With supplies limited and professionals not in enough numbers, heart attack is bound to take lives
Cardiovascular diseases are the number one human-killer in the West. And this trend is especially present in the 40-60 year age group.
According to an estimate 30 per cent of all emergency hospital admissions are due to cardiovascular problems. In Pakistan, the commonest cardiovascular disease affecting the adult population is hypertension (high blood pressure). If left untreated it leads to heart failure, stroke, kidney failure and death. According to an estimate, there are over 20 million Pakistanis suffering from hypertension. Other common diseases vary from coronary artery disease, heart attack to angina, vascular disease and strokes.
The most lethal cardiovascular disease affecting our population is coronary artery (ischaemic heart) disease which results in angina and heart attack. Not too long ago, the coronary artery disease used to occur mainly in people belonging to the age group 50 and above. In the West, this is still the cases. But over the last three decades, Pakistanis even in their thirties are now the targets of this killer while those in their forties are on the regular hit-list. Coronary artery is responsible for 50 per cent of all deaths in the working-age group and 90 per cent of all sudden deaths.
However, increase in incidence of fatal coronary artery attacks is also helped by the fact that few people, if any, opt for routine medical checkups. Hence the patient is always too late whenever he reaches a doctor.
It can rightly be said that in our country doctors have to deal with a sicker population. Often, patients experience symptoms but usually people have the tendency to ignore milder problems and wait till the disease has taken a serious course. Even then, patients often do not take preventive measures and leave the treatment half-way when symptoms considerably subside and the patient is feeling relatively better.
The disease affecting mainly the adolescents and young adults is rheumatic heart disease. Known as the disease of the poor, it has almost been eliminated from West but is still quite prevalent in our country. It causes swelling of the joints and leaking and narrowing of the valves between the heart chambers.
Diseases affecting children and newborns are mainly congenital malformations of the heart which arises during development in the womb. About one per cent of all children are born with congenital malformations of the heart. The problems most commonly seen are hole in the heart and defective valves. Besides this, there may be a child whose whole anatomy is twisted; the heart may be switched sides, chambers confused or the heart may be incomplete. The cause of such problems is mostly unknown, but certain infections in the mother during pregnancy can also lead to malformations.
Most cardiovascular diseases, if diagnosed in initial phase, can be treated with medication alone and the patient can continue with his day-to-day life. Besides specialized cardiovascular centres which are very few in number, almost all major hospital in the country has a cardiologist available.
Those who can afford private medical care have no problem, they can seek treatment at any centre they choose. But the poor patients have to go to the government run hospitals, which are always over-crowded and the doctors over-burdened; the laboratory services and medicines are not sufficient. Though it is claimed that at public hospitals, patients are provided laboratory services and medicines either for free or at a very nominal charge, often the patients are asked to get the tests done privately and even purchase the medicine themselves. This discourages the poor patients, most of whom can hardly afford to arrange two square meals for his family.
How can a person continue with the expensive treatment when he does not have enough to eat? Perhaps this is the one reason for the large dropout rate, and high rates of emergencies and sudden deaths.
Another factor for non-compliance can be lack of the awareness about the seriousness of the disease. People need to be educated about health in general and cardiovascular health in particular.
In certain cases even if surgery is not the only option it is more beneficial than medical treatment, e.g. it is better to have a bypass done when a blockage in vessels is detected rather than risk an attack, or bear constant problem. But unfortunately, surgical facilities are not widely available, specially for the poor and the downtrodden. As with the medical option, those who can afford can avail the opportunities at any of the major hospitals performing the required procedure.
But for there are millions who can’t afford to pay the exorbitant charges there are limited facilities. There are only a few established centres for cardiac surgery in our country, where advanced surgery is being done.
NICVD, Aga Khan University Hospital, Civil Hospital Karachi, Ziauddin Hospital, Punjab Institute of Cardiology Lahore, Armed Forces Institute of Cardiology (AFIC) Rawalpindi and Lady Ready Hospital Peshawar are few of these.
Some small hospitals are also performing simpler procedures but even there the cost is too high for the poor.
There are a very few centres in the public sector where such surgeries are performed. But here too it is not hundred per cent free of cost. The National Institute of Cardio Vascular Diseases (NICVD) has to take the bulk of the load, as it is the major cardiovascular institute of the country, which provides care to almost half a million patients each year, from all over the country.
