What Cardiologists Can Bring to Global Health

Michel Ibrahim, MD

"The model of the teaching hospital, which links research to teaching and service is what's missing in global health." – Paul Farmer

As the global burden of cardiovascular disease continues to increase on the international stage, what role does a cardiologist have in global cardiovascular health?

Cardiovascular disease remains a leading public health concern worldwide, with an increasing number of deaths occurring in low- and middle-income countries where health care forms a key determinant of public health and resources are often limited to the affluent population.

This global health story starts with my own journey. My parents are Syrian, and I was born and raised in Haiti. My early medical training was in the Dominican Republic. I quickly developed an interest in pursuing cardiology training in the U.S. in order to bring the most advanced and evidence-based medical care back to Haiti, where poverty, limited access to health care and resources, and a distinct lack of socioeconomic policies contribute to significant health disparities.

The vast majority of individuals within Haiti have experienced the failure of its health care system at some stage in their lifetime. My aunt suffered a large anterior myocardial infarction with resulting debilitating heart failure due to a lack of preventive and therapeutic treatments, including PCI and thrombolysis. My younger cousin was born with complex congenital heart disease that required multiple surgeries, and he has ongoing complex care needs. He travels abroad to Europe or the U.S. to obtain health care which is otherwise unavailable locally and this comes at a significant financial and psychological burden. Despite recent advances in medical care, Haiti remains a third-world country where urgent or emergent medical care remains largely limited and critical illnesses have a high risk of morbidity and mortality. This has spurred my ongoing interest in influencing positive change for resource limited communities such as my own.

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Although my plans to pursue advanced heart failure and transplant fellowship may seem at odds with my interest in global cardiovascular health, certain areas such as my work in peripartum cardiomyopathy (PPCM), which constitutes a significant cause of cardiovascular morbidity and mortality in Haiti, has been at the intersection of my interest in heart failure and global health. We have worked on developing clinical and educational protocols aimed towards primary care physicians and obstetrician-gynecologists in order to facilitate earlier diagnosis and timely management of PPCM and reduce adverse sequelae. Our work also includes specific screening tools to help differentiate heart failure from pregnancy-related symptoms which will enhance early disease recognition, thereby improving outcomes.

PPCM remains highly prevalent among pregnant women in Haiti with a high burden of adverse health consequences. Since women in Haiti play a pivotal role in family and community life, the high morbidity and mortality associated with PPCM not only affects these women but also creates significant health disparities, widening socioeconomic inequities and impacting the stability of the family unit. It can have far-reaching consequences, impacting the physical and psychological well-being of children and the broader community.

In recent times, cardiovascular disease has become the leading cause of adult mortality in Haiti, with hypertension being the most common risk factor. Other common cardiovascular conditions include nonischemic cardiomyopathy, hypertensive cardiomyopathy and rheumatic heart disease. The extent of ischemic heart disease remains unclear in the Haitian population as more specific diagnostics, such as invasive or noninvasive coronary angiography and nuclear stress testing are not locally available. In fact, there is only one stress testing facility to service the entire region of Haiti. Moreover, there are only four Haitian cardiologists currently performing echocardiograms in Haiti.

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I find myself wondering: how can I, an individual cardiologist, contribute to change the current landscape for cardiovascular care in Haiti? Ideally, this would incorporate multilevel systemic reforms targeting health care policies, education and research. In order to truly contribute to cardiovascular care in Haiti in a meaningful and tangible way – beyond the usual clinical acumen – it will require active participation in health care policy reform, educating the next generations of physicians, and creating research opportunities in order to better understand the epidemiology and natural history of cardiovascular disease in Haiti.

Implementation of tailored cardiovascular educational tools targeting medical schools and residency programs throughout the country will be integral to health care reforms. These programs would include learning modules on research methodologies, common cardiovascular disease and contemporary cardiac diagnostics.

From a research standpoint, Haiti lacks institutions and standardized guidelines to help promote medical research. We plan on developing standardized research guidelines with the hope of collecting cardiovascular data throughout the country, which would not only help develop health care policy but also promote more effective resource allocation. U.S. guidelines are based on contemporary evidence derived from the latest clinical trials and expert opinion to guide management of various cardiovascular conditions. However, the available data must be balanced with the patient's clinical context and local factors such as resource availability when considering management decisions. Research is an essential communication tool that will allow us to better understand the pathophysiology and epidemiology of cardiovascular disease among the Haitian population. Moreover, development of local practices will likely fortify knowledge, enhance patient care and improve clinical outcomes.

It will be important to foster collaborative partnerships with policy makers in Haiti in order to establish a tailored health care model that is relevant to Haiti's population, taking into consideration both availability and gaps in resources, the current socioeconomic and politic climate, and cultural awareness when considering educational interventions. By doing so, we hope to continue to bridge the gap in developing countries such as Haiti to promote advances in cardiovascular care at an individual and population level.

Michel Ibrahim, MD

This article was authored by Michel Ibrahim, MD, Fellow in Training (FIT) at Boston University Medical Center in Boston, MA. (Twitter: @DrMichelIbrahim)