Medical, Socialogical and environmental issues in cardiovascular disease epidemiology, prevention and rehabilitation.
Gundu H.R. Rao
Founder, Secretary General, South Asian Society on Atherosclerosis and Thrombosis
Professor, Lillehei Heart Institute, University of Minnesota, USA
South Asians (Indians, Pakistanis, Bangladeshis and Sri Lankans) have the highest incidence of coronary artery disease (CAD) compared to any other ethnic group in the world. To create awareness, develop educational and preventive programs, I started a society (South Asian Society on Atherosclerosis and Thrombosis, SASAT) in 1993 at the University of Minnesota. Since then, we have organized international conference on "Atherosclerosis and Thrombosis", every other year in India. We also have published two books on the subject (1. Coronary Artery Disease in South Asians: Epidemiology, Risk Factors and Prevention. Editors: Gundu H. R .Rao and V. V. Kakkar, JP Medical Publishers, New Delhi, India, 2001; 2. Coronary Artery Disease: Risk Promoters, Pathophysiology and Prevention. Editors: Gundu H.R. Rao and S. Thanikachalam, JP Medical Publishers, New Delhi, India. 2005), and a third one is under preparation (Diabetes Mellitus (Type-2): Epidemiology, Risk factors and Prevention. Editors: Gundu H. R. Rao and V. Mohan, JP Medical Publishers, New Delhi, India). SASAT is currently raising funds to facilitate the development of a project in India, called "India Heart Watch".
The World Health Organization (WHO) estimates that incidence of diabetes (type-2) will increase by 200% in India in the next two decades. The WHO estimates 60% of the world's cardiac patients will be Indian by 2010 and half of all deaths in India, probably will be due to CAD by 2015. According to a recent communication (September 20, 2005) by Amitava Banerjee and Bhargavi Rao on ProCor platform ( cardiovascular diseases (CVDs) are not included in the top priority list in the Ninth-Five Year Plan for Health, prepared by the Government of India. This seems to be true of the World Health Organization agenda as well. Indeed, it was India that was responsible for requesting the WHO to initiate a cardiovascular program some fifty years ago. At that time, probably there was no hard data available to suggest that this disease was a major epidemic or a health burden. However, now it is very well recognized that Diabetes, CAD and Cancer constitute a major health burden for the developing countries. Indeed, Cancer and Cardiovascular Diseases together, account for over 72% of the global mortality from non-communicable diseases.
At a time like this, when immediate action is needed, there seems to be very little interest in India to create a national platform or develop action plans for primary prevention and integrated treatment of these chronic and malignant diseases. I have been watching the growth and activity of the non-communicable disease section of WHO, and I do not see any hope for its expansion or a greater role. I strongly feel the need for a renewed effort from professionals, individuals with interest in community health, NGOs, and professional societies, to develop their own action plans and find ways and means to implement such plans. Furthermore, every attempt should be made to convince the decision making bodies in India, to establish a national platform for the fight against non-communicable diseases. Individual Nations should approach WHO, and request them to prioritize their programs and play a significant role in alleviating these chronic and malignant diseases.
In a recent communication to ProCor, Doctors Banerjee and Rao reviewed the Global picture of CVD, assessed the impact of these diseases on the workforce potential for economic development in the developing nations. They also addressed the need for increased health care workers, funds and infrastructure to improve health care delivery in India. Based on their views on this subject they felt that National strategies to meet the objectives must be developed and effectively implemented by individual countries and on a regional basis. In the same article they also mentioned lack of adequate facilities for diagnosis and treatment and the unaffordable cost of medical care. According to them there are about 35 well-equipped centers for modern diagnosis and treatment located in 6 major metropolitan cities. In these facilities cardiologists perform approximately 40,000 angioplasties a year.  Compared to the national need of specialty hospitals for doing interventional procedures, what is available (less than 50 centers) at present is inadequate. In addition, thousands of children are born every year with congenital heart defects. Only a small percentage of these children get needed medical care.
