By Kaboni Gondwe and Shaoqing Ge
The heart is an interesting organ in the body; it beats continuously even when asleep. Such a simple thing that signals the presence of life during embryonic period, signals the end of life at its cessation. While important to our survival, cardiovascular disease remains a silent killer. We have come through decades where heart disease was thought to be an issue for people who were overweight and obese or a problem for people with high socio-economic status. However, the burden of heart disease in global affecting people from all walks of life.
Heart disease has thus been described as the number one killer globally. And it is the 2nd leading cause of death in developing countries.
Dr. Bloomfield mentioned how developing
countries are challenged by the dual burden of communicable and non-communicable
diseases. The epidemic of non-communicable diseases such as cardiovascular/heart
diseases has dramatically increased in recent years. In countries where
resources are limited and are unaware of their risks for heart disease the
people die without understanding why someone who looked perfectly normal could
just collapse one day and die. In Malawi, most sudden deaths in the rural areas
are usually thought of as witchcraft and gaining weight was for a long time
viewed as a sign of wealth and peace. There was an incident where a man in the
urban area felt a sharp pain in his chest while driving, he rushed to the
hospital and he was in time to get the best treatment. This man was educated
and was aware of the signs and symptoms, thus he knew he needed to seek medical
attention and he survived. Other cases form the rural start with complaints of
chest pain and headaches. People eventually die in their sleep with blood
coming through their nose. “zitheka
bwanji munthu oti anali bwino bwino dzuro lero muziti watisiya, ufiti” (How
could someone who was fine yesterday die today, this is witchcraft). This lack
of sensitization of the signs and symptoms is bound to result into more deaths
that could have been prevented.
The problem of increasing cases of cardiovascular
disease has equally affected developed countries like China. In China, the
prevalence of diabetes among Chinese adult population has increased from less
than 1% in 1980 to 11.6% in 2010 (Xu, Wang, He,
& et al., 2013). China has the largest population in the world, with
an estimated 113.9 million diabetic adults (Yang
et al., 2010). Cardiovascular disease has also become a chronic problem
for Chinese population and a challenge for older adults whose health is already
diminishing. Shaoqing’s grandmother, an 80 year old Chinese lady, has lived
with hypertension for 30 years, had stroke around 20 years ago and developed
atrial fibrillation around 5 years ago. She now controls her situation with
medicines and exercise regularly. However this was not the case when she
initially diagnosed with hypertension, she was a regular smoker back then and
she absolutely had no idea of self-management. The only thing she knew was she
would not die soon only with hypertension. This situation was not changed until
she had that stroke tragedy; she then realized the importance of
self-management, such as diet, exercise and medicine. However, as age grows,
the situation kept deteriorates to arterial fibrillation but just slower.
These stories reveal that behavior change
will not happen suddenly; it is highly related to education and self-awareness.
Strengthening education is especially valuable for countries with limited
resources, which is the case for most developing countries. Back 30 or more
years, people were not aware of the relationship between smoking, salty diet
and cardiovascular diseases, now even though this can be a common sense to some
people but can still be unfamiliar to people in certain lower-income countries
and areas. We believe this is both a challenge
and opportunity for stakeholders, practitioners and global health researchers,
to provide information, technology, and treatment.
References
Xu, Y., Wang, L., He, J., & et al. (2013).
Prevalence and control of diabetes in chinese adults. JAMA, 310(9), 948-959. doi:10.1001/jama.2013.168118
Yang, W., Lu, J., Weng, J., Jia, W., Ji, L.,
Xiao, J., . . . He, J. (2010). Prevalence of Diabetes among Men and Women in
China. New England Journal of Medicine,
362(12), 1090-1101. doi:doi:10.1056/NEJMoa0908292
Thank you Kaboni and Shaoqing for sharing. One follow thought related to the CVD burden in developing countries. I totally agree that education is critical in terms of behavior change. However, other factors such as motivation and social norms should also be considered while promoting health behaviors. For example, it is pretty inappropriate for you to turn down a cigarette when someone is offering you one, even if you don’t want to. In this particular case, people may be award of the impact of smoking on cardiovascular diseases but lack of the motivation to change their behaviors.
