For the majority of people who live in sub-saharan Africa, cardiac surgery is completely out of reach, even for much of the middle class. However, thanks to the work of Dr. Russ White and his highly trained team, open heart surgeries are saving the lives of many needy Kenyans. Tenwek Mission Hospital lies four hours west of Nairobi amongst beautiful hills in a rural village, and thanks to a passionate team of both talented locals and westerners, the mission hospital has been around for almost 100 years, providing primary and tertiary health services to 850,000 people. Tenwek was not unique in its nascency as a missionary hospital-15% of all of Kenya’s hospitals are faith-based. What it is more unique in is its large size, capacity to provide highly technical training to rising cardiac surgeons and perfusionists (people who run the cardiopulmonary bypass machines, which are highly technical), and ability to perform many complex procedures like open heart surgery. Another large, tertiary mission hospital that we visited (Kijabe) is similar in providing both quality medical training and highly specialized procedures (they focus on pediatric neurosurgery); the hospitals will refer patients with specific needs to each other and sometimes even share staff!
Why open-heart surgery?
In order to understand the importance of Dr. White and his teams’ work, it’s crucial to provide a breakdown of reasons for cardiac surgery. In most western nations (and a swiftly growing amount of developing nations), the most common need for cardiac surgery occurs in the adult population due to lifestyle-related chronic diseases-we’ve all heard about people needing a coronary artery bypass graft (CABG) or requiring the placement of stents to decrease the risk of recurrent myocardial infarctions, A.K.A., heart attacks. One out of 100 children are also born with a congenital heart condition, many of which require surgery (this is the field I work in). Many of these babies require open heart surgery in their early years, often when they are less than one year old.
The prevalence of lifestyle-related chronic diseases is swiftly growing in the third world, becoming a major public health concern, as economic and lifestyle changes are resulting in a population that eats more unhealthy food and exercises less. Many Kenyans are moving into urban areas (25% [1]) and are consuming larger amounts of fatty, sugary, processed foods, while still maintaining a large intake of their carbohydrate-loaded staples: a thick, gelatinous white substance typically made from corn (or cassava) that is eaten throughout much of Africa. While the leading causes of death in Kenya continue to be the communicable diseases we commonly associate as “global health problems” (HIV/AIDs, tuberculosis, diarrheal diseases, etc.), it is projected that by 2027, non-communicable diseases (such as cancers and cardiovascular disease) will become the leading causes of death. Indeed, the need for lifestyle-related cardiac surgeries is rising, and more preventative health measures are needed. However, Kenya faces an additional cardiac condition that we do not see in the west: rheumatic heart disease.
An easily preventable condition: Rheumatic Heart Disease
So, what is rheumatic heart disease? Rheumatic heart disease (RHD) is the result of an (one or more recurring) infection from the bacteria group A streptococcus, which attacks and causes inflammation of many parts of the body, most significantly, the heart. Let’s break this down in simpler terms. We know this bacteria as the one that causes the common “Strep throat” (group A streptococcal pharyngitis) for which we take a simple course of basic antibiotics (such as penicillin, which costs around $2-4 for a week’s course in the developing world) for a week-10 days, and rarely have any further need for medical intervention. However, if you do not have access to antibiotics or do not know that you need antibiotics, such as many people in rural parts of Africa, the bacteria from Strep throat will invade the rest of the body, leading to a more serious infection called rheumatic fever. Rheumatic fever, if left untreated (as it often is in many developing nations), will often eventually lead to rheumatic heart disease. This is a slow process; the destruction of cardiac tissue takes some time, so patients often are not aware of what is going on until they are incredibly weak and sick. By this time, the cardiac tissue is really, really damaged: patients will have cardiac arrhythmias (abnormal heart rhythms), infection of the heart valves (thus, the heart is unable to pump effectively), and then, heart failure.
Data collection in many developing nations is still sometimes a bit inaccurate (usually a low estimate) and difficult to obtain, but the best numbers the global health world has are that one in 325,000 children in the world get rheumatic fever every year [2], but in sub-saharan African children, it occurs in one in 175 [3]! In about half of these cases, the heart will be involved; there are roughly 33.4 million people in the world, mostly children between the ages of 5 and 15 years old, living with this debilitating disease in 2018. Without proper treatment, which often requires open heart valve repair surgeries, as many as 12.5% of these people die each year [2], and 7 out of 10 die before the age of 25 [3].
