The future of heart disease in East Africa

Interventional cardiologist Dr Nasiruddin Jamal, head of the cardiology unit at the Aga Khan Hospital in Dar es Salaam, Tanzania, answers a Raconteur Q&A on the challenges and opportunities of treating and preventing cardiovascular disease in a developing country with an at-risk population

Q. How does the treatment of cardiovascular disease (CVD) differ in developing economies compared with the UK?

A. The incidence of CVD is on the increase worldwide. Mortality from CVD has declined in Western countries, but it is on the rise in developing countries. Treating CVD in countries such as Tanzania is certainly more challenging, mainly due to lack of awareness and knowledge about the disease, and how to prevent it, among local populations. This lack of knowledge, coupled with lack of resources, leads to a high non-compliance rate with prescribed treatments. You also have to understand, we’re working with populations that have a high prevalence of other infections, especially HIV, which can sometimes be a causative or exacerbating factor. Meanwhile, there’s very little epidemiologic information available, a general lack of highly trained medical personnel and the cost of treatment remains very high.

Q. What are the biggest barriers to reducing CVD?

A. The top priority is public education. This is a must if we want to decrease the number of CVD cases. Secondly, lack of knowledge among healthcare workers about the relevant guidelines and the importance of evidence-based treatments are getting in the way of early and more frequent diagnoses. Informing and educating healthcare workers about these guidelines is critical.

Q. What are the low-cost treatment options?

A. There are low-cost medications, but there is a lot that can be done without medication, which is a very cost-effective way to prevent or decrease CVD. Things such as low-salt diets for hypertension, low-fat diets, which help with coronary artery disease, exercising, stopping smoking and drinking alcohol. What we need is education on diet, safe places for people to exercise, and anti-drinking and anti-smoking campaigns to help address what we can do without having to medicate.

We’re working with populations that have a high prevalence of other infections, especially HIV, which can sometimes be a causative or exacerbating factor

Q. What is the nature of local treatment?

A. I think local treatment is frequently influenced by the pharmaceutical industry. Unfortunately, many practitioners may not be doing their own research or following guidelines. Not enough education is being imparted to patients to help them manage the situation, and while doctors might be quick to perform some tests, such as echocardiograms, to satisfy patients that their heart has been checked, the quality of research and interpretation of the results is debatable.

Q. What are local attitudes to cardiovascular health?

A. People are very concerned about CVD. They lack education. There is a lot of misinformation. Even young people with any pain anywhere in the chest think they have heart disease or have been told they have angina. We need a good education campaign to increase understanding.

Q. What are people’s concerns?

A. They are concerned about the possibility of heart attacks and strokes, and about the affordability of diagnostic tests and treatment. But generally, patients lack insight about the chronic nature of the illness and often stop treatment after just a short time.

Q. What is your vision for treating and preventing CVD?

A. We are working to become centres of excellence for cardiovascular disease, providing preventative, diagnostic and tertiary care for treatment. This is happening in both Dar es Salaam and at the Aga Khan University (AKU) Hospital in Nairobi, Kenya. Our rural health centres are also providing evidence-based basic diagnostics and management. We plan to roll out the use of telemedicine to improve on what we can offer patients and help us make timely, appropriate referrals.

Q. What are your personal aims?

A. My number-one aim is to establish a state-of-the-art, world-class cardiac programme at the Aga Khan Hospital in Dar es Salaam, and become a referral centre for CVD throughout Tanzania and neighbouring countries, in close linkage with AKU Nairobi. Part of my agenda will also be improving basic cardiovascular care in the outlying clinics and implementing the successful use of telemedicine across our network in the region. In order to do this, a big job will be training local personnel.

Q. What are the three top priorities for reducing CVD in East Africa?

A. First, a massive public education campaign about hypertension and diabetes as well as CVD. Second, relevant local research on changes in nutrition. And third, affordable medication.

Q. What role does the government play with CVD in Tanzania?

A. Government hospitals are trying to provide free or low-cost diagnostics and management. I am not sure if there is a well thought out long-term strategy or a dialogue between government and local cardiovascular experts to come up with a strategy.

Q. Should non-communicable diseases, including CVD, be part of the United Nations Millennium Development Goals?

A. Most definitely. Developing nations will all need massive assistance. They will need human resources, financial assistance and educational campaigns similar to those for HIV. I do not believe developing countries can combat CVD by themselves.