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Strategies for heart disease in sub-Saharan Africa
  1. A J Brink,
  2. J Aalbers
  1. Cardiovascular Journal of Africa, Durbanville, South Africa
  1. Correspondence to Professor A J Brink, Cardiovascular Journal of Africa, PO Box 1013, Durbanville, South Africa; cvjsa{at}cvjsa.co.za

Abstract

The commonest forms of heart disease in sub-Saharan Africa are chronic rheumatic heart disease, dilated cardiomyopathy, pulmonary heart disease, infectious forms of heart disease including chronic, constrictive and infective endocarditis, genetic forms of heart disease and arrhythmias. Malnutrition, with cardiac manifestations such as beriberi, and alcoholism also play a part. Ischaemic heart disease in sub-Saharan Africa at present affects mainly the small, Westernised white population. Heart disease is a less important cause of morbidity and mortality than many other infectious diseases but is likely to escalate in the next generation(s). The changing demographic picture dictates the way in which funds for research, prevention and treatment must be channelled to best advantage. A concerted effort must be made by cardiologists of African countries to arrest the advance of heart disease, and a declaration outlining these strategies has been endorsed by the Pan-African Society of Cardiology (PASCAR).

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Limited information is available on the prevalence of heart disease in sub-Saharan Africa. Adequate research in this region is lacking and the data available frequently relates to divergent geographical areas and population groups. For example, the Heart of Soweto study supplies information on a black population exposed to a Western lifestyle over a period of more than 50 years, living close to the large city of Johannesburg.1 In this context, when referring to a black population, we indicate the indigenous blacks of African countries with their own indigenous language. We do not include people of mixed origin, with a westernised culture, who are more comparable with Americans. Nor do we include the Asian Indian population, which is also westernised. Together with the whites, they account for about five million of the total approximately 45 million people of the country.2

Other reports on heart disease in sub-Saharan Africa are confined to descriptive research on selected topics triggered by observation. Examples of these are the frequent occurrence of dilated cardiomyopathy,3 the presence of familial hypercholesterolaemia in Afrikaner families,4 and the infrequency of the symptom of angina pectoris in the black population. These observations and reports lead to further research into mechanisms and probable causes.

What has been startlingly evident and has common consensus from all observers is that acute rheumatic fever and its sequel, rheumatic heart disease (RHD),5 is the commonest form of heart disease throughout Africa. Almost on an equal footing is dilated cardiomyopathy (DC). Both diseases are strongly associated with poor socioeconomic conditions and malnutrition. The brunt of these diseases is borne by children and young, potentially economically active men.

Many African countries are undergoing internal strife accompanied by violence and homicide, causing physical disabilities in active members of the population. Children are educationally disadvantaged by the political instability. AIDS fosters an associated resistant and fulminate form of tuberculosis, which is taking an enormous toll on lives, leaving mothers as bread winners and care takers of their families, or leaving orphans living on the streets. The urbanisation process, which is still in progress, results in huge underserviced squatter camps with little access to health services and medicines. Good education, a basic requirement to combat the evils of poverty, is in short supply.

What can be expected for the future for heart disease, and what should we be striving for?

Cardiovascular Journal of Africa

Information has been collected from my own observations in clinical practice over more than 50 years and from discussions with other South African cardiologists. Knowledge has been gleaned from available medical publications, and from the increasing submission of articles to the only cardiovascular journal serving the African continent, the Cardiovascular Journal of Africa. This journal has stimulated workers in this region to record and publish, swelling the data on heart disease in Africa. We invite authors to submit their articles to this journal to more rapidly increase the database.

African priorities for cardiovascular disease

From the background sketched, we can expect the demographic profile of African populations to become more predominantly that of children and the surviving youth. During their formative years they will be largely uncared for and uneducated, and will become progressively weakened owing to disease. The life expectancy of an African male is now 46 years.2 Heart diseases associated with these conditions—namely, RHD and DC, which primarily affect the young, are likely to increase. Diseases of older age groups and Western lifestyles, including obesity, diabetes and the metabolic disease, will be virtually non-existent. Ischaemic heart disease will not be a serious threat as it affects older men. Black populations will have fewer people in this category.

We should be preparing for a significant increase in RHD. Unless socioeconomic conditions can be rapidly improved, the medical profession will only be able to organise campaigns to encourage health education, provide penicillin to patients and engage in interventional surgery. The costs of surgery may well be prohibitive and a philosophical but cruel solution would be that because of the minimal improvement in the quality of life of the children, it would be best to let nature take its course.

With diabetes mellitus being so closely related to poverty, life can be prolonged by the treatment of cardiac failure, by ensuring improved nutrition and with rehabilitation programmes. However, the prognosis remains poor and probably little improvement will be seen in the available manpower and the stability of family life.

It is my contention, like that of Commerford and Ntsekhe,6 that there is no need to prepare for the widespread epidemic of ischaemic heart disease that others have predicted.7 This is most unlikely to occur in the next few decades or during this century. Money and capacity must be diverted to the real and threatening problems—namely, identifying the disease entities, and research on causation and prevention of these diseases, particularly RHD and endomyocardiopathy.

The Pan-African Society of Cardiology (PASCAR) and the Cardiovascular Journal of Africa (CVJA) concluded that the already poor socioeconomic conditions in many African countries are rapidly worsening owing to rampant disease and political strife.8 AIDS has decimated many areas, leaving orphans to fend for themselves. Breadwinners have died, leaving their children without an income for the food necessary for normal growth and development. Lack of education because of inadequate governance undermines attempts to prevent disease. The absence of trained medical personnel leaves communities without guidance and medical support.

RHD, which should have been on the decline or even eradicated, is still the commonest form of heart disease in African countries. The most susceptible are the large numbers of children in the population. DC of uncertain aetiology is the next most common form of heart disease, occurring in all age groups, and it is directly associated with poverty. Where developing populations come into contact with Western lifestyles, the incidence of hypertension, obesity and type 2 diabetes is higher, largely related to culture shock and changing lifestyles.

For these reasons, we need a call to action to provide guidelines for strategies to combat the burden of disease in Africa. The 10-point declaration (box 1) has the endorsement of all practitioners of cardiology in Africa.

Box 1 Declaration for cardiovascular practitioners in Africa by CVJA and PASCAR

  • Consider the forms of heart disease occurring in Africa

  • Provide geographical data on the prevalence of defined disease entities

  • Develop the capacity for appropriate clinical services at primary, secondary and tertiary levels

  • Establish diagnostic and treatment centres of excellence guided by the tenets of evidence-based medicine

  • Provide ready access to all services for all citizens

  • Develop adequate and rapid communication channels between people and institutions involved in services and research

  • Promote active research in both laboratory and clinical cardiology

  • Ensure rapid implementation of relevant research findings

  • Keep in daily contact with worldwide developments in cardiovascular medicine

  • Strictly adhere to internationally accepted ethical standards in all forms of medical practice

REFERENCES

Footnotes

  • Competing interests None declared.

  • Provenance and peer review Not commissioned; not externally peer reviewed.

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