NATIONAL 4 - (Spotlight Weekly)

‘Prevention Programs Are Vital To Controlling Cardiac Diseases’

—Dr. BHAGWAN KOIRALA

BHAGWAN KOIRALA is one of the renowned cardiac surgeons of the country. Director of the Shahid Ganga Lal National Heart Center, Koirala is also associated with the Tribhuvan University Teaching Hospital (TUTH). Trained in Ukraine, Bangladesh, United States and Canada, Koirala is known for establishing the regular open-heart surgery unit in the TUTH since 1997. He spoke to KESHAB POUDEL and SANJAYA DHAKAL on various issues relating to cardiac ailments in the country. Excerpts:

How do you find the situation of heart disease among Nepalis?

In Nepal, we really do not have a nationwide survey that would give us the exact number of heart patients. But we do have small-scale studies and sample surveys, which indicate that there are hundreds of thousands of cases of heart diseases — a majority of which would need some kind of surgery at some point of time. There are three broad categories of heart diseases — congenital, rheumatic and ischemic. Congenital are the ones that comes by birth and the prevalence of this kind of disease is universally similar in terms of incidences. It is said that 1 percent of all live births carries congenital heart disease. That means if there are 400 children born in Prashruti Griha today — that is how it is — there would be about 4 children born with heart disease everyday in Prashruti Griha itself. If you consider the total number of births that occur in one year in Nepal, 1 percent of all them would be suffering from heart disease. There would be an accumulation of so many children with only congenital heart diseases. The next category is valve disease or rheumatic heart disease. It is born from the complication of throat infection. According to some sample surveys in Nepal, this disease is present in 1 in 1000 school children. We cannot translate that into a usual population of Nepal because the population sample is different. But we do have figures from India and Bangladesh where it was shown that rheumatic heart disease is found in 3 in 1000 population, which is a tremendous number. The third category is called ischemic heart disease, which means there is a less blood supply to the cardiac muscles. The blood supply becomes blocked by deposition of fat particles in the blood vessels. The incidence of this kind of heart ailment is ever increasing because of dietary factors, stress, pollution, smoking, presence of diabetes and hypertension all of which increases its risk.

How are the present facilities for treatment of heart disease in the country, including the Ganga Lal National Heart Center?

There are now many centers that deal with the treatment of heart diseases. Some of them are in the private sector and others in the public sector. Shahid Ganga Lal National Heart Center is one of them. It was formally opened recently. We do have all sorts of invasive and non-invasive diagnostic tests available. There is TUTH, which does non-invasive diagnosis and does cardiac surgeries as well. Bir Hospital also has most of the non-invasive diagnostic set-up and cardiac surgery facility. These ones have surgical facilities in the public sector. Among the private ones, we know of Norvic, which has invasive (they have cathlab) and non-invasive diagnostic set-up — but they do not have surgical facilities. There is B&B where they have non-invasive diagnostic set-up and some surgical services. Then there is Medicare Hospital, which has non-invasive diagnostic set-up and some surgical facilities as well. Apart from these, there are other private hospitals and nursing homes, which do non-invasive tests.

What is ratio of cardiac manpower available in the country?

Well, I cannot give you the exact numbers. But I can give you some odd numbers that would indicate the overall status. We have about 22 doctors for 60 beds, about 10 cardiologists for 60 beds and two cardiac surgeons for 60 beds.

How many surgeries do you perform in a day? Is the cost of cardiac surgery affordable to the common people?

Right now, I do about six heart operations a week. The heart operation facilities are, I would say, accessible to a majority, not all. There are patients who cannot afford to pay even Rs 1,000. I cannot claim this is all free — this is not designed to be free. But we do have provisions for absolutely poor patients. We have, in the center, 10 percent of the beds made free for totally destitute patients. It means they can come here for the surgery even if they have nothing. I approve such services depending on the recommendation from the head of the department. The whole hospital service is free to them. Every week we can do two patients free of cost. But the design is, we have about 5/6 private rooms where the charges are high. The hospital will make some money out of that. This additional money is theoretically used for the subsidies of the poor patients. However, the majority of the beds are of general category. Here the patients pay for themselves — the principle being the hospital does not make a penny from them. The center is the government's national investment. It would be cheaper for the patients here because they will not have to pay for the investment cost, which is the case in private hospitals. In the private hospitals, the patients have to bear the doctor's charge, the medicine fee as well as the investment in the machine. Therefore, the center is reasonably affordable to the majority of people.

