Amid palpable changes in lifestyle and food habits, the urban population is becoming more vulnerable to heart diseases. As facilities for treatment of cardiac problems expand, so has the number of heart patients. Studies show a large number of heart patients living in different parts of the country, with many in the rural areas dying without knowing they had the disease. As fatalities from heart attacks among the economically active 40-50 years age group go up, the long-term damage to the nation becomes incalculable. Once regarded as the bane of the privileged, heart diseases are now common among all sections of the population. Isn’t it time for emergency treatment?

By KESHAB POUDEL

Surendra Shrestha, 42, an employee of a government bank, collapsed at dinner with his family. Shrestha’s relatives rushed him to nearby Bir Hospital. After preliminary treatment at the Cardiology Care Unit for a few days, Shrestha headed straight to India for surgery.

Each year, thousands of Nepalis like Shrestha get coronary artery diseases (hardening of the arteries leading to loss of blood supply), one of the main causes of heart attacks. One third of those suffering heart attacks die. More worrisome is the fact that a large number of people who suffer heart attacks die before they reach the hospital.

A patient in hospital : Is the treatment satisfactory?
A patient in hospital : Is the treatment satisfactory?
Shrestha, who comes from a middle-class family, is a chain smoker and is obese. He hardly had any physical activity and liked high-cholesterol food. “I never realized that obesity and lack of physical activity would cause a heart attack,” Shrestha said.

A large number of Nepalis do not realize that, either. Because heart disease is so common and often silent until it strikes, however, it is important to recognize the factors that put you at risk.

Krishna Kumar Rai, 45, a gazetted officer at a government department, did not realize something was wrong with his heart until he was hospitalized. Although he felt chest pains a week before the heart attack, Rai was rushed to Tribhuvan University Teaching Hospital in Maharajgunj. Certain surgery facilities were available there, but Rai’s family decided to take him to India after his condition stabilized. Rai, who is now living a normal life, spent Rs.700,000 on surgery and treatment.

On an average, half a dozen Nepalis fly to India or Thailand for heart operations or check up every day. According to unofficial studies, millions of rupees are spent each year for the treatment of heart diseases. Despite the availability of facilities in Nepal, most affluent patients still prefer to go abroad.

Martyr Gangalal national heart center : Providing succor to cardiac patients
Martyr Gangalal national heart center : Providing succor to cardiac patients
A person’s heart is about the size of his or her fist. As the body develops, the heart grows at the same rate as the fist. So an infant’s heart and fist are about the same size at birth. As the child’s body grows, the requirement for oxygen is the greatest. The heart’s rate of pumping oxygen-rich blood is fastest in infancy, about 120 beats per minute. As the person grows, the heart rate slows.

Heart Treatment

Until two decades ago, heart problems were regarded as a something that afflicted people of the upper class and were largely ignored . Thanks to the sustained efforts of people like Dr. Mrigendra Raj Pandey, one of Nepal’s first cardiologists, public awareness has increased dramatically over the years. The government has agreed to set up specialized services.

Although the first heart surgery was performed in Nepal nearly 15 years ago at Bir Hospital by Dr. Lok Bikram Thapa, patients had to wait until 1999 for such operations to become regular. At the initiative of then-director of the Tribhuvan University Teaching Hospital, Dr. Govinda Sharma, Dr. Bhagwan Koirala and his team started regular heart surgery in the country.

Dr. Koirala, who now heads the Shahid Ganga Lal National Heart Hospital, alone performs five to six operations ó both open- and closed-heart surgery — a week. Hospital records show a very high success rate.

Although government-owned Bir Hospital has the distinction of performing Nepal’s first heart surgery, the operation theater is now virtually closed. Three years ago, when Dr. Ram Prasad Shrestha served as director, the hospital reopened its heart surgery department. But it was closed again after Dr. Shrestha’s departure. The hospital today offers out-door facilities for cardiac patients.

Bir Hospital : Patients in queue
Bir Hospital : Patients in queue
It took Dr. Damodar Pokharel, who specialized in heart surgery in Australia, nearly two and half years to perform his first surgery. But the patient developed post-operation complications and died within a week. Dr. Pokharel has not performed a surgery after that.

