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Reliable statistics on health, life-expectancy and disease incidence in Africa are not readily available. The WHO 2007 report ranks the quality of cause-of-death information for most of Africa as low or non-existent. In this regard, Africa does not compare well to the rest of the world, and for much of Africa there is no information.1 2 The poor quality of the available information renders definitive comment and prediction problematic.
The publication of the landmark global burden of disease report in 1996 drew attention to the potential impact of degenerative cardiovascular diseases as causes of future morbidity and mortality in developing countries.3 Since then, there has been considerable speculation and discussion about the impact of the epidemiological transition on the health and healthcare needs of the people of Africa. In this issue, Dr George Mensah4 reviews the historical evidence for the rarity of ischaemic heart disease (IHD) in Africa, the factors considered to have contributed to a rise in the incidence of IHD in Africa, the opportunity afforded to interrupt that rise and the very serious consequences if such a rise in incidence is not addressed appropriately (see page 836). His call mirrors that of others who consider that IHD and other chronic degenerative diseases in people living in developing countries receive insufficient attention.5 6
These are important issues for those of us practising, teaching and researching cardiovascular disease in Africa. Perhaps the most important single question is whether there truly has been a change or a tendency towards change in the prevalence of IHD in the indigenous majority Black African population in whom the disease has always been considered to be uncommon. If there has been, it is not immediately obvious in sub-Saharan Africa. The INTERHEART study referred to by Dr Mensah investigated ethnic differences in risk factors in patients with myocardial infarction and showed that risk factors are the same in all individuals irrespective of ethnic origin.7 In Africa, the investigation was conducted in nine sub-Saharan countries.8 The intention was to enroll as many black African patients as possible precisely because atherosclerotic coronary disease has traditionally been deemed uncommon in this population as reviewed.4 Despite the best efforts of investigators, very few cases (n = 144) of acute myocardial infarction were identified in the large Black African population of the region. The majority of cases were identified in South Africa.8 Most cases were detected in the minority populations of white, Indian people and those of mixed race (populations in which the condition has always been known to be common during the last few decades). These are truly minority populations comprising less than 10% of the total South African population and a very much smaller proportion of the sub-Saharan population.
Many reasons have been advanced for this discrepancy in detection. Among them is a suggestion that medical practitioners in sub-Saharan Africa do not recognise coronary disease in Black African patients. That seems an unlikely explanation for this discrepancy and the failure to detect acute myocardial infarction, the most dramatic manifestation of coronary disease. Another, sometimes advanced, is that black African patients do not have the same access to quality healthcare as other ethnic groups. That is more difficult to answer definitively, but at least since 1994 all public health facilities in South Africa have provided equal access and care to all patients presenting to emergency units and casualty departments as they have on the rest of the continent. The same medical, paramedical and nursing staff take care of all patients. It is hard to believe that they have completely failed to recognise acute myocardial infarction in some patients while meticulously documenting it in others based on racial/ethnic profiling. A careful evaluation of all patients presenting to an emergency unit in a large secondary level hospital, serving an ethnically diverse population in Cape Town, revealed that acute coronary syndromes were a very uncommon reason for presentation to an emergency room in black African residents of the city.
Does all of this matter? We believe that it does, and there are important issues for both the planners of healthcare for populations and practitioners.
With regard to the former, some government health departments (among them those of South Africa) have taken laudable positions on preventive measures with regard to smoking, exercise and obesity. These are important but only if the predicted epidemic is going to manifest. There is a grave and all too often ignored danger in our view that preparations for the proposed and as yet unseen epidemic may compromise the very real necessities of the care of patients with diseases currently endemic in Africa.9
Much training in cardiac care in Africa seeks to emulate western models with its major emphasis on degenerative vascular disease. How did this come about? First, the international cardiological literature is dominated by IHD with little reference to rheumatic heart disease, constrictive pericarditis or cadiomyopathy; yet these are the cardiac diseases of Africa which doctors in Africa need to know about, be able to diagnose and treat. Second, IHD is undoubtedly common in the minority populations, members of which are most likely to have the financial resources to pay for the investigations and treatment necessary. Understandably, doctors wish to train to treat conditions which occur in patients who can pay for treatment, often in private rather than public healthcare facilities.
If we focus on “the impending epidemic” of coronary disease and teach and research this rather than the very real and current epidemics of untreated rheumatic heart disease, pericarditis, hypertensive heart disease and cardiomyopathy, we will be training a generation of doctors and cardiologists unable to diagnose, research and treat the diseases prevalent in their own countries and who are only suitable for medical migration to Europe or North America. The common diseases of the majority Black African population will remain unrecognised and untreated. That is the last thing Africa needs.
We in Africa need to acknowledge and understand the realities of the potential impact of the projected “epidemiological transition” as eloquently elucidated by Mensah and others. There is an urgent need for accurate prospective data on cardiovascular disease epidemiology in Africa. Healthcare planners need such information to ensure that limited resources are appropriately allocated to prevention as well as to investigation, treatment and training of healthcare professionals. We also need to ensure that simple strategies to prevent recurrent rheumatic fever are not forgotten and that strategies are in place to identify and treat the common cardiac diseases of the majority of the population. It is essential that we recognise that the projected transition may not occur or may be delayed because of the impact of a competing epidemic, that we are aware of the cardiovascular complications of the competing epidemic and that we know how to manage patients with cardiac disease who happen to be HIV positive. This is a unique contemporary challenge to those who practice cardiology in Africa.
Competing interests: None.
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