As Nigeria grapples with rising cardiac diseases, President of the Association of Cardiovascular and Thoracic Surgeons of Nigeria, Professor Anietimfon Etiuma, in this interview with BIODUN BUSARI, reveals the root causes and proffers potential solutions
How prevalent are cardiovascular diseases among Nigerians?
Cardiovascular diseases are enormous. We divide them into four. About one-third of all deaths in the country are cardiovascular-related. One-quarter of all deaths from injuries involve cardiovascular and thoracic systems.
Also, one-quarter of the remaining group will die from cardiovascular-related complications. This means that 50 per cent of individuals suffering from injuries may ultimately die from cardiovascular illnesses related to trauma
We have children who are born with congenital heart diseases. That’s another group of congenital heart diseases. The main treatment of congenital heart disease is surgical intervention. Many of these children die and many of them don’t grow into responsible adulthood.
When they get to two or three years of age, some of them will look like six months or a year old. A major hindrance to addressing this issue is the lack of access to affordable surgical interventions.
Then, we have acquired adult heart diseases that affect the valves, blood flow, and the heart itself. And most of these are caused by blood pressure-related problems and diabetes, including excess cholesterol. They form the basis of either heart attack from valve failure or heart attack because of the blockade of blood flow within the heart itself. We call it coronary artery heart disease. These whole groups of diseases are increasing by the day. They form the bulk of what we call non-communicable diseases. And, for adults who are 50 years and above, it is a major cause of death apart from cancer.
And, when it comes to infections affecting the lining and valves of the heart, as well as lung infections such as tuberculosis and pneumonia, the consequences can be quite severe. Many of them will require chest surgical operations for the removal of diseased parts or drainage.
The other group that remains is cancer. Lung cancer is a known killer worldwide. Before, it looked as if it was rare in Nigeria, but now because of changes in lifestyles, especially in our eating, smoking, drugs, and air pollution, lung cancer is becoming very common.
Apart from the primary lung cancer, other cancers like oesophagus, and cancers from other sites, whether breasts, womb, limbs, skin, bone, or colon, finally set to the lung because all blood goes to the lung for oxygenation. The common site of the spread of all cancers is the lungs.
Why do all cancers have to affect the lungs?
Blood from all parts of the body gets channelled to the heart, to the lungs for oxygenation. And if they carry cancer cells, they get to litter the lungs and begin to develop. Therefore, the lungs are a common site for the spread of various types of cancer.
What is responsible for these congenital heart diseases in children?
Some of the diseases are caused by genetic abnormalities that are transmitted from parents. If a parent has heart disease or a hole in the heart, the chances of the child having it is about four times higher. There are also environmental factors including infections.
Some infections are transmitted when the babies are in the womb, like rubella, and they give rise to heart disease.
Many mothers these days are giving birth at older ages. The older a woman is when giving birth, the higher the chances of congenital abnormalities in their children. When women give birth at 35, 40, and above, the likelihood of these abnormalities increases significantly.
In addition, environmental factors such as pollution from dust, gas flaring, vehicular emissions, illegal bunkering, and related activities contribute to congenital problems. Radiation, including ultraviolet radiation from sunlight, also plays a role.
Another factor is the indiscriminate use of drugs, especially during pregnancy. Some of these drugs may have been used in an attempt to abort, and when the abortion fails, they affect the baby’s development. In other cases, the drugs might have been taken before the mother realised she was pregnant, impacting the baby’s growth. Sometimes, these abnormalities occur without any known cause.
What is the estimated cost for both adults and children to undergo surgery for congenital heart diseases in Nigeria?
The cost, initially, was about N3m either for adults or children. But, currently, the cost has gone up to about N5.5m. That’s the average cost. This is because most of the materials used are imported and they are affected by exchange rates. The surgical consumables have gone very high. At the end of the day, the prices are beyond what individuals can afford.
Even the cost of treatment in Nigeria is lower compared to getting treated in other countries. When considering the cost of heart surgeries abroad, it can range from $10,000 to $20,000, depending on the type of surgery. In addition, you have to factor in flight costs, accommodation, and other expenses.
What are the challenges faced by cardiovascular and thoracic surgeons in the country?
One of the challenges is affordability. This is because it would take an average family a lifetime of savings to afford just one heart surgery.
There is a problem with prompt and accurate diagnosis because the centres equipped to provide accurate diagnoses are few in Nigeria.
Additionally, we have a shortage of personnel. Only a few individuals have made the sacrifice to undergo training, and ACTSON as an association encourages them to remain in the country to help our population.
Also, one of the challenges we face is the need for more equipped centres. However, in the last three years, several facilities have emerged across the country offering heart surgeries, stretching from the South to the North. Notable institutions include the University of Calabar Teaching Hospital, the University of Benin Teaching Hospital, and various private and government-owned hospitals in Lagos. We also have facilities at the University Teaching Hospital in Ibadan and the University of Nigeria Teaching Hospital in Enugu, as well as hospitals in Abuja, Zaria, Jos, Sokoto, and Maiduguri. These locations have successfully conducted open-heart surgeries in recent years.
Are you saying the Japa syndrome also affects cardiovascular and thoracic surgeons?