ReplyDeleteThe battle against NCDs adds to the huge burdens that LMIC are already facing. It is key to consider the impact of cost-effective measures. Most of them can cost nothing to governments. Some of them can be quite controversial: we only had time to talk about tobacco control but I am glad we will continue that discussion with Professor Anthony So in a future class.
ReplyDeleteBut this made me think about a range of regulations that governments can enact in the fight against obesity. I was recently in Ecuador, where a label system using colors to classify packaged food was implemented in 2014. Here is how it looks:
Although food labels are widely used to convey information to consumers, research has evidenced that giving more information is not enough. Labels have to be easy to read: people are not able to process too much information and make rational decisions, specially when it comes to decide what food to eat! Let’s not add the problem of prices for the moment.
Color-based labels have been largely used in other countries. Here is an example of how they look like in the UK:
What impressed me about the Ecuadorian version was the way in which information could be easily understood. I consider myself a rather well-informed consumer and yet, I was surprised about the quantity of sugar, salt and fat in some products that I would have considered “healthy”.
Of course governments can and should go further in some cases. One example we recently studied in another course was a controversial measure that Mayor Bloomberg wanted to endorse in NYC. During his term he succeeded at implementing measures to promote healthier lifestyles specially for the poorest and working class populations. The trans fat ban and the initiative to reduce the consumption of salt were highly successful. But the size limit on soft drinks largely failed. It was opposed by many and then rejected by a Court.
Professor Lawrence Gostin defines these examples as the “new” public health. Countries (all low, middle and high income) have a great responsibility in enacting “smart”, “novel” and science-based regulations that can promote health. In the context of NCDs this is a cost-effective approach that LMIC should be aware of.
You can read Professor Gostin’s article here:
http://scholarship.law.georgetown.edu/cgi/viewcontent.cgi?article=2294&context=facpub
Sorry, here's how the color-based label looks like:
ReplyDeletehttp://elpoderdelconsumidor.org/saludnutricional/aprueba-ecuador-etiquetado-de-semaforo-en-alimentos/
Thanks Kaboni and Shaoqing for your introduction (and great video) for Dr. Bloomfield’s CVD presentation and blog post.
ReplyDeleteI enjoyed Dr. Bloomfield’s presentation, and had heard him present on his work in Eldorat, Kenya previously. I think both of your vignettes bring to light such poignant and important things for those of us interested in global health to remember – education and prevention can go very far. Yes, invasive and expensive diagnostic and therapeutic techniques can save lives and, like Dr. Rice mentioned in regards to childhood congenital heart disease/anomalies, can drastically change health outcomes. However; as your two stories show, a little education on the signs and symptoms of a heart attack in rural Malawi, or behavior modification in China, can save, or improve morbidity and mortality.
Hanzhang and Rosa bring in great points that local implementation are crucial and understanding the context and culture may make an intervention or project completely fail. This is a recent Guardian article about failed projects in Malawi after donors left when money dried up…unfortunately this is not new news to most of us who are from LMICs, traveled abroad, worked for NGOs, or even just follow the news, but I think its worth a quick read!
http://www.theguardian.com/global-development-professionals-network/2015/sep/28/ngos-in-malawi-what-happens-when-donors-leave?CMP=new_1194&CMP=
Brittney Sullivan
This comment has been removed by the author.
ReplyDeleteThank you ladies for your inputs on the discussion. The discussion is very inspiring to read.
ReplyDeleteHanzhang really brought up an important issue that happens all the time in the real life. I believe Hanzhang and I have known this very well as we were from China, where people are supposed to show a lot of respect back to the person who offered them with something, or it can be impolite and conveys the idea that you hate him/her.
Social norm is so deeply implanted in the history and culture, and very specific to each country, so it is challenging to address, especially for global NGOs. From here we can organically link back to what Rosa and Brittney brought up, that the government's intervention and collaborations with the community are highly required. Still, these are all challenging. As Rosa mentioned, some government intervention meant well but still can be failed because of its conflict with social norm and people's expectations.
