The Heart Institute of the Caribbean: an interview with Dr Ernest Madu

Citation

by Alistair Craven, I. (2010), "The Heart Institute of the Caribbean: an interview with Dr Ernest Madu", Leadership in Health Services, Vol. 23 No. 1. https://doi.org/10.1108/lhs.2010.21123aaf.001

The Heart Institute of the Caribbean: an interview with Dr Ernest Madu

Article Type: Talking heads From: Leadership in Health Services, Volume 23, Issue 1

Interview by Alistair Craven

The Heart Institute of the Caribbean (HIC) is an innovative, dynamic health care centre that serves as the centre of excellence for cardiovascular diseases (CVD), occupational health, diabetes care and general internal medicine in the West Indies. The Heart Institute of the Caribbean is located in Kingston, Jamaica, and is the regional centre for comprehensive and sophisticated diagnosis and management of all forms of heart diseases.

Cardiovascular disease is the number one cause of death, hospitalisation and disability in the West Indies. Among the four leading causes of death in this region in the 1990s are heart disease and cerebrovascular disease. Despite the high prevalence of cardiovascular diseases, there was previously no identifiable centre of excellence in this region for cardiovascular disorders. The Heart Institute of the Caribbean fills this niche and has become the regional leader in the diagnosis and treatment of cardiac and vascular diseases.

Dr Ernest Madu is the Founder, Chairman and CEO of the Heart Institute of the Caribbean Ltd. Prior to his role at the Heart Institute, Dr Madu was on the faculty of the Division of Cardiovascular Medicine at Vanderbilt University in Nashville, Tennessee. He is an expert in non-invasive cardiovascular diagnostics, with broad training and experience in all areas of cardiovascular diagnosis. He has advanced training in echocardiography and nuclear cardiology and is versatile in advanced cardiac imaging modalities. Dr Madu is an internationally recognised cardiologist and an accomplished clinical investigator whose research works have been presented internationally, and published and cited in leading journals of cardiovascular medicine.

AC

Hello and welcome. Can you tell us about the mission of the Heart Institute of the Caribbean?

Ernest Madu

The mission of the Heart Institute is to provide accessible and affordable high-quality cardiovascular care in the Caribbean. We find that the current global imbalance in the availability of modern cardiovascular care has created an exploitative system wherein citizens from low-resource nations expend considerable financial and emotional capital to access high-quality cardiac care in high-resource nations, further depleting limited reserves from the lower-resource nations. We find such a situation morally unacceptable and are committed to changing that.

AC

What is involved in your day-to-day role?

Ernest Madu

My role is to provide the vision and strategic direction to achieve our objectives. Additionally, it is my responsibility to translate our vision into concrete performance from our staff. In addition, I leverage my contacts to ensure that we keep our cost basis affordable without compromising quality. Externally, I work to share our vision of sustainable cardiovascular care programmes and self-reliance to policy makers and others to usher in a paradigm shift that:

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  high-quality cardiac care is essential for development; and

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  such high-quality cardiac programmes can be developed and sustained locally at a fraction of the cost of similar services overseas.

AC

Currently you are looking at responsible and appropriate technology transfer for sustainable, efficient and affordable health care development in low-resource nations. Can you provide us with some background on this?

Ernest Madu

Essential ingredients of development must include relevant education and appropriate use of technology. Most low resource economies continue to run educational curricula that do not address their national development needs or stated objectives. Many of these nations continue to import and adopt technology that is expensive and ill-suited for their needs and for which they have no manpower to implement or sustain. This partly stems from ignorance and partly from corruption, often with active connivance of the high resource nations. Fortunately, we are living in an era of phenomenal technological growth and innovation that has created an opportunity for the use of affordable technology to improve the quality and content of health care in low-resource nations.

I will give just few examples of what we have done:

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  We understood that the use of web-based systems would allow us the opportunity to tap into the global intellectual capital without the need for geographical relocation. All of our systems operate on a telemedicine grid that allows for retrieval of data from any location in the world, thus facilitating consultations from internationally renowned experts at no additional cost to the patient.

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  We partnered with a company in Canada to create a web-based platform that allows all of our diagnostic images to go into an online telemedicine platform. With this system in place, we have been able to tap into talents around the world without the extra expense of bringing them on site.

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  We have also been able to improve our efficiency by being able to review studies from multiple locations at any place and time. Our patients and referring physicians are able to get near real-time reports. We are also able to grant access to other physicians or other facilities that may wish to see these studies while attending to our patients. This improves the quality of care, and makes it more seamless.

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  We have also implemented an electronic medical record system that ensures that all patient reports are generated in an electronic reporting format and can be e-mailed to the patients, designated family members and referring physicians. The electronic medical records are available to all practitioners involved in the care of our patients and improve the quality and accuracy of care, and keep medical errors at bay because accurate information is always available at your fingertips.

