The magazine of the World Health Organization November 1969 UK: 2/3 d USA: 0.50 - IIIK:IRLD HEALTH VVORLD HEAL'TH This nomad of the Samburu tribe lives in Northern Kenya. Should he become sedentary his blood pressure will increase. contents Heart of the matter 3 The telltale heart, by Dr Z. Fejfar and Dr A.G. Shaper 4 Pyramid clinic, by Didier Henrioud 14 Hearts that fail in their teens, by J.-M. van Gindertael 18 The long watch, by Prof Michael Davies 22 Venezuela arms against Chagas' disease 26 •••••■•••■■■■■•11110 141‘14r., •( .-41•104t'ke "." • r. 4 • * • `04'. r* 494 - 710 4... 9 Q 141 • • .41 ,s l•-•••• • — • Jamaica 29 Around the world 30 . ..110. 0".***I.M.1■01 {.0111004 2 ,14- 114" ( 4.3 *N..' !wr.9g. 6--ffir-P-77 -*4 11;0 , 1-4 0 .1)1 r1, • - ' 0 4 • p. • .• heart of the matter Diseases of the heart and blood-vessels are the leading causes of death among adults in the economically advanced coun- tries. This association gave rise to the erroneous belief that cardiovascular dis- eases were rare among people living in the warm, but poor, tropics. In fact, the word "tropical" calls to mind sleeping sickness, yellow fever and other diseases directly related to the environment. But new evi- dence now suggests that the very use of such terms as "tropical" may be misleading and that what counts is the standard of living in a tropical or subtropical country, measured socially and economically, and not the average temperature and number of sunny days. The fact that many tropical countries are at a lower stage of develop- ment is more important than their climate when comparing their health problems with those of temperate countries. Therefore the use of the word "tro- pical" in this issue of World Health should be taken broadly to indicate not only the general climatic features but that the coun- try is engaged in all the crises implicit in passing from a peasant, rural society to an industrialized and urban one. More- over, by using the term in this way we drop the fatalistic overtones that seem to imply the inevitability of certain diseases as a result of climate; rather this points the way to a possibility of beneficial change. After all, more than half of the Australian continent lies in the tropical belt, but the pattern of disease there, especially of cardiovascular diseases, is similar to that seen in other prosperous countries. What is more, many countries north of the Tropic of Cancer that are afflicted with poverty show a pattern of heart disease which could well be described as "tropical". Climate apart, the mortality from certain cardiovascular diseases, e.g. arterio- sclerotic and degenerative heart disease, increases with a rising national income whereas other disorders, such as rheumatic heart disease, decrease. The geographic distribution of the various disorders of the heart and blood vessels thus depends to a considerable extent on social and econono- mic development. not so uncommon Surveys in "tropical" countries show that cardiovascular diseases are of con- siderable importance in many of the coun- tries and that the situation may be worsen- ing. By studying conditions now rare in affluent countries we can perhaps under- stand the interaction that takes place bet- ween man, disease and environment, and how environment modifies the natural his- tory of a particular disease. The rarity of coronary heart disease, in spite of the pre- sence of such known "risk factors" as hypertension and diabetes mellitus, pro- vides a unique opportunity to assess the relative importance of these factors, which supposedly bring on the disease. Finally, what we learn may lead to the primary pre- vention of coronary heart disease in com- munities where it is not yet a problem. The frequency and severity of rheumatic heart disease among children in "tropical" countries and its poor prognosis present us with a challenge to end the suffering of the young in this large portion of the world which is now undergoing rapid change. World Health in this issue examines ways in which comparative studies of cardio- vascular diseases in the tropical develop- ing areas and in highly developed countries in temperate zones may lead to a better understanding of the causes of heart disease and so provide new weapons for the fight against this world-wide menace. ■ 3 the telltale heart by Dr Z. Fejfar * and Dr A. G. Shaper ** The public, and even some specialists, may have the impression that cardio- vascular diseases are confined to the highly industrialized countries and spare people in less developed areas. Yet, as the authors of the following article show, diseases of the heart and blood vessels exist the world over and vary according to geographic area, economic condition and food habits. After reviewing the most frequent heart diseases in "tropical" countries, the article stresses the need to study communities that are apparently free of coronary heart disease, since for the research worker the absence of a disease may often be as revealing as its presence. Information now being gathered should help to solve a num- ber of questions awaiting answers in countries where cardiovascular dis- eases are a widespread and acute problem. * Chief, Cardiovascular Diseases, World Health Organization, Geneva. ** WHO Research Professor, Department of Medicine, Makerere University College, Kampala, Uganda. The human heart, that vital, busy pump made of muscle interwoven with blood- vessels, is an organ about which we know much but need to find out far more. If it slows down and fails to supply any part of the body, that part may literally die; the result may be paralysis of an arm or a leg, or part of the brain may cease to function; if the heart itself is deprived of blood, death may occur. Like any hard- worked machine, the heart is subject to mechanical failure from a variety of cau- ses, some known, others obscure. The dis- tribution of these ailments in the world's population is not uniform but varies ac- cording to sex, diet, area and economic status. A disease may also lead to different complications in different settings ; for example, the main consequences of high blood pressure are different in developing and highly developed countries. the pressure riddle In most of the affluent societies of the world, the level of arterial blood pressure rises progressively with increasing age, especially after 40. Whether this is a nor- mal pattern or should be regarded as an environmentally induced disorder remains a source of heated discussion. Studies of the aging process in developing countries may provide the answer to this question. The Medical Research Unit in Welling- ton, New Zealand, has investigated several groups of Polynesians. The population of Pukapuka (Cook Island) does not show the usual rise of blood pressure