Many Nepalis still fly to India and elsewhere for treatment of cardiac ailments. How can they be discouraged from doing so?

There are many factors that send patients out. Number one, I would say, is the lack of confidence of people in local doctors. Until we create that confidence, people will keep on going out. It is not going to happen overnight. Even if we have a good set-up, they will still want to watch us, they will want to see the results. If the results are as good, the cost being cheaper, why would anybody want to go to some other country where you are not even considered a decent citizen? But there will be people who will still ignore local expertise. There is a psychological factor here. We may not be able to stop them. But we do not care. That's not the people we are looking at.

There is a popular conception that heart diseases affect only upper class people who live a sedentary life. What do you say?

As I said, there are different kinds of cardiac diseases, and some of them, interestingly, affect poor patients. Moreover, paradoxically, the treatment of this disease is more expensive than the one that affects the rich. For example, in rheumatic heart disease, the valve is damaged. Some of them can be repaired at low cost, but a majority of them would need expensive total replacement. That valve itself costs Rs 70,000 to Rs 80,000. Rheumatic heart disease is the disease of the poor. Ischemic heart disease — or heart attack and similar disease — affect the more affluent people. It does happen to the poor also, but probably more to richer ones. Congenital heart disease does not discriminate between the rich and the poor.

It was recently reported that Nepal has an unusually high prevalence of heart disease among its young population — up to 16 percent of people below 45 years of age being affected by cardiac ailments. Do you agree with this figure?

I am not aware of any scientific study that has proven that. I would still doubt the number. Rather, I would like to see that figure being quoted. But, truly, we know for sure that incidences of some of the diseases like ischemic, is going up.

There is a trend toward adopting alternative treatment instead of going for surgery even in the West. What do you say?

Well, we do have alternative medicine being practised for ages. These are essentially the same alternative practices that the westerners are trying to use now. But, there should be clear indication for modern medical treatment and for those that the modern medicines cannot help. For those that require psychological treatment, I think alternative medicines really help. But there are clearly defined situations where we have to treat with modern science.

What kind of facilities does the Shahid Ganga Lal National Heart Center have?

We have two cathlabs. One is the old one, which was broken and lay idle for one year and a half. It is now fixed. It is now generally functional. We have been doing lot of X-ray works from it. We do thermal angiograms and we are now trying to do coronary angiograms, too. The problem with this machine is the resolution is not perfect. We can only record it in VCR tape. We have not sent tapes out for somebody else to see because of poor quality of the picture. So, we are not doing it publicly and in open manner. We are rather hesitant to publicize it. However, we are using it for our own purpose. We do have a new cathlab that is already in the building. The process of installing the machine is almost complete, it will be complete within next two months or so. After that, we will have the state-of-the-art facility.

The World Health Organization (WHO) has pointed out that cardiac diseases are going to be one of the chief public health problems in Nepal by 2020. What should the government do to prevent this from happening?

Interestingly, the WHO would not approve any project that we would ask for cardiac purpose until time ago. Now things have changed. The WHO has now realized that even in Nepal, cardiac disease is really coming up and is one of priority now. Indeed, in developing countries, it is one of the leading causes of death. It may well be that, as the WHO has predicted, it may be leading cause of problem. It is possible. To prevent from that happening, we have to act now, work on prevention programs, educating people for all rheumatic heart disease projects. All relative education things have to be done now. Even the congenital heart disease can be partly controlled by certain precautions during pregnancy. Prevention programs are the only solution.

Smoking is quite prevalent in Nepal. How much does this affect the cardiac situation?

Smoking is one of the factors that we can educate the people about. It is very hard to correlate what is the exact quantitative effect of smoking on development of incidence of heart disease. But it is proven, by many population-based studies, authentic studies that smoking is the real and one of the important risk factors for developing coronary heart diseases and thus, increases the risk of heart attacks and cardiac complications as well as other cancer and other diseases. It is a problem. We have to go on a nationwide campaign against smoking.