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  We are now in discussion with another partner to provide health care content for follow-up and health maintenance to our patients through SMS text messaging. These systems allow us to implement processes that keep costs down and keep efficiency up. More importantly, these approaches improve quality and maintain high standards of care.

AC

With regard to Africa, why is it that funding for cardiovascular disease care is, and to quote you, “totally ignored?”

Ernest Madu

Historically, people have become comfortable with the erroneous and misinformed thinking that the only health problems in Africa are related to infectious diseases. I guess this plays into the Western mindset of the place of Africa in the scheme of things. The narrative of health care in Africa revolves largely around poverty and infectious disease and unfortunately has made our reasoning impervious, even in the face of overwhelming evidence against that line of thought.

AC

What are the key risk factors for heart disease?

Ernest Madu

The usual culprits are the same in Africa and other low-resource nations as they are in the USA and Western Europe. The modifiable risk factors include hypertension, diabetes, peripheral vascular disease, tobacco use, physical inactivity, high cholesterol and obesity, while the usually non-modifiable risks include male gender, age, genetics (family history) and post-menopausal state.

It is well known that the burden of disease in Sub-Saharan Africa (SSA) is estimated to be about five times greater than that of established market economies. However, the thinking that all of this is due to infectious or communicable diseases is flawed and not supported by the evidence. As far back as 1990, the World Health Organisation (WHO) estimated that of the nearly 30 million deaths caused by non-communicable disease, 18.7 million occurred in developing countries versus 9.4 million in developed countries. During the same period, 63 per cent of the world mortality due to cardiovascular diseases occurred in the developing world. A significant proportion of this occurred in Africa. Unfortunately, Africa and many other low-resource nations, unlike the established economies, face a double burden of disease (communicable and non-communicable), compounded by bad governance and social unrest, resulting in a devastating impact. This new burden is facilitated in part by an epidemiologic transition that has occurred in varying phases in many African countries over the past several decades.

For some inexplicable reason, we have been slow to reshape or rethink our assessment of the scope of cardiovascular diseases in Africa. We ignore the fact that African countries are experiencing the highest rise in the rate of smoking, increasing at a rate of 4.3 per cent per year. The prevalence of hypertension in many African communities exceeds 20-25 per cent or one in four adults. More worrisome is that many of these patients are untreated or poorly treated. In a study of rural and urban Tanzanians, hypertension prevalence was about 30 per cent in both genders, and just fewer than 20 per cent of the study sample were aware of their diagnosis; only about 10 per cent reported receiving treatment, and fewer than 1 per cent were controlled.

The prevalence of diabetes is increasing in many African countries. It is projected that by 2025, developing countries – including many in Africa – will experience a 170 per cent increase in the prevalence of diabetes, from 84 million to 228 million, representing more than 75 per cent of diabetics worldwide. In Mauritius, for example, the adult prevalence of diabetes is about 20 per cent. Because of these uncontrolled risk factors, it has been estimated that by 2020 SSA will see CVD mortality prevalence rate increases of 126 per cent in women and 134 per cent in men, as opposed to increases of less than 50 per cent in most developed economies. At the same time, Africa will have less than 5 per cent of the global resources available for containing or treating cardiovascular disease.

AC

You note that everybody is willing to provide basic aid to developing countries, but nobody seems to be interested in sustainable investment. Why is this so?

Ernest Madu

This is an issue of mental state and narrative. For some reason, the idiocy that all developing countries need is “dependency aid” has taken deep roots and is difficult to shake from the collective consciousness. Some of this thinking derives from deep-seated attitudes that devalue low-resource nations and assume that certain levels of excellence are beyond the reach of these nations. The thinking has become so dominant and entrenched that well-meaning individuals with laudable and good intentions have unfortunately developed a mindset that encourages them to look at development in low resource economies through a dependency and subservient framework, and discourages them from thinking in the broader context of meaningful and sustainable development.

The truth of the matter is that no nation in history has ever reached the next level of development through dependency aid. It is instructive that Dambisa Moyo in her recent book Dead Aid calls for an end to such unproductive dependency aid in Africa and to redirect attention to sustainable aid. She was widely attacked by what I call the “aid industrial complex” and yet loudly cheered by Africans like me who believe that Africa can only rise through sustainable investment and development that includes relevant education, appropriate technology and infrastructural development, private sector investment and good governance.

AC

In a recent presentation you stated that through the Heart Institute you have been able to demonstrate high-quality health care comparable to anywhere in the developed world. Was scepticism high in Jamaica about the possibility of receiving first-class cardiac care “at home?”