With the kind of facilities it has, Bir Hospital can still perform heart operations. But experts and policy makers are discussing whether the country should scatter its scarce resources over various hospitals or simply concentrate them on one state-of-the-art facility.

“The resources need to be concentrated on one center in order to equip it with modern facilities,” says Dr. Shrestha. “Because heart operations are very expensive, the resources need to be concentrate on one institution. Cardiac problems have been increasing because of changes in lifestyle and eating habits and in tobacco consumption.”

Surgery still remains out of the reach of most Nepalis. “The Ganga Lal Center should be developed as a well-equipped cardiac center and its resources should be concentrated on serving the common people,” says Dr. Shrestha.

In the last two years, the quality of heart treatment facilities in the country has improved remarkably. Along with some private nursing homes like Norvic Heart Center, one can find surgical facilities in Tribhuvan Teaching Hospital and Ganga Lal National Heart Center. Medicare Hospital also has well-equipped facilities for cardiac patients under Dr. Avani Bhushan Upadhyaya, a prominent cardiologist.

Surgery Cases

Every week, groups of surgeons perform seven to eight operations in two hospitals. Interestingly, patients from all strata of the population prefer Ganga Lal Heart Hospital. If a patient like Pradhan wanted to perform surgery inside the country, Ganga Lal National Heart Center has all kinds of facilities he would need. Each year about 500 heart operations are performed within the country.

The World Health Organization and the Ministry of Health have accorded high priority to heart diseases. This is a significant shift in official thinking from a decade ago, when such diseases were hardly considered a major health threat. Today it is one of the top 10 diseases Nepal is working to combat.

With this shift in priority and the rise in the number of heart patients, the ministry has set up a focal point for non-communicable diseases. According to an estimate, more than one million Nepalis suffer from heart-related diseases.

“Frankly speaking, heart diseases are on the rise. Both coronary heart diseases and rheumatic heart diseases are rising among the poor and rich,” says Dr. Koirala.

Health Ministry : Tough task in hand
Health Ministry : Tough task in hand
From the moment it begins until the moment it stops, the human heart works tirelessly. In an average lifetime, the heart beats more than two and a half billion times, without ever pausing to rest. Like a pumping machine, the heart provides the power needed for life. The heart has many complexities in terms of its development and structure.

Leading Problems

Heart disease is one of the leading causes of death in the developed countries and claims more lives each year than cancer, accidents and AIDS combined. While Nepal faces similar problems, the situation is compounded by a lack of awareness of the disease. In the rural areas, a large number of patients die without ever knowing they had a heart ailment.

Medical researchers have identified the conditions that increase a person’s risk of getting heart disease. Some are not changeable and are, therefore, termed non-modifiable risk factors. Males, older people, those with a family history of heart attack or angina (chest pain caused by lack of oxygen to the heart muscle), post-menopause women, smokers, and people with high cholesterol levels and/or hypertension (high blood pressure) are at greater risk of getting heart disease. Physical inactivity and obesity are among the other leading risk factors.

Ways to Prevent Attack

Many Nepalis lead sedentary lives and exercise infrequently or not at all. People who don’t exercise have a higher rate of death from heart disease compared to those who perform mild to moderate physical activity. Leisure-time activities like gardening and walking can lower the risk of heart disease.

One reason for the high incidence of heart diseases may be that Nepal has one of the world’s highest smoking rates. According to medical researchers, smokers are twice as more likely to have a heart attack than non-smokers. Moreover, smokers are more likely to die after suffering a heart attack.

As people in urban areas tend to eat foods that are higher in fat content, they are more prone to high cholesterol levels. The risk of angina and heart attack increases over the entire range of elevated blood cholesterol levels, with a sharp increase in risk at all levels of total cholesterol over 240. In urban areas, the large section of the population has hypertension or high blood pressure, making it the most common heart disease risk factor.

Maintaining a healthy weight is one of the essential factors to prevent a heart attack. As body weight increases, the blood pressure rises. In fact, an overweight person is two to six times more likely to develop high blood pressure than a person with desirable weight. It is not just how much you weigh that is important. It also matters where your body stores extra fat. Even small amounts of weight loss can make a big difference in helping to prevent high blood pressure.

“One can actually reduce the risk for heart disease and angina if some modifiable risk factors are followed,” says a medical practitioner. Foods high in starch and fiber like fruits, vegetables, dry peas and beans as well as whole-grain cereals, pasta, rice and breads are excellent substitutes for those high in fat.

