- Development of Cardiology in India: Are We on the Right Track?
- History of Thrombolysis
- Epicardial Reperfusion
- History of Beta-Blockers
- History of Antithrombotic Agents
- History of Statins
- History of Angiotensin Receptor Blockers
- History of Heparin and Cardiovascular Disease Protection
- History of ACE-Inhibitors
- Antibiotics in Cardiology
- Polypill in Cardiovascular Disease: Current Evidence and Future Promises
- The History of Acute Coronary Syndrome
- History of AMI: A Saga of Transition from Tortoise Walks to Rabbit Run
- History of Nitrates
- History of Calcium Channel Blockers
- Antiplatelet Therapy—History and Future Trends, with Special Reference to Prasugrel
- History of Antiarrhythmic Drugs
- Enhanced External Counterpulsation and its Clinical Applications
- Lycopene and Related Tomato Carotenoids in Coronary Heart Disease
- History of Oils, Fats and Coronary Heart Disease
- History of Cardiac Fitness
- History of Blood Pressure and its Measurement
- History of Blood Pressure Amplification between the Heart and Peripheral Arteries
- The History of Cardiac Rehabilitation: An Evolutionary Perspective
- A Brief Historical Chronicle of Hypertension
- History of Risk Factor Stratification of Hypertension
- Retracing the Heroic Steps from Lipid Hypothesis to Aggressive Treatment of Blood Cholesterol—A Revolution in Preventive Cardiology
- Past, Present and Future of Cardiovascular Dysmetabolic Syndrome
- History of Obesity and Cardiovascular Disorder
- History of Dilated Cardiomyopathy
- History of Hypertrophic Cardiomyopathy
- History of Restrictive Cardiomyopathy
- Peripartum Cardiomyopathy
- History and Clinical Implications of Myocarditis and Pericarditis
- History of Infective Endocarditis and Future Directions
- The History of Deep Vein Thrombosis and Pulmonary Thromboembolism
- Lessons Learnt from History of Rheumatic Heart Diseases
- History of Pediatric Cardiology: From the “Untouchable” Heart to the Brave New Era
- History of Pulmonary Embolism
- History of Stroke in Cardiac Patients
- Tobacco and Heart: A Historical Perspective
- History of Stress and Heart Disease Relationship
- History of Cardiorenal Connectors
- History of Oxidative Stress and Cardiovascular Disease Protection
- History of Hormone Replacement Therapy and the Heart
- Tuberculosis and Heart
- History of Cardiac Syncope
- History of Markers of Sudden Cardiac Death
- History of Women and Heart Disease
- History of Heart and Trans-Fat Relationship
- Coronary Artery Disease and Homocysteine Relationship
- Savitri Satyawana: The First Described Cardiac Revival of the Vedic Times
- History of Sildenafil: From Angina to Erectile Dysfunction
- Cardiocutaneous Diseases
- ARBs and CVD Protection
I was amazed at the member of specialists who have contributed articles for this volume. Dr HK Chopra must be congratulated on his powers of persuasion in obtaining articles from just about every cardiologist in India. And the number of contributors is immense.
In the following paragraph the positive and negative aspects of this phenomenal growth are reviewed.
CARDIAC SOCIETY AND FOUNDATION
Modern Cardiology as a super specialty came into existence only after World War II. Earlier “Cardiologists “were merely internists who had a special interest in the subject. No less a person than Braunwald testifies to this.1 According to World Health Organization (WHO) (2005)2 30% of all deaths in India are due to heart disease and stroke. The risk factors are high blood pressure, diabetes and smoking in the majority. The numbers are likely to increase phenomenally by 2020.
India jumped on the bandwagon much earlier than most industrialized countries. The Cardiological Society of India (CSI) was formed in 1948 [earlier than the American College of Cardiology (ACC) 1949] and many others. The All India Heart Foundation (AIHF) was founded in 1962, one of the first in Asia. Both these societies are affiliated to the World Heart Federation (WHF), which in its earlier incarnation; the International Society of Cardiology was formed in 1946. The CSI has held regular annual meetings and has chapters throughout India. The AIHF equally active has not yet established centers all over the India. Through the WHF they are connected to the Asian Pacific Society of Cardiology (APSC) and Asian Pacific Heart Network and to all Asian countries. There are now over 1,000 cardiologist listed as members of the CSI. It has Councils in various subspecialties. In short it is very well organized and is far ahead of cardiac societies in most developing countries.
FUNDING OF HEALTH CARE
And yet there are many short comings one cannot ignore. First Indian health care is 85% in the private sector. The government is concentrating on “growth” and its trickle effect, which is in effect helping the private sector to thrive. In spite of 9% growth until last year its health indices are some of the worst in the world, e.g. under 5 years mortality, appalling number of maternal deaths in child birth and access to safe sanitation to mention a few. The indices are far lower than Bangladesh or Pakistan and just above Sub Saharan Africa Primary Health Care in the rural areas is in the doldrums.
