Stroke, heart attack and heart failure are some common cardiovascular disease (CVD), which are quite common that can result in death or serious injury. The CVDs are the top-ranked killers and caused 30 per cent of global deaths in 2008. Not only that, by the year 2030, heart disease and stroke are forecast to be responsible for taking almost 23.6 million lives. Interestingly, over 80 per cent of the CVD deaths take place in low and middle income countries. However, studies show up to 80 per cent of strokes and heart attacks could be prevented through lifestyle changes and healthcare services to control health conditions. But how can this be accomplished?
The New Zealand experience
It was May 2008. My wife and little son had just returned to Auckland after a two-month holiday in Bangladesh. As soon as she looked at my face she said, “Oh my God! You’ve probably gained too much fat. How much do you weigh now?” I took my weight on our scale at home. Amazingly, I was 5 kilos over the weight I should be according to the height. It was risky at that age of 44. The next day I saw my General Practitioner (GP) Mr Wu, a Hong Kong-born New Zealander, at our local community healthcare centre. He checked my blood pressure, took my weight and asked me some health-related questions and then referred me to a diagnostic centre to have some tests for cholesterol, diabetes, kidney, prostate and some other health conditions. He advised me to have the tests as quickly as possible and asked me to see him in a week. Accordingly, I had the tests and saw Mr Wu on time. Before seeing Mr Wu, I received my test reports by email from the diagnostic centre, but did not try to understand what the report said as I was short of time and blank-headed about technical pathological jargons and the measurement system.
When I entered Mr Wu’s office room, I found him ready with a hard copy of my test report in his hand. After spending a few seconds exchanging pleasantries, he informed me that the level of my cholesterol was nearly double the normal one, measured at 6.8. He explained to me how the cholesterol level is measured, what the components of cholesterol are – LDL, HDL, tygergliceride, etc. – and the importance of ratio measurement. Then, he took a piece of paper and his ballpoint pen and started drawing how blood moves and functions, how an artery works and gets blocked, when a heart attack, stroke, death or paralysis takes place from high cholesterol, and how the level of my cholesterol at that stage affected my life. He also explained what kinds of treatment can be taken to address the level of cholesterol at that stage and what could happen if any action was not taken. Finally, he asked me if I wanted to die soon or later. Naturally, I opted for a longer life. Then, he put me on a lifelong medication – one Bezalip a day. Also, he gave me two separate printed documents – one was about dietary recommendations while the other was about physical exercises. The dietary documents focused on what to eat and what not to eat.
He asked me to start my medication straight away and retake the medical tests in three months. I started the medication, had tests and saw him again. That time, he asked me to have tests in six months as the level of cholesterol went down considerably. When I saw him in six months, my cholesterol level came down to normal, and because of that, Mr Wu asked me to have the next test in a year.
Every time before a due date for having a test, I receive a letter and a phone call reminding me about the date of having the tests. The medical centre where my GP sits sends the letter and makes the call. Mr Wu always used jargon-free layman English and made me understand what he wanted to let me know.
I have been on medication since 2008 and am still alive. I have maintained a dietary discipline and do some physical exercises. Sometimes, the cholesterol level goes up when I get careless about having foodstuff and/or get lazy to do exercise, and in that case, I have to see the doctor and have tests every six, or even three months. However, my life is quite normal. I do not feel like a patient, have never experienced any stroke or heart attack, have never have had an angiogram or used rings to remove heart blockages thus far.
I did not need to pay any money for any test in New Zealand, where I lived as a citizen/permanent resident until 2013. I used to pay a partial fee for GP and a token price of medicines. In Australia, where I have been living since 2013, I pay the total price for medicines, no fees for GP while tests are for free.
Bangladesh experience: The hole
I have not gone to see any medical doctor in Bangladesh for the last 14 years as I have been overseas since 2003. However, as I was born, brought up, studied and worked in Bangladesh and still have had contact with my family members, relatives, friends and former colleagues via phone, email or social media like Facebook and Twitter, and with the mass people via Bangladeshi newspapers online I have some idea of the situation.
I observed that heart attacks, strokes, and consequent death or paralysis are quite common in Bangladesh. One of my family friends has been in coma since he had a stroke nine months ago. His family has been paying a handsome amount of money to a hospital every day. Recently his father had a stroke and became paralysed, which could, at least partially, be attributed to his mental stress caused by his son’s condition and hospital pauments.