Ernest Madu

When we began the journey in Jamaica we encountered different modes of thinking, as you would expect. We encountered significant bureaucratic hurdles, partly because of the high dose of scepticism, and partly because of the complexity of the operations we proposed. We encountered an environment where most of the services we proposed were not offered anywhere in the English-speaking Caribbean. Residents of these countries have long depended on facilities in Florida to access these services at exorbitant rates. More significantly, only the few elites with means and the access to the USA had any opportunity to do so. The majority had no options. Our plan, therefore, meant that the order of things would have to change. Change as a concept is always a controversial proposition anywhere. Entrenched interests that benefited from the existing status quo predictably were uncomfortable with the change we were bringing, and as we expected this group resisted any change. Yet another group were afraid of change because of the uncertainties that change brings. Fortunately, these groups were in the minority as the majority of physicians and patients saw the value in what the Heart Institute was bringing and supported our plans, and continue to support our efforts to this date. With the success of our programme the nay-sayers are finally coming around, and we attribute this to the fantastic work done by our staff, our physicians and our community physician advisers; proof positive that high quality cardiac care can be delivered locally.

AC

Your Institute provides health care at around 10 per cent of the cost required to provide it in the USA. How have you been able to achieve this?

Ernest Madu

We recognise that the ultimate value of good quality health care hinges on access. Access in low-resource nations is primarily determined by affordability and availability. By building the facility in Jamaica, we accomplished the first goal of making the services locally available. From the conception phase to the implementation, we were cognisant of the issue of access and affordability. We implemented processes that improved cost efficiency and minimised waste. We evaluated our equipment needs and concentrated on multi-modality systems to emphasise consolidation without duplication. We paid attention to recruitment, and focused on individuals with multiple skills or individuals eager to acquire additional skills to allow cross-coverage of personnel. We encouraged continuous education and professional development to improve performance and efficiency. We encouraged appropriate use of technology in areas such as image management, electronic medical records, use of nuclear generators for local elution of radioisotopes etc, to improve quality of care while keeping costs down. We rewarded our staff for performance along these lines. Not only have we been able to keep our costs significantly lower than in comparable locations in the USA, we have also been able to implement an Open Access Programme that greatly subsidises indigent care in Jamaica. We have now launched the HIC Foundation to further support those indigent patients and facilitate infrastructural development.

AC

To quote you from a recent talk, “the only way to bridge the gap between the rich and poor countries is through education and technology”. Can you elaborate on this?

Ernest Madu

I have often said that in order to bridge the gap between the rich and poor nations of the world, the poorer nations must make sustained investment in relevant education and appropriate technology. This investment must be clearly thought out, with appropriate legislative backing to force the national policy thrust consistent with national priorities. The current state in many low resource nations – where “expertise” is sought from so called “consultants” with limited knowledge or frank ignorance of the local needs – is ineffective and does not yield tangible benefits. The educational curricula and direction in many low resource nations are often uncoupled from the national development needs and aspirations. Certain programme and course outlines seem designed to perpetuate the status quo. Students must be taught in a way to empower them to believe in their abilities and to be change agents rather than to absorb foreign concepts without local content or relevance.

Technology application must have defined objectives that support national development priorities and goals. Policy direction should aim to encourage students who undertake learning in deficient but relevant areas, and must support institutions which adopt relevant technologies that improve outcomes and quality of life. We recognise that in the current state of affairs, poor nations of the world continue to subsidise the rich nations by exporting their best brains to the rich nations where the infrastructure is there for them to accomplish their professional goals. Many of these individuals would welcome an opportunity to come back home if unnecessary bureaucratic hurdles are removed and the appropriate technology is in place to facilitate their professional growth.

More importantly, their foundational training must instil them with self-confidence and empower them to reject failed approaches and to embark on positive change that can make a difference for the benefit of all.

AC

You also recognise that technology cannot be a solution on its own, and that prevention must be a key part of the equation. Can you tell us about the work you do in relation to disease prevention, for example the 3k walk and the Heart Healthy Fair? How important is this work?

Ernest Madu

Prevention is an essential and fundamental part of our approach to cardiovascular care. An underlying part of our mission is our firm belief that sustainable and affordable high-quality cardiovascular care must rely on smart design and appropriate use of technology, anchored on aggressive prevention and treatment strategies – more so in low-resource economies. We believe that cardiovascular disease is largely a lifestyle disease and thus would require an integrative approach to care. We recognise prevention strategies as critical to our success. This is so central to our approach that we have recently built a Life Centre – “BREATH” – where we focus primarily on preventive strategies including weight management, exercise prescription and training, cardiac rehabilitation, nutritional support, smoking cessation programmes and so on. We invest heavily in community and group prevention strategies including heart walks, heart healthy fair, radio programmes, our Doctors in the Pulpit programmes (with local churches) and community service announcement. Through our Heart Institute of the Caribbean Foundation, we have designed work site and school site programmes to promote healthy habits and exercise to combat cardiovascular diseases.

