When I did my internship at Shanta Bhawan Hospital ( now Patan Hospital), it would be rare to see a patient with a myocardial infarction ( heart attack). How things have changed! Now heart attacks happen  across the social range. In countries like Nepal because the state does not help out with the hospital bill nor is there any insurance cover, the economic burden for the average Nepali for cardiovascular illness is stunning. With infectious diseases ( TB, typhoid, typhus) you can take a course of antibiotics and usually you are cured. This is hardly ever true of cardiovascular illnesses like heart attacks where the illness may be there to stay.

40 year old Ram Maharjan was a taxi driver. One day he experienced sharp chest pain with nausea and vomiting, but he drove himself to Bir Hospital where with tests he was diagnosed to have a heart attack. He was refereed to another hospital and after further testing, they told him he required a stent (a tube to prop open the artery) to be put in one the coronary arteries where there was very significant narrowing which was the cause of the heart attack. However after payment for all these tests, he’d run out of money. He had no money left over for the potentially life saving procedure of stent placement. In addition he would need follow ups and expensive drug regimens.  

This is an often repeated, sad narrative in the hospitals in Nepal which two to three decades ago saw mostly  infectious diseases. But the tragic part is that the infectious diseases have not quite gone away. We continue to see rampant TB and typhoid. A true double whammy situation. And now there is also HIV to contend with. What happened to cause the sudden  increase in cardiovascular problems?

People talk about lifestyle changes ( more sedentary life, the diet is more processed, easy availability of sugary drinks, smoking) which have promoted cardiovascular illnesses. Importantly diabetes has  become rampant. South Asia holds the dubious distinction of having the largest collection of diabetics in the world. Diabetes, although this is an endocrine ( gland) problem, is the king of cardiovascular diseases because it affects the heart ( you tend to get more heart attacks), the brain ( you get more strokes), the eyes ( you may go blind), or the kidneys ( you may have kidney failure and require dialysis). All of this has obviously spelt trouble for Nepal and the rest of South Asia.

As though this were not enough, there may also be a genetic component that predisposes people from South Asia to heart disease. When studies were carried out in South Asians  living in the UK,  it was found that the South Asian population for the same sex and age group had a higher risk of heart disease than the local UK population. Similar studies have also come out of the USA. In fact, a well established cardiac gene defect ( MYBPC3) has been shown to afflict 4 % of the South Asian population predisposing them to cardiovascular illness. Four percent in South Asia translates to millions of people. Indeed the WHO says that South Asia will be the hub for cardiovascular illness starting from this year.     

 
These cardiovascular problems have become so severe in poor countries such as ours that mathematical modelling to see if taking a preventive pill (a poly pill  that reduces cholesterol, blood sugar, and high blood pressure) after the age of of 50 has been carried out. The results are very promising and even some field trials by the drug company Cipla are ongoing. There are  ethical issues that need to be resolved about the polypill; but for sure, in countries like Nepal where treatment of cardiovascular diseases and its complications can be financially so devastating (as in the example of the taxi driver above) that any kind of preventive measure is an attractive idea.

In the meantime as far as possible we need to drink clean water, avoid fatty food, stop smoking, avoid sugary drinks and instant noodles, eat dal bhat, and go for morning walks.  These lifestyle suggestions would be ideal if adherence to these good habits could be improved.