The news that Brittney mentioned states a real problem that brings great obstacles to forbid NGOs from being effective in a long term. Again, this refers back to education, which will help to increase local people's awareness, improve their behaviors, and thus preserve the benefit generated by the work of NGOs.
Again, thank you for the discussion, and hopefully these crucial issues could be well targeted in the LMICs.
Thank you ladies for your inputs on the discussion. The discussion is very inspiring to read.
ReplyDeleteHanzhang really brought up an important issue that happens all the time in the real life. I believe Hanzhang and I have known this very well as we were from China, where people are supposed to show a lot of respect back to the person who offered them with something, or it can be impolite and conveys the idea that you hate him/her.
Social norm is so deeply implanted in the history and culture, and very specific to each country, so it is challenging to address, especially for global NGOs. From here we can organically link back to what Rosa and Brittney brought up, that the government's intervention and collaborations with the community are highly required. Still, these are all challenging. As Rosa mentioned, some government intervention meant well but still can be failed because of its conflict with social norm and people's expectations.
The news that Brittney mentioned states a real problem that brings great obstacles to forbid NGOs from being effective in a long term. Again, this refers back to education, which will help to increase local people's awareness, improve their behaviors, and thus preserve the benefit generated by the work of NGOs.
Again, thank you for the discussion, and hopefully these crucial issues could be well targeted in the LMICs.
Thank you for your acknowledgement on the importance of education. I think especially with the prevalence of NCDs rising so rapidly, the governments should make significant efforts to address this issue. More specifically, preventing rather than treating the diseases should be the focus of the governments. It is in their best interest to do so because otherwise they will be burdened with more medical expenses and lose productivity in their workforce due to NCDs. The governments could initiate a short, effective campaign with many diagrams to ensure that those who are illiterate are not excluded in this education and awareness intervention. I also think that the role of primary care should be emphasized more with regards to NCD prevention and control. With weak infrastructures, this task may be difficult, but perhaps this could be an effort spearheaded by an NGO. Increasing primary care in general will help prevent and treat NCDs as well as initiate NCD awareness and education.
ReplyDeleteThank you Kaboni and Shaoquing
ReplyDeleteI think Yujong makes a good point about the role of primary care in NCD prevention. There is a shortage of primary care physicians globally. The few primary care physicians are ill equipped to address the emergent threat of a growing NCD burden. Fortunately advances in technology now offer health care providers and the population at large an opportunity to leverage use of devices such as wearable bands to track habits and lifestyle, including early identification of persons at greatest risk. Hopefully in the near future, health policy will evolve to integrate exercise and daily activity monitoring as a new tool in waging the war against NCDs.
Thank you for your valuable posts. I agree that education is incredibly important and would also like to acknowledge the power of clear dissemination of information to the public through campaigns and share a story from Ukraine.
ReplyDeleteA Ukrainian advocacy group called Life worked with the Minister of Health to provide support for legislation to make Ukrainian public cafes, bars, and restaurants smoke-free. They launched a two year multi-media campaign and worked with the owners of these public spaces to promote the campaign within their establishments. They found that the majority of Ukrainians were actually in support of the legislation passing but did not know how they could make an impact. This campaign catalyzed the support of the people and led to the passing of the legislation in 2013. In a follow up assessment Life found that 90% of all public establishments included in the bill (cafes, bars, restaurants, etc) were adhering to the smoke-free policy and only 9% of citizens were violating it. This is a huge stride for Ukraine as 90% of deaths in the country are attributed to NCDs with cardiovascular disease being the number 1 killer. Smoking and tobacco use is the highest risk factor for CVD and in Ukraine over 35% of the population smokes cigarettes, the fourth highest rate of smoking in the world.
Something as good as this campaign has started to combat the amount of smokers and rate of second hand smoke experienced and is an example of how education and campaigns can be successful.
The following breeds are generally free of the genetic disposition toward heart disease.
ReplyDeletehttp://www.bluesupplement.com/womens-multivitamin/
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