Out of the Darkness
Cardiac Care in East Africa Offers a Brighter Future for Pediatric Patients
By Kristin Hubing
Strep throat is a ubiquitous childhood illness in the United States — and easily treated with a short course of antibiotics. Soon it’s a distant memory for the infected child. But in the developing East African country of Uganda, where recurrent Streptococcal infections often go untreated, the consequences are dire. Rheumatic fever can ensue, which causes chronic rheumatic heart disease (RHD). Without surgical intervention, RHD–induced cardiac fibrosis can lead to heart failure and possibly death.
According to the World Heart Federation, the global burden of disease caused by RHD falls disproportionately on children and young adults living in low-income countries. This resolvable cardiac problem, which has been extremely rare in the developed world since 1960, is still responsible for more than 230,000 deaths worldwide annually. This makes it the most common cause of cardiovascular disability and death in children and young adults.
Enter Craig Sable, M.D., professor of pediatrics at the George Washington University School of Medicine and Health Sciences (SMHS), and executive director of telemedicine and director of echocardiography at Children’s National Health System in Washington, D.C. Since his first trip to the African continent in 1999, Sable has been keenly interested in global health as it affects children with heart conditions. Despite the region’s pervasive lack of access to care, he is encouraged by the fact that with intervention, most children with heart problems can survive into adulthood. “This got me interested in seeing how we could expand beyond our borders,” says Sable, who focused his efforts on not only bringing children to U.S. hospitals for cardiac surgery, but also expanding capacity in their home countries.
By 2007, Sable had teamed up with the Uganda Heart Institute (UHI) at Mulago National Referral Hospital in Uganda’s capital city, Kampala. That year marked the country’s first pediatric open-heart surgery, which was performed by a team of U.S. medical professionals led by Sable. The partnership blossomed, and after two years of collaboration, Ugandan physicians were doing open-heart surgeries on their own. Uganda is “one of only three countries in sub-Saharan Africa doing that,” says Sable, who leads one of four visiting teams that travel to UHI annually.
Peter Lwabi, M.D., head of pediatric cardiology and deputy director of UHI, credits Sable and his team with proving that “world-class cardiac surgery can be done in countries with meager resources.” Lwabi values the partnership as a “model of skills transfer that is done within the local environment and does not require sending health care workers abroad for costly training.”
In addition to treating RHD, Sable and his team see pediatric patients with a variety of other heart defects, including ventricular and atrial septal defects and Tetralogy of Fallot, and they opened a cardiac catheterization laboratory in 2012 that was built by and is fully funded by the Ugandan government. They are also in the process of building a telemedicine room at UHI for videoconferencing, which, Sable says, “will allow us to complement our time on the ground with ongoing patient consultation and distance education.” This doesn’t change the fact that in Uganda there is currently only one cardiac unit for every 13 million people — compared to one for every 120,000 people in the United States — but it allows the UHI to expand its reach, says Sable.
The partnership with UHI has also generated a research component aimed at preventing RHD in sub-Saharan Africa. Led by Andrea Beaton, M.D., assistant professor of pediatrics at SMHS, the initiative is funded by a three-year Clinical and Translational Science Award. Her 2012 study titled “Echocardiography Screening for Rheumatic Heart Disease in Ugandan Schoolchildren” was published in Circulation, a journal of the American Heart Association. The study shows that in resource-constrained settings, “screening by echocardiogram improved early detection by 300 percent compared to clinical exam alone,” says Beaton. The findings were named one of the top 10 advances in heart disease and stroke research in 2012 by the American Heart Association.
The Larry King Cardiac Foundation, Gift of Life International, Samaritan’s Purse International Relief, and British-based Chain of Hope are among the organizations that have helped fund the cardiac procedures performed at UHI. Beaton notes that “Craig has been fundamental in the development of a sustainable cardiovascular surgery program in Uganda. He is involved at every level, from on-ground coordination to recruitment of volunteers and continued distance education. On top of all that, he is a tireless and successful fundraiser, who is uniquely able to inspire donors with his vision of lifesaving cardiovascular surgery for the children of Uganda, in Uganda.”
Sable stresses the importance of government support for the endeavor. “We have to convince the government that investing in a program like this will help enhance their reputation and build overall medical infrastructure, despite all the other challenges the country faces,” he says. “At the end of the day, when you look a parent or child in the eye who knows that their life depends upon whether or not they get this procedure, it’s heartbreaking. But we can have an impact.” And, as Lwabi attests, they already have.