Heart diseases turn deadly

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Kamrun Nahar
Heart ailments have become a major health problem and emerged as the country's top killer, but high treatment cost and poor services are sending more people abroad despite mushrooming of specialized hospitals at home.
As economy soared over the past one decade, it brought changes in the country's food habit and lifestyle, and spawned hundreds of thousands of sedentary jobs, making Bangladesh a perfect ground for heart diseases.
According to a recent study, prevalence of hypertension in adult population is about 20-25 per cent, ischaemic heart disease - or ailment related to reduced blood supply to coronary muscle -- in adults about 10 per cent, rheumatic heart disease about 1.2 per thousand and congenital heart disease eight per thousand in new born baby.
The study claims that heart diseases have emerged as the country's leading killer, overtaking infectious diseases and other deadly ailments in a span of a couple of decades.
"We are no longer immune from the diseases that we considered as exclusive problem of rich nations. The number of heart diseases are growing like anything; we are sitting on a time bomb," said Brigadier general (retd) Abdul Malek, the doyen of the country's heart treatment.
But experts and patients have told the FE that cost of treatment is still too high and care facilities are not adequate, forcing more and more people to seek treatment abroad.
"What has started as a trickle 10-15 years back, is now a flood," said a top cardiologist, referring to outbound travel by Bangladeshi patients. He added treatment facilities, availability of doctors, quality and nursing and other services are in a dire strait at public hospitals and to a great extent in so-called posh private clinics.
"People only buy luxury and comfort at the private hospitals. These clinics spend big on promotion, but they don't have the required number of expert doctors to perform heart surgery or do other risky treatment," he said, requesting anonymity.
Doctors at the state-owned Institute of Cardiovascular Diseases claim government hospitals can provide quality treatment at a low cost as they have the best doctors. "But unfortunately, people are unwilling to go there," said one doctor.
During a recent visit at the Institute in city's Sher-E-Bangla Nagar area, patients were found lying on the floors and their anxious relatives hanging around helplessly.
Rich or middle class patients do not come here for acute seat crisis, unhygienic and chaotic environment and low quality service.
"I took my brother-in-law to the national cardiovascular institute for admission as it's cheaper. But I failed to get a seat. I also found their treatment facilities and services inadequate," said Nazrul Islam, 40.
Nazrul finally took his relative to a private clinic. But he had to rip his pocket to bear the cost of treatment in the hospital situated at Dhanmondi.
A 24-hour package of coronary angiogram costs Tk 5,000 at public hospital while it becomes Tk 15,000 at private hospitals, said Dr Abul Hussain Khan Chowdhury, a cardiologist with extensive work experience at government and private clinics.
The same treatment cost differs at various private hospitals and non-for-profit organizations like Ibrahim Cardiac Hospital and Research Institute (ICHRI) and National Heart Foundation.
Cost of Open Heart surgery ranged between minimum Tk 180,000 and Tk 400,000 depending on packages. The same surgery costs Tk 50,000 at public heart hospitals and about Tk 200,000 at non-profiteering organizations.
The cost of angioplasty -- for normal and high risk -- varies between Tk 60,000 and Tk 110,000 at private hospitals. It excludes the cost of stent -- a tiny tube placed into an artery, blood vessel, or other duct to hold the structure open -- or Intra Aortic Balloon Pump (IABP) which is done almost free at public hospital.
The IABP can give support to the heart for about 12 to 16 hours after an operation, if the heart cannot maintain the pressure of blood. As the machine is not easily available in Bangladesh, private clinics charge Tk 10 to 12 thousand per hour.
A physician who was unwilling to be named said price of various medical devices like valve, catheter, guide-wire and stent is almost same in every private hospital. "But most clinics charge extra bucks by adding undue procedural costs. They are simply swindling the patients,"
He termed the dealings of some private hospitals as "gross profiteering". "These hospitals have ready-made excuses: they would say that they have invested heavily in modern treatment tools and hiring doctors and technicians at a much higher payment."
The cost of stent differs depending on size, type and availability, said D Kent McAllister, a cardiovascular technologist of University of California Irvine, who has trained many Bangladeshi cardiologists and technicians.
He defends some private clinics saying cost of stent varies because one does not know the expenses beforehand since complications may occur during the treatment.
"A person who really needs one stent before, he may need two during the procedure as things can change. It's impossible to know 100 per cent what its going to be the total cost," Allister said.
Allister said the USA made-stents are pricey, followed by those from the European countries. "Now China is making good quality stents and other heart treatment tools. They are also cheap," he added.
"We use stents imported from the United States, Germany, France, Japan, Singapore and Ireland. We don't use Indian stents, which is cheaper," said Abul Hussain Khan Chowdhury, a director at the institute of cardiovascular diseases.
The bare-metal stents cost between Tk 45,000 to Tk 1,65,000 while the drug-eluting ones ranges between Tk 1,20,000 to Tk 1,75,000, he said
Aside from the high cost of treatment, patients also regularly complain about lack of care at the public hospitals and in some relatively cheaper private clinics. Mistreatment, carelessness and exploitation galore, but most patients keep mum due to a climate of impunity in these hospitals.
"I could not rely on any doctor in Bangladesh as their behaviour was not good. I had my valve replacement in India," said AZM Anas, one of over 20,000 heart patients who sought heart treatment abroad last year.
In the past few years, private cath-labs have mushroomed providing various heart-related treatments like angiogram or angioplasty. Sources said most of these labs operate without approval from any authorised bodies.
"My concern is not the cost but mistreatment. For example, some unscrupulous centres and hospitals recommend stents in case of 50 per cent blockage, which is no way acceptable," said a physician requesting anonymity.
He told the FE that there are at least 40 private cath-labs in the capital and they exploit patients in right, left and center.
"Who approves, regulates or monitors them? There must be some regulations and monitoring to control the activities of the private hospitals and this type of centres providing risky heart treatment," he said.
Most countries have set up regulators to monitor clinics treating heart patients. In the US, the Food and Drug Administration oversees the activities of all health service providers and hospitals.
In a recent cardiovascular conference health minister admitted that heart diseases have become a major health issue in Bangladesh. He urged the cardiologists and private entrepreneurs to help expand heart treatment facilities down to district level.
It would reduce excess pressure on referrals and public hospitals in the capital, he said, stressing the need for cheap treatment down to district levels.
He accused some private clinics of poaching top doctors from public hospitals, eroding state-run institutes' treatment capacity.
The menace of cardiovascular disease calls for lower treatment cost, more educated and trained doctors and technicians and more public hospitals, he said.
Doctors say cost of heart treatment could be reduced greatly if local companies set up plants to manufacture medical devices.
"We are still very much dependent on imported devices, which cost a lot," said Yunus Ali, a doctor and an expert on medical equipment. "Heart treatment expenses can be reduced by a half or three quarter if our firms start manufacturing these tools. They can even do it through joint venture with foreign firms.
"We have big success in pharmaceutical production. They can repeat the feat in manufacturing of stents, valves and other devices."
But Brigadier Malik who spent the last 50 years treating heart patients and saw the diseases emerging as a major health issue, said stress should be laid on prevention, not treatment, "because cardiovascular diseases would continue to be a costly affair."
Lifestyle changes like quitting cigarettes, losing excess body fat, switching to a low fat diet and taking regular exercise such as walking every day can significantly improve the situation, said the National Professor at a recent conference on cardiovascular diseases.
"These good habits will prevent a lot of deaths and save the country a lot of money."