As many new specialized facilities become available in Nepal and awareness increases, heart patients are visiting hospitals and health centers in larger numbers. “In general, the pressure from heart diseases is rising in accordance with the population. But in the hospital, the percentage is rising many folds,” says Dr. Koirala

Although the exact number of people with heart diseases in Nepal is hard to determine, tentative figures show an alarming level of incidence. On average two people out of every 1,000 have rheumatic heart disease. A study conducted by Dr. Pandey in Kathmandu valley found coronary heart disease in about five percent of 100 government employees examined. Dr. Pandey’s research has also shown the vulnerability of the disease. One percent of all live births has heart disease. In short, tens of thousands of Nepalis have heart disease.

The facilities Nepal has are not adequate to treat such a large number of patients. According to a medical practitioner, the existing system can provide surgery for 500 patients, whereas more than half a million people are in need of operation.

Surgery Facilities

The establishment of the National Heart Hospital helps to train surgeons and doctors. There will be more doctors to perform the surgery. After the expansion of its facilities, the center will be able to expand the 8 to 10 operations it now performs in a week.

“We are performing 10 to 12 surgeries a week,” says Dr. Koirala. If we maintain this rate, we can perform more than 500 surgeries in a year. I don’t have records of other hospitals, but I can say the trend is encouraging. In teaching, another team of heart surgeons is building up.”

As they say, prevention is better than cure. In the case of heart diseases, this adage is more relevant because of the costs involved. Heart surgery is more expensive than a gall bladder operation because it requires more disposable equipment. In terms of total expenditure, heart surgery in Nepal costs one tenth of what it does in any other country in the region.

On an average, a patient has to spend more than half a million rupees to perform heart surgery in our neighboring countries. By investing more in heart facilities, the country can save millions of rupees that are spent by Nepalis abroad and save more lives.

Treatment costs vary with the nature of the disease. “Closed-heart surgery is cheaper than open-heart surgery,” says Dr. Koirala. “Closed-heart surgery normally cost Rs. 10,000 to 15,000. In the case of open-heart surgery where one does not have to change the valve, the cost will range between Rs. 70,000 and Rs. 80,000,” he says. “If someone needs to change the valve, it will cost an additional Rs.75, 000 per valve. We can reduce the price.”

Asked whether Nepal had all the facilities needed for treatment, Dr. Koirala says: “I cannot say all, because that is a relative thing. Even in the United States, one cannot get hundred percent treatment for heart diseases. But we do have all kinds of facilities available in other parts of South Asia. We still lack some facilities, including angiography. On the surgical side, we can perform all kinds of operations like in other hospitals in South Asia.”

Dr. Koirala says the rush at the hospital these days shows how public perceptions have changed. “We have a long queue of patients. The category of patients is changing, which is a good indication. Many patients who can afford going abroad are coming to us. In the beginning, we only had patients from low-income group.”

As food habits and lifestyles in urban areas continue to change, the government and the medical community need to prepare for an increase the number of heart patients. Along with generating public awareness, the country needs to invest more in expanding and modernizing health facilities.

‘We Need Preventive Programs And Additional Facilities’

— Dr. BHAGWAN KOIRALA

Dr. BHAGWAN KOIRALA, one of the leading heart surgeons of Nepal, is director of Ganga Lal Heart Hospital. Dr. Koirala, 38, started regular heart surgery in Nepal and has performed more than 100 operations at the Tribhuvan University Teaching Hospital. He spoke to SPOTLIGHT on various issues relating to heart diseases in Nepal. Excerpts:

How do you see the general trend of heart diseases in Nepal?

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The World Health Organization and His Majesty’s Government have given high priority to preventing and treating heart diseases. Until a decade ago, nobody saw heart diseases as a major health threat. Now the priority is shifting. This is one of the top 10 diseases the country is focusing on. Realising the importance, the ministry has set up a focal point for non-communicable diseases. This shows that the government has realized that non-communicable diseases like heart diseases are taking many lives.

What is the rate of incidence in the country?