Doctors Banerjee and Rao recognize such problems and raise a pertinent question. What is adequate or appropriate, especially in countries such as India, where health care facilities are distributed unevenly?  It is rather difficult to answer this question. However, each group providing much needed health care in India, should develop their own novel methods, to meet their particular need. For instance, Dr. Madhavan a consultant cardiologist, Apollo Hospital, Madurai, India  suggests his idea for  a “model clinic” in a letter to editor: Prevention & Control 1:21, 2005. His model clinic is a small room, equipped to measure body mass index (BMI), check blood pressure and urine sugar by dipstick by a trained volunteer. He estimates the cost to run such a clinic to be less than USD100 per month. The cost per patient is estimated to be 20 cents. In his letter he also mentions of another similar clinic already in operation in Tamilnadu.
The clinic in Karaikudi, Tamilnadu, India is established by Mrs. Shakuntala Chockalingam of Vancouver, Canada. With funds from Somayya Foundation, a private philanthropy (Letter to the editor Prevention Control 1, 155, 2005), trained volunteers screen individuals at risk for hypertension. She wants to expand her program to include diabetes and provide blood glucose monitoring. However, adding such a simple screening test also costs additional money. Although, I hear people saying that these tests could be done for as low a budget as 10 rupees per assay, I have not found reliable answers or the cost-effective methods. SASAT is working on several ideas for developing low-cost diagnostic methods for monitoring blood pressure as well as blood sugar.
Mohan et al from Madras Diabetes Research Foundation (, Chennai, India  have recently described a simplified Indian Diabetes Risk Score (IDRS) for screening Undiagnosed Diabetic Subjects (JAPI 53:759-763, They used just four risk factors to come up with IDRS: age, abdominal obesity, family history of diabetes and physical activity. They concluded from their studies that IDRS is useful for identifying undiagnosed subjects in India and could make screening programs more cost effective. Dr. Shashank R. Joshi of Department of Endocrinology, Seth GS Medical & KEM Hospital Mumbai, India, has reviewed this subject in the same journal (JAPI, 53:755-757, 2005). He concludes that IDRS has a sensitivity of 72.5% and specificity of 60.1% and is derived based on the largest population based study on diabetes in India CURES. Mohan’s group in Chennai is expanding their CURES study to reach over a million people at Chennai with awareness program (Prevention Awareness Counseling Evaluation, PACE) and has targeted screening of over 200,000 individuals for blood sugar free of charge. The advantages of IDRS developed by this group are its simplicity, low cost and are easily applicable for mass screening programs.  Many of us feel that IDRS should be tested in other population based studies in India, both rural and urban.
Banerjee and Rao in their communication “integrated treatment and prevention –ischemic heart disease in India” describe a proven, successful community health model by Aravind Eye Hospital, as an example of delivering affordable health care to the rural poor. This group of hospitals (7) has over 4000 beds and has performed 2,225,225 cataract surgeries.  According to reliable sources, almost 70% of all surgeries performed are free of charge. They discuss the applicability of this model to cardiology services and suggest their own proposal, which incorporates three principles from the Aravind model to cardiovascular disease in India, using the private specialist services to improve treatment and prevention services.
In the proposed model, the mobile unit includes: 2 ambulances, 3-4 paramedical staff required (including drivers), computers, BP monitors, height/weight measuring capabilities, glucose monitors, cholesterol/lipid monitoring capabilities, basic blood and urine investigation capabilities, communication to hospitals and physicians via cell-phone and internet, access to internet for information and protocols, emergency cardiac drugs, protocols and automated defibrillators (AEDs), and tele-medicine capabilities. Each village (comprising of up to 5000 people) will be visited every 2-3 weeks. The aim will be to screen all people over the age of 40 for CAD and its basic risk factors. In this way the mobile unit is used to recruit people to prevention and refer those requiring treatment to the cardiology hospital. The patient records are fully computerized using EMIS (Egton Medical Informations System). They also describe a new initiative in Coimbatore for reproductive health service which is “piggy-backed” onto existing rural diabetes screening clinics. The novelty of the approach according to them is that it is much more patient-centered without necessarily involving more cardiologists than exist now.
