Wednesday, August 01, 2007

Does Cite Soleil Deserve Simple Technology?

Since 1995, Haitian Hearts has helped bring approximately 150 infants, children, and young adults to the United States for medical treatment unavailable in Haiti. The vast majority of these kids have suffered congenital heart disease or rheumatic heart disease.

Congenital heart disease means the patient was born with an abnormally formed heart. Rheumatic heart disease is an acquired heart problem due to Group A beta hemolytic streptococcus infection. The streptococcus infection is usually a pharyngitis that goes untreated in resource poor settings.

The teenagers in Haiti with rheumatic heart disease break our hearts when we examine their broken hearts. These patients usually have valves that have been injured and do not work well. They are leaky or calcified and tight and won’t open like they should. Many times the valve is leaky and tight at the same time.

These teenagers are in a constant state of congestive heart failure. They have missed much school over the years and can’t contribute much to the family because they can’t physically exert themselves. Their hearts are just too weak from rheumatic heart disease.

Many of these kids die in Haiti before we can find an accepting hospital in the States to operate them. The children and teenagers that have made it to the States and have their valve repaired or replaced have a new lease on life. But surgery is very difficult, being placed on a blood thinner can be problematic, and sometimes more surgery is needed if the valve fails again or another episode of rheumatic fever occurs.

The New England Journal of Medicine has two excellent articles on rheumatic fever this week (August 2, 2007).

Important points made in the two articles:

1. Rheumatic fever is a disease of poverty. Overcrowding and poor hygiene allow the easy transmission of streptococcus. Malaria, tuberculosis, and AIDS are bad diseases and are very prevalent...but so is rheumatic heart disease.

2. In the mid-20th century, children with rheumatic fever occupied many of the beds in pediatric wards in industrialized countries---some hospitals were totally dedicated to the treatment and rehabilitation from rheumatic fever.

3. In the later half of the 20th century, rheumatic fever receded as an important health problem in almost all wealthy countries because the standard of living is so high and because penicillin is available.

4. For the resource poor world, rheumatic fever and rheumatic heart disease are huge problems right now.

5. It was recently estimated that worldwide 15.6 million people have rheumatic heart disease. These are conservative estimates. A walk through Port-au-Prince and Cite Soleil would prove that to you. And almost all of these cases and deaths that occur happen in the resource poor world like Haiti.

6. An unfortunate consequence of the decline in rheumatic fever in industrialized countries has been a parallel reduction in related research. In other words, if we in our well-to-do world don’t get this disease, why do much research?

7. Most resource poor countries do not have effective primary or secondary preventative measures and higher degrees of treatment such as medication for heart surgery, valve surgery, and anticoagulation are not found in places like Cite Soleil.

8. The authors of one of the articles studied kids in high risk settings in Cambodia and Mozambique, and found that echocardiographic screening found many subclinical cases of rheumatic heart disease that could be treated to prevent further valve destruction. Echocardiography picked up many more cases than did the stethoscope and clinical exam.

9. The authors concluded that it is not acceptable to leave these cases undiagnosed and these children at risk for recurrence of rheumatic fever simply because echocardiographic screening is seen as an inappropriate use of modern technology in developing countries. Instead, further research is needed to define models of echocardiographic screening that are practical, affordable, and widely applicable.

10. Portable on site echocardiograms are not difficult, the machines are small and give very good images, and should be done in research poor settings. That would include Cite Soleil.

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