Saving time, money, and lives
At Tenwek, Dr. White and his team are doing remarkable work to save the lives of these young people. We had the opportunity to see one of these triple valve repairs in person; it was incredible to see the surgical precision and quality training which occurred in the operating room. Dr. White has focused on teaching new surgeons who will soon be able to autonomously perform these valve repair procedures. However, training staff takes time-as do cardiac surgeries themselves-and resources do not flow without end as they may often seem to do in western hospitals. No matter how talented, hard-working, and resourceful the staff are, the burden of this disease is greater than the capacity of one quality cardiac facility to handle. A better public health prevention strategy is needed so that Dr. White’s team can focus on existing cardiac cases-and the many new ones that will occur from the rising prevalence of lifestyle diseases and pediatric congenital cases.
So, what can be done? To someone that grew up with access to quality medical care in the United States, it seems like it shouldn’t be that difficult to just provide people who get Strep Throat with simple and cheap antibiotic regimens. Indeed, this disease course poses fewer obvious external difficulties than many other complex diseases common to the tropics like malaria and HIV/AIDs. However, seeing any disease process as one that should be “relatively easy” to eradicate reveals a naivety of how economic and cultural factors can form complex barriers. If it was really that easy, smallpox would have been eradicated much more quickly than the 14 years (1966-1980) it took us to do it, and RHD would no longer be a concern. It’s important to understand our cultural biases, and seek to understand what are the true barriers to getting rid of highly preventable diseases like rheumatic heart disease. I still have a lot to learn from this idea; but by studying concepts like this, I have faith we may come one step closer to not only ridding the world of rheumatic heart disease, but of many preventable diseases like it.
Baby Steps Towards Lives Saved
Currently, basic public health measures to prevent and treat rheumatic heart disease focus on education of patients and providers, improving initial access and follow-up, financial aid for patients who can’t afford even comparatively cheap antibiotics like penicillin, and engaging both the public and private sectors to work together against this disease. Primary prevention has focused on early detection of Strep Throat by integrating better health education into public spaces such as schools and improving health education of existing personnel, such as nurses and clinical officers (a practitioner model that performs a role similar to that of a physician assistant or nurse practitioner common in eastern Africa), in local clinics and dispensaries. For example, one program used an interactive digital model to promote learning about RHD in schoolchildren, while another non-profit taught using simplified animated presentations linking sore throat, rheumatic fever, and RHD, as well as prevention strategies [4]. A hospital in Nairobi, Kenya has also implemented a school-based early detection outreach program in various parts of the country [5]. Secondary prevention has involved interventions aimed at avoiding spread of the infection and treating sore throats properly (including education on ensuring that patients comply with their antibiotic regimen and take their full dosage even after they feel better). Some groups have created RHD family support clubs which promote financial independence in patients living with RHD by helping them achieve this medication affordably and continue life even when they are too weak to work. Finally, if patients develop rheumatic heart disease and do not receive timely treatment, cardiac surgery is their only chance of survival. While research is underway, vaccination development is difficult and slow, so no vaccine is currently available. Clearly, much has been begun, but there is still a long road ahead to effectively reach the millions of vulnerable people who need help preventing this disease.
Rheumatic heart disease is not the only highly preventable disease that otherwise can result in loss of life, but its ease of prevention in a western context and the high price patients who get it pay (both a physical price and actual financial one) makes it worth studying and understanding. Tenwek Hospital is partaking in this fight from both a community level (engaging in preventative activities) and an individual level (providing accessible open heart surgeries to many, many Kenyan children). A continuous effort to learn how to prevent rheumatic heart disease is worth the focus of the global health community, and those who donate their money to work done in global health should also have an understanding of this disease.
–Elly
[1] https://www.rvo.nl/sites/default/files/2016/10/2016_Kenyan_Healthcare_Sector_Report_Compleet.pdf
[4] http://www.wiredinternational.org/kenya/kenya_RHDprojectTestsWiRED.html
Elly & Josh 