It is very commonly observed in Bangladesh that a person aged 35 or more after experiencing a chest pain has an angiogram and gets some stent or ring implanted to avoid a possible heart attack, but there is nothing observed in general to avoid such a chest pain or its root cause — narrowing or blocking of arteries. Advice to avoid such conditions can be found all over the mass and social media, which suggest some precautionary steps, such as getting physically active, quitting bad habits like smoking, managing stress, maintaining a healthy weight, eating a healthy diet, managing high blood pressure, managing high cholesterol and controlling diabetes. Doctors in Bangladesh informally provide some dietary and physical activity related advices in relevant cases. But, except managing diabetes, and, to a little extent, high blood pressure, all the advice fails to yield a noticeable result. The failure, I argue, is because of the absence of a systemic approach in the healthcare system. Specifically, there is no noticeable treatment of high cholesterol in the country, though cholesterol contributes a lot to heart attack and stroke. In an ideal healthcare system, all of this advice is accommodated and doctors create a treatment plan for everyone to help prevent heart attack and stroke by keeping their arteries healthy. Unfortunately, Bangladesh does not have such a system. Apparently, since prevention of heart attack and stroke by keeping arteries healthy does not look like a primary healthcare necessity, it is not emphasised by the government of a poor country like Bangladesh, and, for the same reason, donors also do not fund this area of healthcare. This is a hole in the Bangladesh healthcare system. The exception is that a tiny section of aware and well-off people possibly receives the regularity and accuracy of adequate tests on their personal efforts and initiatives.
Besides, Bangladesh system has some related problems: pathological tests are mostly unreliable and doctors are allegedly after repeated and indiscriminate tests, a lack of discussion between patient and doctor, lack of non-medication treatment such as dieting and exercise, absence of communication between patients and healthcare centre, prescribing excess medicines are some other issues.
The way out
So, what is the way out? New Zealand has two types of healthcare providers: hospitals and local community healthcare centres. The community healthcare centres provide all primary healthcare services including the ones relating to prevention of heart attack and stroke by keeping arteries healthy. Ordinary citizens or permanent residents get most of the services for free as the government pays for them. Every citizen and permanent resident has a personal doctor called a GP and gets all primary treatment, referral, advice and suggestions from the GP. There is no question about the accuracy and authenticity of any health-related test. A typical NZ community healthcare centre provides a set of services including: reminding, organising and completing required tests for cholesterol, diabetes, blood pressure, prostate, kidney and other conditions on time for the people who are generally 40 or above and ensures 100 per cent reliability in all the tests.
Who will provide these services in Bangladesh? Since Bangladesh is still a poor country and its government usually runs on a deficit budget, and there is no foreign funding for this area of healthcare either, it is not possible to copy the NZ community healthcare centres straight away in Bangladesh. Under the circumstances, we may think consider the following three options:
Unlike NZ centres, all categories of centres mentioned above will have their own testing lab with the latest technological equipment.
Professional integrity will be the basis of all centres. Proper professionals will be hunted through a stringent recruitment process and offered a lucrative career prospect that includes exceptionally higher salary, benefits and facilities.
Every centre will deal with its own local people. There will be a registration system which facilitates data collection and research on the trend of the rate of heart attack and stroke in the locality.
The centres will provide a GP for every person ranging from a newborn baby to the oldest person of the locality. In addition the proposed centres will customise the NZ system in the context of Bangladesh by providing the services that will include but not limited to:
I have planned to set up a self-run not-for-profit local community healthcare centre in my countryside locality of Nowdapara under Bheramara Upazilla, but the plan fell flat as I am overseas. If a philanthropist or a health sector entrepreneur comes up to set up a centre of any of the categories, I am ready to provide free consultancy as much I can from my NZ experience. I hope setting up of one centre may influence setting up of some others.
I am not a medical doctor and have prepared this write-up using my NZ experience, some social research skills and philanthropic thinking. This piece is dedicated to mankind and it is expected that the centres that may come into being using the idea expressed here will cite this publication as their key conceptual document. At the same time, any constructive criticisms of this article are welcome.