According to Dr Azhar Farooqui, Director NICVD, out of the half-a-million people, only 10-15 per cent are fully paying patients — and they too are charged on a no-profit basis — while 70 per cent are general ward patients who are given treatment at 80 per cent subsidized rate, and 20 per cent are zakat mustaheqeen.
Patients who come at the OPD are charged only Rs20 which includes examination by a doctor, ECG and medicine — in most cases for a month. Patients who come to the emergency are charged Rs100/- for all these services. Though, a bypass costs Rs150,000/- for paying patients here, poor patients are charged only Rs20,000/-.
The Department of Cardiac Surgery at the CHK, which started functioning in 2000, is another place which claims to provide completely free of cost heart surgery to the less privileged. The DCS meets its costs mainly through donations by philanthropists.
Here, a special appreciation for philanthropists as well as those arranging donations, considering the fact that heart surgery is quite an expensive affair: coronary bypass costs about Rs250,000 to Rs300,000, palliative surgery needs Rs30,000 to Rs60,000, the cost of an artificial valve is about Rs60,000 while the surgery costs about Rs100,000 to Rs300,000.
When we are talking about cardiac surgery we have to differentiate between adult cardiac surgery and paediatric cardiac surgery. While adult surgery is itself quite sophisticated, surgery in children is one of the hardest because of the delicacy and sophistication involved and requires a specialized setup and specially trained surgeons.
Here too, Pakistan has very few paediatric cardiac surgeons while there isn’t any paediatric cardiology unit in the country. We have yet to have the required setup for paediatric cardiac surgery at any of the major hospitals.
Though sophisticated procedures like switching of arteries in children are not done, most procedures such as plugging of holes, correction of defective valves, etc. are routinely conducted.
Dr Farooqui says that at the NICVD, holes have been plugged in thousands of children since its establishment in 1963. Likewise correction of defective valves is a routine procedure. The only limitation is that total correction is not possible in newborn and children under one year of age. To them only palliative treatment is offered. Nevertheless, the CHK and AKUH have operated children as young as six-days-old and two-days-old, for correction of congenital heart problem.
To treat such young children a very sophisticated setup is required. It is not only a matter of expertise, expertise can be developed if the resources and set-up is available, but in a hospital already facing severe budgetary constraints it is not possible to establish a whole new set up with all the sensitive equipment etc.
According to Dr Farooqui the priority at the NICVD is to maintain the present services as the hospital is already working at almost double its capacity.
It is unfortunate that in our country there are very few paediatric cardiologists. There is an urgent need to increase the number of such professionals. It cannot be achieved overnight. That needs long term planning and would involve a strong infrastructure for facilities to train doctors, paramedics, technical facilities etc.
But the picture is not all that bleak. We have the case of baby Alina. The three-year-old is suffering from a rare condition known as “Absent sternum with exposed heart”. Doctors at the NICVD performed a delicate procedure to reconstruct an artificial sternum at the gap exposing her heart. Not more than 10-20 such cases have been reported worldwide and the procedure adopted in baby Alina’s case was the first of its kind in South Asia. The successful surgery is a ray of hope, showing that our doctors are not less than any other in the world. They are capable of performing the most sophisticated and unique procedures if the need arises; even the lack of resources cannot come in the way of providing care to those who find it difficult to meet the expenses. Our people do not need to go anywhere; they can find a solution to their problems in their own country.
There is a need to establish more cardiac hospitals in the public sector to provide coronary care to the burgeoning population, and services are not centred at a few centres. There is a need for the well-to-do people to come forward and help develop facilities, as it is not possible for the government alone to provide free medical care to the entire population.
In a developing country like ours it is very difficult for the government with its limited resources, to provide free medical care to the entire population. It is imperative that efforts are made to seek the support of philanthropists.
There is no harm in charging those who can afford to pay. It is their moral obligation to not seek free treatment so that the burden on the public facilities could be lessened. We have the example of AKUH which charges those who can afford to pay and the extra funds are diverted to give subsidies to those in need. Dr Hasanat M. Sharif, Cardiovascular Surgeon and Assistant Professor at Department of Surgery, AKUH, is of the opinion that other centres specially in the public sector should also adopt such policy so that they have more funds for the needy. For this a mechanism has to be evolved to assess who is needy. No hospital can run for long just on donations, and at some point they will have to think about charging those who can afford. No patient should be turned down for want of resources.
With supplies limited and professionals not in enough numbers, heart attack is bound to take lives 