Since the model program described by Doctors Banerjee and Rao is based on the Aravind Eye Hospital Model, in this article, I will  briefly describe two ongoing projects in Bangalore, India that have focused their efforts on serving the poor in the area of diabetes and CAD. One is a high-tech project conceived and promoted by Dr. Devi Prasad Shetty, Managing Director of Narayana Hrudayalaya (Narayana Hrudayalaya Heart Hospital: Cardiac Care for the Poor, Harvard Business School. To obtain this article call 1-800-545-7685 )  and the other is a low- tech project conceived and promoted by Dr. S.S. Srikanta, director SAMATVAM, a Diabetes and Endocrinology Clinic ( I met Dr. Devi Prasad Shetty when he joined Manipal Heart Hospital in Bangalore, as the Managing Director. At that time, I was accompanied by the President of Children's Heart Link, an NGO organization in Minneapolis, who wanted to collaborate with this group. Children's Heart link staff, volunteer doctors and nurses have gone several times since that time, to Bangalore and performed several hundred cardiac procedures for deserving children suffering from heart problems.
In the year 2001, Dr Shetty started his own Heart Specialty hospital called Narayana Hrudayalaya (NH: means God's Compassionate Home) in Bangalore. Now it has more than 500 beds and has 10 operating theatres and two cardiac catheterization units.  Since the inauguration of this facility they have completed over 12,000 open-heart surgeries and half of these are pediatric. Because of the excellent reputation of the staff at NH, large number of wealthy patients gets admitted for cardiac procedures. Hospital has developed a scheme called Karuna Hrudaya (Kind Heart), which helps those financially constrained. They do open heart procedures for these patients, for 65,000 rupees ($1400) and absorb the remaining cost from funds made by charging those who can afford higher cost. Just like the way Tom Friedman describes of a flat world in his recent book (The World is Flat), Dr Shetty talks about his strategy as "Wal-martization of healthcare". He has developed several novel schemes to reduce the cost of procedures as well as treatments. With the help of Indian Space Research Organization (ISRO), Bangalore, he has developed an excellent telemedicine program to provide cardiac care for the poor. He has set up nine cardiac care units (CCUs) across India, linked to NH. Indeed, when I was with him last month he was trying to set up a CCU at the Bangalore Hospital. Since Bangalore is the hub of IT, he has developed software program that allows ECG images to be scanned and transmitted via internet. With the initial success, the State of Karnataka has planned to sponsor 29 additional CCUs. In addition to training doctors, the staff of NH has trained over 700 nurses. Training included minimum of six month period of critical care. Through this high-tech medium even the GPs have access to the expertise available at NH. Since the inception in 2001 NH has performed over 10000 tele-consultations. Both in Bangalore and at Calcutta they have mobile cardiac diagnostic laboratories, which go to rural areas as remote as 800 kms away on weekends. On an average each camp screens 400 people a day on a no fee basis. These programs are sponsored or supported by various NGOs like Lion Club, Rotary International and IT companies.
Of all the innumerable things happening at this hospital, the most novel development is an insurance scheme for the care of the poor. The scheme is called Yeshasvini. NH has set up a health insurance scheme for 1.7 million farmers in the State of Karnataka. This scheme was launched in 2002, for farmers belonging to state cooperatives. The way it works according to Ms Lakshmi Mani,
Manager, Charitable Wing NH, is for 5 rupees (one cent) a month, cardholders will have access to free treatment at 150 hospitals in 29 districts in the State, for medical procedures costing up to 100,000 rupees. According to the staff less than ten percent of the cardholders would require medical procedures, therefore, the total funds collected will cover the cost of the treatment for those in need.
Dr. S. S. Srikanta is the medical director of SAMATVAM: Endocrinology Diabetes Center in Bangalore. He was trained in the USA at the prestigious Joslin Diabetes Center, Harvard Medical School. Samatavam is a non-profit, charitable trust dedicated to the promotion of human welfare through service of health care, education and research. The special strength of this organization includes merited faculty and staff, on going international collaboration, sincerity and dedication in public service and human good.  The diabetes care unit of this clinic currently provides 2 special health care programs targeted to help people with diabetes and their families to obtain the best in comprehensive health care. These programs are administered by a “team” of highly experienced diabetologists, dieticians and nurse educators supported by laboratory services and consultant referrals. They run an outreach program every weekend. They screen at risk individuals for diabetes. These screening programs, which include blood sugar monitoring, are free of charge.
