting or requiring COVID-19 testing of prospective or incoming international travellers is not recommended as a tool to mitigate the risk of international spread.”
With the case count rising, Barbados then finally amended its travel protocols. The isolation period has been lengthened from two days to five, and tourists are now monitored through a mobile app called BIMSafe, in keeping with PAHO’s emphasis on symptom reporting and location tracking. However, the new quarantine may still be insufficient, as it remains below BAMP’s recommendations.
There are additional issues with Barbados’ dependence on negative test results. Multiple factors can result in a viral load that is too low to be measured, even if the person has COVID and can transmit the disease. The result is a fairly high false negative rate, particularly in the earlier stages of infection.
When the FDA first granted test authorisations, it noted this limitation by indicating that “negative results do not preclude SARS-CoV-2 infection and should not be used as the sole basis for patient management decisions.” Testing is therefore meant to be used in concert with other measures, rather than alone.
Still, Barbados continues to depend on it in a way that is inappropriate, including the implementation of a third test on arrival as part of its travel protocols. And despite this heavy reliance on testing as a sole determinant in key decision-making, Barbados still fails to employ testing where it is most powerful — to monitor COVID incidence in the local population.
Although controls at the border were inadequate to prevent the importation of COVID, this risk could have been mitigated by regular, widespread testing of the local population. Doing this would have captured any spread early on. Without it, anyone missed at the border would remain hidden until long after there was significant transmission, and the consequence of such a failure would be a sudden large spike in community cases, with the added disadvantage of not knowing how large or how far the disease had spread in the interim — exactly as has happened.
Barbados did not and has never sufficiently tested its own people, despite a relatively high total test number. And while the focus on searching for negatives is partly to blame, much of it is due to the use of long out-of-date criteria to identify positive cases.
A significant percentage of people who have COVID are asymptomatic, and both these individuals and those who are pre-symptomatic can pass on the disease. Guidance for testing a population has therefore shifted away from focusing on those who report that they feel ill. Instead, it is recommended that countries frequently and randomly test a sample of their population, even if apparently healthy, as a way of more accurately determining current incidence.
Nevertheless, Barbados’ testing approach, even now, continues to depend on the appearance of symptoms, leaving many asymptomatic cases undetected. Backlogs at the local laboratory are now being managed by a triaging system that contributes to this and other issues. And the first attempt at mass testing — a door-to-door program known as Operation Seek And Save, where a survey of the population is followed by testing households that report symptoms — was largely unsuccessful. It has netted only a handful of additional cases after thousands of interviews, likely due to major flaws in how the survey was designed, deployed and managed.
All of this means that it is still unknown how much and how widely COVID has spread in Barbados, although high case-positivity rates and rising case numbers hint at how many were missed.
Barbados has also largely neglected to empower their population with the tools to protect themselves. Education and support has been minimal, and an absence of systemic protections — like temporary legislation preventing eviction, stricter enforcement of existing labour laws or free mask distribution to those unable to afford them — have left poorer citizens especially vulnerable.
Part of the problem here is ineffective communication. Early messaging just prior to the current outbreak seemed meant to reinforce the idea that COVID remained absent from the community, rather than emphasising the need for continued vigilance once tourism was active. There was little sensitisation or education, no mandate to wear masks, and limited oversight. The capital lacked billboards or posters in its most high-traffic areas, and few attempts were made to downsize or reduce gatherings in anticipation of holiday surges.
There was also almost no centralised guidance or training for workers and business owners, and efforts were mainly confined to online documents short on details. This left the labour force poorly equipped, with measures unlikely to be deployed uniformly or with the necessary stringency.
Compounding the issue was that even official sources of information did not provide consistent, accurate messaging. The Barbados Government Information Service sometimes presented questionable guidance, such as images of masks known to be ineffective against viral transmission. And members of parliament were frequently captured on camera unmasked or failing to social distance.
Behavioural changes are a key part of COVID management, and while Barbadians have overwhelmingly complied and adjusted, additional support is required. Recent attempts to improve communication have included regular, but overly long press conferences, loudspeaker campaigns across the country, and dramatic skits available through a variety of media.
To be effective, communication should be clear, concise and consistent, but attempts continue to fall short in these identified areas. Even the recently-passed mask mandate is inconsistent, as it contains a confusingly-worded exception for talking, and support for workers remains poorly organised and lacking.
It seems likely that the ongoing surge in Barbados may be due to specific policy failures, frequently in opposition to expert guidance, and with attempts at correction faring little better. The final hopes now rest in the recently procured vaccine, and that science will finally be enough to overcome fumbles where it has too often been ignored.
Image: Grantley Adams International Airport. Copyright Andre Donowa. Views expressed by guest contributors are not necessarily those of AMG.