AC

According to a recent article in ODE Magazine, you are worried that the advance of Western-style development means Jamaicans and other people of the developing world are losing the few health advantages they enjoy compared to wealthier nations. What do you mean by this?

Ernest Madu

In many low-resource and developing nations, migration from rural to urban settings occurs with development and demographic shifts. Often, part of these demographic shifts and mobility include adoption of Western styles and values, which is often misinterpreted to mean sophistication, enlightenment and affluence. This mindset encourages increasing sedentary lifestyles, increased use of tobacco products and adoption of high-fat Western diets. This change in habit over time leads to rising prevalence of traditional risk factors for cardiovascular disease. Epidemiologic studies demonstrate a link between prolonged exposure to risk factors such as tobacco consumption, high cholesterol, high blood pressure, physical inactivity, obesity, poor diet and CVDs.

Lifestyle diseases like diabetes, obesity and hypertension constitute a major public health concern for developing countries and will continue to do so for the foreseeable future. The impact of these diseases on public health and national economies of developing societies cannot be overestimated. In Jamaica for example, as many as one in six adults are thought to be afflicted with diabetes. More worrisome data is emerging in the young as well, fuelled in part by obesity and physical inactivity. A recent report from one of our physicians at the Heart Institute of the Caribbean, Dr Marshall Tulloch-Reid, suggests that more adolescents become obese at an early age and are therefore at an increased risk for developing type II diabetes. Data from Dr Tulloch-Reid suggests that as many as 19 per cent of adolescents in Jamaica are considered obese. He also noted that 20 per cent of diabetics in this population are afflicted with type II diabetes. This data is consistent with the global phenomenon showing that we in the Caribbean region are not insulated from the negative health consequences that result from the Westernisation of indigenous cultures.

It further indicates how poor nutritional choices, physical inactivity and obesity fuel the global epidemic of diabetes and cardiovascular disease. The International Obesity Task Force estimates that more than 150 million children worldwide are either overweight or obese, including about 22 million children under the age of five. In some Caribbean and Latin American nations like Mexico and Colombia, the prevalence of childhood overweight and obesity is in the range of 20-25 per cent. These children are at risk for diabetes. We now understand that the epidemic of cardiovascular disease is intertwined with the rising prevalence of diabetes. In 2003, the worldwide prevalence of diabetes was estimated at 5.1 per cent among persons between 20 and 79 years of age. By 2025, the worldwide prevalence is projected to rise to 6.3 per cent, a 24 per cent increase compared with 2003.

A significant majority of this increase is in low resource, developing countries. More recent estimates from the WHO indicate that the actual number may be triple the current estimate, and that 80 per cent of deaths and disability-adjusted life years related to diabetes occur in developing countries. Available data suggests that diabetes and cardiovascular disease will account for about a million deaths annually in Latin America, representing over 25 per cent of all deaths, affecting an equal number of men and women. In the Caribbean and South America, diabetes and cardiovascular disease will be responsible for three times more deaths and disability by 2025, affecting mainly individuals in their mid-life years, disrupting the future of families, undermining social structures and depriving nations of workers in their most productive years, thus precipitating economic decline and underdevelopment. Ironically, these are countries with already limited resources and limited access to advanced technologies and treatment modalities to mitigate the complications resulting from diabetes and the associated cluster of cardiovascular risk factors that include hypertension, physical inactivity, high cholesterol and obesity. Economic transition, urbanisation, industrialisation and globalisation encourage lifestyle changes that promote diabetes and heart disease.

Diabetes and heart disease impose significant economic burden and stress on national health systems and adversely impact national economies, disrupt the social order and burden families.

AC

Finally, what do you hope to have achieved in ten years’ time?

Ernest Madu

We have embarked on a mission to change the way cardiovascular health care is delivered in low-resource nations with our primary focus in Africa and the Caribbean. We are under no illusion as to the difficulty of the task, complicated by the desire of entrenched interest groups to perpetuate the status quo as well as the mindset that discourages sustainable investment.

We believe that our model represents a practical and solution-oriented model and we have shown that it can be done and can be sustained. Our goal is build on our current success and replicate this model across different communities in Africa and the Caribbean directly or indirectly through other associates and potential partners. In the process, we hope to advance the level of health literacy in Africa and the Caribbean to empower ordinary people to become advocates for high quality health care across the regions. We believe that the type of high quality cardiac care that is standard in the USA and much of Europe can indeed be routinely available globally, and we believe this can be accomplished at a fraction of the cost of such services in the USA and Europe.