It will be wonderful to develop a community-based comprehensive health care delivery system for all the rural individuals in India. Recently (Aug 23, 2005) National Rural Employment Guarantee Bill of 2004, was passed by Parliament of India. The Bill guarantees at least one member of every family, 100 days of work, at a minimum wage of 60 rupees per day (500 rupees a month per family). According to the latest estimate, 720 million people live in rural areas in 600 districts. The funds allocated (>12,000 crores) will only cover 200 districts including 150 districts under the Food for Work Program. This simple example reveals the magnitude of the problem. Even at the level of Government, we do not have resources to provide work for all the individuals at rural areas. Therefore, it is hard to envision a national platform or action plan in the near future that will develop a comprehensive prevention and integrated treatment strategy for the non-communicable diseases in India. Before concluding this article, I would like to include a well known saying by Margaret Mead, “Never doubt the capacity of a few dedicated individuals to change the world; in fact, it is the only way it ever has.”
Can such a comprehensive program be developed by public-private partnership? Of course, it can be done, provided we net work with like minded groups and create a suitable dedicated platform. In a recent article in the journal of Science (309:401-404, 2005) Morel et al express their viewpoint on “Health Innovation Networks to Help Developing Countries Address Neglected Diseases”.  Improving health of the poorest in the developing world depends on the development of many varieties of health innovations, including, new drugs, vaccines, devices, diagnostic techniques, preventive programs, and integrated treatment programs. According to the authors of this article, some countries are more scientifically advanced than others and are starting to reap benefits from decades of investments in education, health research infrastructure, and manufacturing capacity. They refer to these as innovative developing countries (IDCs). The India-Brazil-South Africa Dialogue Forum, established in June 2003, has a focus on intellectual property, access to medicine, (traditional/alternative), R&D on vaccines and pharmaceutical products to address national health priorities. India has the largest number of FDA approved pharmaceutical companies outside of USA. Since there is a great opportunity to generate revenue in the health care sector in these IDCs, pharmaceutical companies as well as IT companies (Ranbaxy, Reddy’s Lab, GE Medical, Wipro-Biomed, Manipal-Acunova-Life, to name a few) can initiate novel programs to develop comprehensive health care delivery packages for the urban as well as rural populations.
If a private specialty hospital like NH can develop a successful health insurance scheme for the farmers, I have no doubt in my mind, that public-private partnership or some other venture organization also can develop insurance schemes for urban as well as rural populations. Let us assume that we develop two insurance schemes, one for the rural with 10 rupees per month per person, and another for urban with 100 rupees per person per month. Then we will have a total of  120 or 1200 rupees per year. That is about 3 USD or 30 USD per year. If we insure 10 million people then we will have 3 million or 30 million dollars per year. Indian population is young (average 25 years), and as such only 10% of the insured individuals need any medical procedures. Therefore, as is the case in all insurance schemes, the money saved by insuring the healthy individuals will not only pay for all the procedures needed for the not so healthy, but also will pay for the  development of  all other components of a comprehensive health care delivery package. Components of a comprehensive package according to my vision will include the following components: Bioinformatics, health insurance, outreach programs, cost-effective diagnostic procedures, counseling, life style changes, novel drug development, cost-effective integrated risk management and treatment, cost-effective interventional procedures, rehabilitation-post stroke and rehabilitation-post myocardial infarction.
Cardiovascular disease is preventable. We are aware of the risk factors that promote this chronic disease.  As I mentioned during my conversations with President A.P. J. Kalam of India, during a video conference at SASAT 2004 conference in Hyderabad, CVD is a challenge of global proportions. Like his “Wings of Fire” missile project, to be successful, it needs dedicated leaders, teams of specialists, volunteers, public-private partnerships, a national platform and well thought out action plans.
Reprinted from with permission.