The numbers under below poverty line (BPL) is the subject of hot debate depending on the criteria used from 30 to 70%. Reasonable estimates are around 45% of the population. How can these be accommodated in the 85% private sector? Its motive all said and done is profit. As their beds cannot be filled with Indian patients, there is a big drive to attract foreigners the so allied “health tourism”, combining surgery and medical treatment with tourism. The government has secured beds for its patients [in the ECHS, (CGHS) from private hospitals at low cost], but this only helps a minority. Hospitals which have been given government land at discounted prices have been the target with mixed success.
It is agreed that modern medicine including cardiology is largely technology oriented and technology is expensive. One cannot avoid it in this day and age of mind boggling scientific expansion. The government is dedicated to right to food, right to education and right to information. It should also ensure a right to health. There should be significant facilities in the public sector for the poor. There are many models from Western countries to choose from.
Professor Jayati Ghosh of the Jawaharlal Nehru University in her 2011 UCL Lancet lecture in London has found the situation disturbing.
Instead of investing in a national publically funded health service which would undermine the private sectors ability to create a market in health, according to her India's economic model destroys health that is health considered as a public good. She has suggested as alternatives a wage employment based health strategy, combined with substantial investments in the public sector health system. Her ideas need consideration.3
PREVENTIVE PROGRAMS
Ischemic Heart Disease
Preventive Programs are conspicuous by their absence. In industrialized countries today there have been substantial gains in labeling food, nonsmoking campaigns and provision for exercise by providing parks and cycle paths all done by the government.4
Cardiac Societies/Foundations in the USA, UK, Western Europe, Australia, New Zealand, and Canada have used guide lines on the three important aspects for preventive heart disease viz diet, exercise and nonsmoking. In India apart from conflicting messages in the newspapers from time to time, nothing has been done. Although, India has joined the Framework Convention on Tobacco Control (FCTC) in 2004, which makes its mandatory to control tobacco, there is a big gap in the implementation. The observance of World Health Day (Sept. 29th) World Diabetes Day (Nov. 14th), which will help in creating awareness, has just begun in India.
Rheumatic Heart Disease
Rheumatic heart disease (RHD) has been eliminated in all industrialized countries, but still takes a large toll of lives of young individuals in India. It is entirely preventable as shown by an Indian Council of Medical Research (ICMR) project (1994) utilizing the School Health Services and Primary Health Centers. Rheumatic heart disease received mention in the Fifth Five-Year Plan (1966–71), but no successive plan make any mention of heart disease prevention.4,5
Pediatric Cardiology
There are no hard data on the number of children with congenital heart malformation, but extrapolating the data from elsewhere it is 8 per 1,000 live births 130,000–270,000 children are born each year with congenital heart defects of whom some 80,000 need same form of intervention in infancy. It is a resource intensive specialty and is expensive particularly of newborns and infants. The facilities for pediatric cardiology and cardiac surgery are restricted to about three or four private centers in the whole country. There has been no attempt to build such centers in the public sector. Research also needs to be done in prevention in this group.
RESEARCH
Although every heart center in India has the label of “research center” following it, research is conspicuous by its absence. There is much scope for research in India in conditions peculiar to this country, both basic and operational. A scrutiny of peer reviewed journals makes this abundantly clear.
LACK OF INTERNATIONAL RECOGNITION
Lastly why have big international conferences on heart disease by passed India? The Fifth World Congress of Cardiology was the only World Congress held in India so far in 1966. It has been held two or three times in many smaller countries since the first one in 1950. The APSC founded 1956 has held only one meeting in Mumbai in 2005. These conferences are now held once in 2 years. Exposure to World Cardiology of a large number of Indian doctors would be an inspiration. Why has it not been done?
It seems, in spite of a well-organized society, the fruits of research in modern cardiology, although available in India in large measure is denied to the majority of Indians. Something should be done and quickly to reverse this trend.
REFERENCES
- Braunwald E. Shattuck Lecture Cardiovascular Medicine at the turn of the Millennium Triunaphs, concerns and opportunities. N Engl J Med. 1997;337:1360–9.
- World Health Organization (2005) Preventing chronic diseases-a vital investment. [online] WHO website. Available from http://www.who.int/chp/chronic_disease_report/en/ [Accessed July 2012]
- Ghosh Jayanti. 2011 UCL Lancet Lecture. The Lancet. 2011;378:1986.
- Padmavati S, Bhatia D. Control of rheumatic fever and rheumatic heart disease in India through School Health Services. ICMR Pilot Project. 1984–1990. [online] ICMR website. Available from www.icmr.nic.in Accessed July 2012]
- Sharma KB, Prakash Kunti. Community control of Rheumatic Fever and Rheumatic Heart Disease. 1982/1990.ICMR 1994.