Cardiovascular Care in Ethiopia

Zachary Hermes, M.D. 

Resident, Internal Medicine at the Brigham and Women’s Hospital, 

PGY3

0208/2020

Ethiopia is located in Northeast Africa, and is one of the largest countries on the continent with a land mass three times larger than Germany and a population of nearly 100 million. Non-communicable diseases such as congenital heart disease, rheumatic heart disease, heart failure, and ischemic heart disease are of growing importance and consequence. Yet, access to cardiac services remains limited in Ethiopia. My time in Ethiopia was spent observing and diagnosing the growing burden of cardiovascular disease, exploring the ecosystem of cardiovascular services, and gaining insight into the challenges and opportunities to expanding cardiac care capacity.

Modern cardiovascular care was first made  available within Ethiopia in the mid-90’s. Most of this care has been at a relatively small scale and come in the form of visiting cardiac surgical and interventional cardiology teams. The first Ethiopian-led non-invasive and invasive cardiology (pacemaker insertion and percutaneous coronary interventions) care began to be offered in 2007. In the decade that followed the national Ministry of Health prioritized the establishment of modern cardiology units in their anchor, tertiary-level University Hospitals. With diligence and commitment a number of internists were trained abroad in non-invasivee and invasive cardiology, though their numbers are in the single-digits. Addis Ababa College of Health Sciences, which is affiliated with Black Lion Hospital, was one of the first to be outfitted with a modern catheterization laboratory in 2016 and they have subsequently launched an Ethiopian Cardiology Fellowship program in 2018. My elective work was spent with these endeavoring attending cardiologists and the third cohort of cardiology fellows. My days were split up between cardiovascular outpatient clinics, inpatient cardiology wards, and an occasional pacemaker implantation or balloon valvulotomy with rounds in the cardiac intensive care unit to follow. In the clinics, I saw over 100 patients in the clinics with roughly 40% of those with rheumatic heart disease spanning a spectrum of heart failure and another 30% with some variation of ischemic heart disease, hypertension, or diabetes. The morbidity caused by rheumatic heart disease was truly striking, with far too many teenage patients already with symptoms of heart failure and advanced structural disease that would necessitate valve replacement in other settings. Unfortunately for these patients, they were relegated to symptomatic management with diuretics. The waiting list for valve replacements hovers around 10,000 patients (!) with movement dependent on the aforementioned visiting groups. It was just in 2017 that the first open heart surgery was performed in Black Lion Hospital by an Ethiopian Surgeon supported by one of the foreign surgical teams. The momentum has been continued as their cardiology fellowship now has graduated their first cohort, a masters of cardiac nursing program is up and running, and a perfusionist training program is in place. Most excitingly, the Ethiopian and Netherlands governments had signed a joint deal with Phillips to break ground on a state of the art cardiac care facility on the Black Lion Campus. I had the pleasure of working with clinical lead of this project, Dr. Dejuma Yadeta, for a number of days and we visited the site. 

With Dr. Berhanu Nega, M.D., Associate Professor of Surgery
at Addis Ababa University School of Medicine, Head Cardiac
Service Team at Tikur Anbessa Hospital, in front of construction
site for state of the art Cardiac Hospital on Tikur Anbessa Hospital Campus

As the largest teaching hospital in Ethiopia, Black Lion Hospital and Addis Ababa University School of Medicine serves as a vibrant training center for undergraduate and postgraduate medical students and trainees. This was my base throughout my elective with interspersed time at number of smaller clinics and districts hospitals, which were envisioned to act as a referral network and means to decentralize care. Still, the hospital and its associated clinics act as the primary source of access for a significant proportion of both the urban and rural population. During my time I saw numerous patients who had traveled more than 300 kilometers for routine management, which highlighted the importance of decentralizing care for Non-Communicable Diseases (NCDs). Though the challenges are undoubtedly immense, I came away struck by the dedication, strategy, and thoughtfulness of my Ethiopian colleagues and sure that I will continue to support and collaborate them in any way I can as I move forward in my career.

Reference

Christian J Leuner, Abraha Hailu Weldegerima, Cardiology services in Ethiopia, European Heart Journal, Volume 39, Issue 29, 01 August 2018, Pages 2699–2700, https://doi.org/10.1093/eurheartj/ehy373