Well, the Japa syndrome affects all categories of medical practitioners. It has seriously affected cardiovascular and thoracic surgeons. Some of the surgeons who were trained had to go abroad to practice, while others who trained outside refused to return. Those who come back often found themselves unable to perform heart surgeries due to a lack of equipment. This year, two of our renowned experienced surgeons returned to the diaspora to continue their practice, highlighting a significant issue: when cardiovascular and thoracic surgeons complete their training and return to their institutions, they often find they cannot operate due to insufficient resources. Currently, we have only about 80 cardiac and thoracic surgeons in the country, which is grossly inadequate. Some states have fewer than two surgeons, and some have none at all.
Regular heart surgeries are conducted in Lagos, Ife, and Abuja, while other facilities perform interrupted heart surgeries, meaning they don’t carry them out regularly. Some may operate only once a month, every two or three months, or even just as part of a mission, with some hospitals only performing heart surgeries once or twice a year, despite the high demand from patients.
Cardiac surgeries require a comprehensive team, not just the surgeon. The team includes anaesthetists, cardiologists, intensive care specialists, bedside nurses, biomedical engineers, physiotherapists, and perfusionists. A large number of experts are essential for each heart operation.
Therefore, it’s not only the surgeons who are in short supply; other team members are also lacking. Until recently, about five years ago, when we began training local team members, we relied heavily on perfusionists from the UK, US, South Africa, or India.
What is ACTSON doing with the Federal Government to remedy these problems?
That is why we are strongly advocating for the government to incorporate heart surgery into the National Health Insurance Authority coverage. Currently, the NHIA does not cover heart surgeries.
If they could include just 1,000 heart surgeries a year, it should be allocated in the budget to fund relevant institutions. The Federal Government is not providing subsidies because heart surgeries are excluded from the NHIA’s catchment, leaving most Nigerians unable to afford these procedures. As a result, many continue to die due to these ongoing challenges.
We are calling for a special intervention fund dedicated to heart surgeries. In Nigeria, most cardiac surgeries are performed by foreign practitioners and non-governmental organisations. Once they finish their work, they return home, resulting in poor follow-up care and limited operations, primarily focusing on simpler cases while avoiding more complex ones that require long-term management.
Many Nigerians seek surgeries in countries like India, the United States, and the United Kingdom, which only a few can afford. Sometimes these are community efforts, private sponsorships, or support from wealthy individuals. However, these initiatives represent just a drop in the bucket. The Association of Cardiovascular and Thoracic Surgeons of Nigeria advocates for the establishment of well-equipped heart surgery centres and calls for the government to enhance the welfare of the heart surgery team members.
Why are men mostly affected by cardiac arrest in Nigeria?
If we say men are more affected, this depends on the spectrum of heart diseases. If we talk about congenital heart diseases, both males and females are affected.
If we talk about acquired heart diseases, both males and females are affected. If we are talking about hypertensive heart disease and diabetes, that is where we have more men.
And of course, this is so because more men are involved in more strenuous adrenaline-driven activities.
Men are the ones who are more involved in political activities or skilled professions and don’t have time for adequate rest. Men are the ones that mostly stay awake in the middle of the night. Inadequate sleep, anxiety and the male sex hormone, which is testosterone cause this.
The male hormone testosterone, which is an androgen, is more likely to raise blood pressure. Additionally, many cases of high blood pressure are not treated promptly, and treatment can be erratic. Some antihypertensive medications that used to cost around N4,000 or N5,000 have now risen to between N20,000 and N30,000.
Men are more affected because high blood pressure is generated in the heart. When the heart becomes fatigued, it can fail. Even if treated, the heart rarely returns to its normal function after experiencing failure.
Moreover, diabetes is becoming increasingly common. High blood pressure often precedes diabetes, and vice versa; these two conditions are closely linked and can reduce blood flow throughout the body, ultimately leading to heart failure. Uncontrolled high blood pressure can negatively impact the brain, eyes, kidneys, heart, pancreas, lower limbs, and the autonomic nervous system, which includes erectile function. This chain of events can lead to heart attacks and sudden death.
If blood pressure is not well managed, it affects the entire body and can result in strokes. Professionals like judges, who may face high-pressure situations while drafting lengthy judgments, are particularly vulnerable if their blood pressure is not well controlled. Such individuals may suffer from cardiac or cardiovascular emergencies, such as aortic dissection, leading to sudden collapse.
What should men do to prevent this?
The most important health insurance programme is regular check-ups for those who are 40 years and above once a year. With the check-up, cardiovascular risk factors can be picked up and things that need to be treated are managed.
That is the most important thing that I have found that can help, not just when somebody is sick. Check-ups help to delay cardiovascular diseases or prevent them. Even when someone has hypertension and it is well controlled, he will live his life like any other person who does not have hypertension. The same thing applies to diabetes. The reason why most people who go to the hospital for the first time in old age don’t return when they are sick is because these diseases silently kill them.
Exercise is a good medicine and most beneficial as a cardiovascular maintenance activity. For exercise to be effective, it must be performed regularly, three to four times a week, for at least 30 minutes at a time, and should induce sweating. Many people mistakenly believe that leading an active life equates to exercise; however, activities such as cooking, sweeping, or house chores don’t qualify as exercise. True exercise requires the full engagement of the body, and an active lifestyle is not the same as structured exercise.
Another one is diet and weight control. In Africa, women like to look well-fed so that their neighbours will know that their husbands are taking good care of them. They eat round the clock without engaging in exercise and gain weight unnecessarily. If this is not controlled, it leads to obesity, which is the foundation for hypertension and diabetes in adult life.
Additionally, the number of kidney failures in the country has risen. Chronic kidney diseases also impact heart health, contributing to the increasing prevalence of heart disease.
