Nepal’s experience of community-trials for heart diseases is very recent. Examples include the community interventions initiated by BP Koirala Institute of Health Sciences and by the Dhulikhel Hospital (called Dhulikhel Heart Study)
Heart, Heart attack, heart disease In Nepal out of every one in five adults die because of heart diseases. Nepal, like many other countries with similar economy, has seen an exponential growth of heart diseases and other non-communicable diseases such as cancer, diabetes and chronic lung diseases in recent years. In fact, four-fifths of deaths due to heart diseases occur in low-income countries like Nepal. Higher exposure to cardiovascular risk factors such as tobacco, and lack of access to effective healthcare services including timely detection services, are some of the reasons why these poor countries have high burden of heart diseases. Adding to the fire are the driving forces of non-communicable diseases such as globalisation, westernisation, industrialisation and urbanization, which are strongly linked with changes in individual and societal lifestyle such as tobacco use, alcohol consumption, reduced physical activity and adoption of Western diets that are high in salt, refined sugar and unhealthy fat and oils. These four behavioural risk factors are the foundations on which most cases of heart diseases originate - directly, but mostly because they give rise to metabolic risk factors such as hypertension, diabetes mellitus, abnormal blood lipids and obesity - which in turn, lead to heart diseases. Considering this continuum of risk exposure and disease, heart diseases may be dealt with at various levels. First, we may prevent the behaviour risk factors from forming. These are called as ‘primordial prevention’. Examples include: eating healthy food to avoid being overweight, avoiding tobacco, restricting salt, etc. Second, we may reduce or remove risk factors which are already present. These ‘primary prevention’ strategies include giving up smoking, reducing excess weight, etc. When diseases have occurred, we apply ‘secondary prevention’, which is basically ensuring timely diagnosis and treatment of hypertension, diabetes and heart diseases. Often, people develop complications, and they need, for examples, a bypass operation or a stent in a heart vessel, dialysis because their kidneys are damaged by high blood pressure, or an eye surgery because of diabetes. These procedures are often termed as ‘tertiary prevention’ as they prevent disability due to the complications and avert death. According to the World Health Organization, primordial and primary prevention strategies that also include policy and other environmental changes may bring reductions in deaths due to heart diseases in all countries for less than $1 per person per year, whereas costs of secondary and tertiary prevention approaches such as individual counseling, drug, or surgical approaches are at least several fold higher. The problem is that we are disproportionately emphasizing on the secondary and tertiary prevention strategies, i.e. the focus is on the ‘treatment’ aspect of the heart disease spectrum. Mushrooming of cardiac-centric hospitals and government funding of curative services are examples that the tilt is more towards ‘cure’ than ‘prevention’. These services, indeed, are important. But the question is: are we doing enough for the ‘prevention’ aspects, inadequacy of which will lead to more and more such cases in the future? The answer is: yes, we are starting to! Unlike the ‘curative’ strategies, the ‘preventive’ strategies begin with apparently healthy and high-risk populations. These strategies are best implemented through population-wide approaches. Nepal’s experience of community-trials for heart diseases is very recent. Examples include the community interventions initiated by BP Koirala Institute of Health Sciences and by the Dhulikhel Hospital (called Dhulikhel Heart Study) and these two can be considered as pioneers in primary prevention of heart diseases at community level in Nepal. Similarly, Nepal Health Research Council has recently undertaken a community-wide intervention called the CIPCON (Community-based intervention for prevention and control of non-communicable diseases) Study in Ilam district with the intention of increasing community awareness through health education programmes as well as improving disease detection and care. The HARDIC (Heart-health Associated Research, Dissemination, and Intervention in the Community) trial in Bhaktapur is Nepal’s first absolute health promotional initiative for primordial prevention of heart diseases. This community trial trains mothers of young children to improve their perceptions and practices of diet and physical activity. Health education programmes with focus on diet and salt, training of health care providers and implementing treatment guidelines form key elements in successful programmes. Indeed, prevention of heart disease risk through community interventions has been shown to be both cost effective and scalable in other low-income countries. Policy-makers of Nepal should use experience and evidence generated by such community trials. Needless to say, focusing on the prevention and management of heart risk factors will create more effective treatment, lower costs of care and reduce overall burden of heart diseases in Nepal. Dr. Vaidya MD PhD is Associate Professor in Department of Community Medicine at Kathmandu Medical College and an expert in Cardiovascular Health Epidemiology and Promotion