Chapter 002. Global Issues in Medicine (Part 10)

In stark contrast to the extraordinary lengths to which patients in wealthy countries will go to treat ischemic cardiomyopathy, young patients with nonischemic cardiomyopathies in resource-poor settings have received little attention.These conditions account for as many as 25–30% of admissions for heart failure in sub-Saharan Africa and include poorly understood entities such as peripartum cardiomyopathy (which has an incidence in rural Haiti of 1 per 300 live births) and HIV cardiomyopathy.Multidrug regimens that include heart failure beta-blockers, ACE inhibitors, and other neurohormonal antagonists can dramatically reduce mortality risk and improve quality of life for these patients. ...
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Chapter 002. Global Issues in Medicine (Part 10) Chapter 002. Global Issues in Medicine (Part 10) In stark contrast to the extraordinary lengths to which patients in wealthycountries will go to treat ischemic cardiomyopathy, young patients withnonischemic cardiomyopathies in resource-poor settings have received littleattention. These conditions account for as many as 25–30% of admissions for heartfailure in sub-Saharan Africa and include poorly understood entities such asperipartum cardiomyopathy (which has an incidence in rural Haiti of 1 per 300live births) and HIV cardiomyopathy. Multidrug regimens that include heart failure beta-blockers, ACEinhibitors, and other neurohormonal antagonists can dramatically reduce mortalityrisk and improve quality of life for these patients. Lessons learned in the scale-upof chronic care for HIV infection and TB may be illustrative as progress is madein establishing means to deliver cardiac therapies over a background of carefulfluid management with diuretic drugs. Because systemic investigation of the causes of stroke and heart failure insub-Saharan Africa has begun only recently, little is known about the impact ofelevated blood pressure in this portion of the continent. Modestly elevated bloodpressure in the absence of tobacco use in populations with low rates of obesitymay confer little risk of adverse events in the short run. In contrast, persistentlyelevated blood pressure above 180/110 goes largely undetected, untreated, anduncontrolled in this setting. In the Framingham cohort of men 45–74 years old, theprevalence of blood pressures above 210/120 declined from 1.8% in the 1950s to0.1% in the 1990s with the introduction of effective antihypertensive agents.While debate continues about appropriate screening strategies and treatmentthresholds, rural health centers staffed by nonphysicians must quickly gain accessto essential antihypertensive medications. In 1960, Paul Dudley White and colleagues reported on the prevalence ofcardiovascular disease in the region near the Albert Schweitzer Hospital inLambaréné, Gabon. Although the group found little evidence of myocardialinfarction, they concluded that the high prevalence of mitral stenosis [sic] isastonishing. . . . We believe strongly that it is a duty to help bring to thesesufferers the benefits of better penicillin prophylaxis and of cardiac surgery whenindicated. The same responsibility exists for those with correctable congenitalcardiovascular defects.2 Leaders from tertiary centers in sub-Saharan Africa andelsewhere have continued to call for prevention and treatment of thecardiovascular conditions of the poor. The reconstruction of health services inresponse to pandemic infectious disease offers an opportunity to identify and treatpatients with organ damage and to undertake the prevention of cardiovascular andother chronic conditions of poverty. 2 Miller DC et al: Survey of cardiovascular disease among Africans in thevicinity of the Albert Schweitzer Hospital in 1960. Am J Cardiol 19:432, 1962. Cancer Low- and middle-income countries accounted for 53% and 56%,respectively, of the 10 million cases and 7 million deaths due to cancer in 2000.By 2020, the total number of new cancer cases will rise by 29% in developedcountries and by 73% in developing countries. Also by 2020, overall mortalityfrom cancer will increase by 104%, and the increase will be fivefold higher indeveloping than in developed countries. Western lifestyle changes will be responsible for the increased incidenceof cancers of the breast, colon, and prostate, but historic realities, sociocultural andbehavioral factors, genetics, and poverty itself will also have a profound impact oncancer-related mortality and morbidity. While infectious causes are responsible for Treatment of cancers is available for only a very small number of mostlywealthy citizens in the majority of poor countries, and, even when treatment isavailable, the range and quality of services are often substandard.