Frankly speaking, heart diseases are on the rise. Coronary heart disease and rheumatic heart disease are rising. The prevalence is prominent both among the poor and rich. We are unable to implement effective programs to control rheumatic heart disease. But we are preparing the groundwork for some effective programs. We may see the results of such works in 10 or 20 years. Rheumatic heart disease will decline in another 10 or 15 years. Now the level remains the same. We feel greater pressure because of the increasing level of awareness and facilities within the country. So many patients are coming to the hospital and the center. I have seen growing pressure of rheumatic heart patients. In general, the pressure from heart diseases is rising in accordance with the population. But in the hospital, the percentage is rising many folds.

What is the level of incidence in terms of population?

The real picture is still cloudy but we have done some studies. On average two people in every 1,000 have rheumatic heart disease. That means the number exceeds tens of thousand. A study conducted by Dr. Mrigendra Raj Pandey in Kathmandu shows that about five out of every 100 government employees have coronary heart disease. Dr. Pandey’s research has also shown the vulnerability of the disease. The figure is very reliable. The total figure of five percent of the adult population is alarming. Many people have coronary heart disease. One percent of all live births has heart disease. In short, tens of thousands of Nepalese have heart disease. There is a clear need to implement preventive programs as well as ease the burden on medical and surgical facilities. This is a very big challenge.

How do you rate the facilities available in the country?

The facilities available are not sufficient to solve the problem. As a dedicated hospital for heart diseases, we have started to provide basic facilities. I can perform surgery on 500 patients a year, but you need to have facilities for more than half a million people who require surgery. You cannot solve the problem by performing surgery on 500 patients alone. One of the important aspects of the center is that it trains surgeons and doctors. There will be more doctors to perform surgeries. After expanding the facilities, we will be able to perform many more operations. The center will increase the level of awareness. If we start implementing preventive programs, they will reduce the number of heart patients in the future. The heart center has strong value in the future, but we are now in no position to provide clinical facilities to patients. The center is capable of performing eight to 10 operations in a week. I also perform two to three heart operations at TU Teaching Hospital. Under my leadership, we are performing 10 to 12 surgeries a week. If we maintain this rate, we can perform more than 500 surgeries in a year. I don’t have records of other hospitals, but I can say the trend is encouraging. In teaching, another team of heart surgeons is building up. A second line of surgeons performs operations even without me. Even in my hospital, some colleagues are opening the heart to perform surgery.

It is said that this is a very expensive disease. How do you look at it?

This is one of the expensive diseases. Surgery of the heart is definitely more expensive than a gall bladder operation. The technology itself is expensive, because it requires many disposable equipment. But we have to see it from the other angle as well. If we didn’t have such facilities in Nepal, how much money would we have ended up paying outside Nepal? Probably ten times more. In the long run, we can save millions of rupees and save hundreds of lives. You cannot have a cost-free operation.

How much money does an average patient have to pay for an operation?

The patient has to pay different prices for different diseases. Closed-heart surgery is cheaper than open-heart surgery. Closed-heart surgery normally cost Rs. 10,000 to 15,000. In the case of open-heart surgery where one does not have to change the valve, the cost will range between Rs. 70,000 and Rs. 80,000. If someone needs to change the valve, it will cost an additional Rs.75, 000 per valve. We can reduce the price.

How many teams do you have?

We have a four-member team in teaching and another one at this center. I supervise almost all the cases of surgery. I normally perform complex cases. Normally, we have two strong independent teams.

Do we have all kinds of facilities available within Nepal?

I cannot say all, because that is a relative thing. Even in the United States, one cannot get hundred percent treatment for heart diseases. But we do have all kinds of facilities available in other parts of South Asia. We still lack some facilities, including angiography. On the surgical side, we can perform all kinds of operations like in other hospitals in South Asia.

How many patients do you get?

We have a long queue of patients. I don’t care whether the patient is rich or poor. The category of patients is changing, which is a good indication. Many patients who can afford going abroad are coming to us. In the beginning, we only had patients from low-income group.

At a time when urban life is changing, what measures are you taking to prevent heart diseases?

We are still weak on the preventive side. We have already identified these problems and developed a strategy. We don’t have a massive awareness program. The urban population is rising and food habits are changing. Coronary heart disease, in particular, is rising. We can control it through massive investment. We are working to set up a national-level coordinating body to prevent and control heart diseases by drawing participation from the private sector, NGOs and the government.