with in- creasing age, but other groups of genet- ically similar Polynesians, who are exposed to the modern affluent way of life, do; their blood pressure rises with age; arterial hypertension and complications are not uncommon. Among the Maoris of New Zealand, the prevalence of hypertension is high and is still rising, while among the Europeans in New Zealand it has been falling; hypertension in the Maoris is frequently associated with a tendency to- wards gout. Tantalizing as these clues are, their true significance has yet to be deter- mined. The peoples of northern Kenya, the Samburu and the Rendille, lead a nomadic existence with their herds of cattle, camels, sheep and goats; they also show no increase in blood pressure levels with increasing age. Studies carried out by the WHO Car- diovascular Research and Training Centre in Kampala, Uganda, have shown that young men from these tribes who join the Kenya army show a significant increase in blood pressure in their second year of ser- vice. One of the many changes associated with their transition from a nomadic life to the disciplined existence of the army is a considerable increase in salt intake, although other dietary changes and such factors as environmental stress may also play a part. In the affluent countries it seems that people with high blood pressure are more likely to develop disease of the arteries and coronary heart disease. In the tropical countries, although long-standing and se- vere hypertension results in brain damage, heart enlargement and heart failure, or in kidney damage and kidney failure, severe atherosclerosis and coronary heart disease virtually do not occur. A similar situation has been observed in China, Japan and Mongolia, as well as in many tropical countries, and shows that hypertension should be regarded as an aggravating phe- nomenon in the development of coronary heart disease and not as a basic causal factor. There is clearly a tremendous need to study the natural history of hyperten- sion in populations not prone to severe atherosclerosis. common heart diseases Coronary heart disease or ischaemic heart disease: Cardiac disability from insufficient supply of blood to the heart muscles; in most cases caused by advanced atherosclerosis in the coronary arteries. Atherosclerosis: Lesions on the inside of the arteries with fibrous and fat deposits which lead to thickening, hardening and narrowing of the arteries and thus impede the flow through the arteries. Heart attack: A sudden disturbance of heart function which occurs in coronary and certain other heart diseases. Hypertension or high blood pressure: Abnormal elevation of arterial blood pressure as a result of narrowing of the small arteries; this increases resistance to the flow of blood and thus may over- work the heart. Cerebrovascular lesions: Diseases of the brain often manifested by loss of conscience and some- times causing paralysis of part of the body (stroke) when small vessels are ruptured or arteries blocked. Rheumatic heart disease: Damage to the heart valves and heart muscle resulting from acute rheumatic fever. Cardiomyopathies: Diseases of the heart muscle of different, often obscure, origin. The dominant feature is the great enlargement of the heart with diminished function (cardiomegaly). Chagas' heart disease is a cardiomyopathy in which the cause is known (see page 11). Endomyocardial fibrosis (EMF): Tropical cardio- myopathy characterized by massive fibrosis (scarring) of the inner wall of the ventricles which leads to the deformation of the cavities and impaired pumping of the heart. Cor pulmonale: Enlargement and failure of the right ventricle as a result of lung disease. "Primary" pulmonary hypertension is of obscure origin and may lead to cor pulmonale. Congenital malformations of the heart: Anomalies in the development of the heart in the foetus. In economically advanced countries, coronary heart disease, high blood pressure and cerebro- vascular lesions are the most common diseases of the heart and blood vessels. In the developing countries, high blood pressure and rheumatic heart disease are in the lead followed by cerebro- vascular lesions, cardiomyopathies and infections of the heart (associated with pus-forming organ- isms, tuberculosis, syphilis and parasitic diseases). In many developing countries, coronary heart disease is virtually absent, in marked contrast to the situation in the economically advanced countries. 4 In Northern Kenya, Samburu and Rendille nomads show no blood pres- sure increase with age. However, when serving in the Kenyan army they are found to have a sharp increase. This may be an important clue.
An electrocardiogram is being made to find if this baby has already suffered heart damage as a result of rheumatic fever. If so, careful follow-up may prevent any new attacks. coronary heart disease The usual cause of the reduced blood supply is atherosclerosis of the coronary arteries, a process which leads to narrow- ing and distortion of the blood vessels. A sudden obstruction in one of these arteries will result in damage to the heart muscle which it supplies; this is acute myocardial infarction, often called by the general term "heart attack". It is the most common heart disease in adult man in all affluent societies. Yet heart attack is rare in developing countries, with the apparent exception of small groups of people with a high level of responsibility and socio-economic ad- vantage. In the affluent societies, cigarette smoking, hypertension, diabetes mellitus, obesity and sedentary occupations are fac- tors known to be associated with the deve- lopment of coronary heart disease, yet these factors do not produce coronary atherosclerosis and coronary heart disease in the "common man" in the developing countries. This is true even for middle- aged subjects with long-standing hyper- tension, diabetes mellitus, obesity and se- dentary occupations! The reasons are as yet not quite clear but there is a strong suggestion that all these "risk factors" are only aggravating factors which accelerate the development of atherosclerosis and its complications in communities already prone to this disease. The relative importance of dietary fac- tors and of physical activity patterns, which are perhaps expressed in the low blood- fat levels of these tropical communities with virtual freedom from coronary heart disease, is of considerable interest. Many claim that the basic causes of coronary heart disease cannot be adequately studied in the communities which suffer most from the disease because all individuals are exposed. Hence the usefulness of study- ing communities relatively free from it. Particularly rewarding studies cover well- defined groups of people with considerable differences in the prevalence of coronary heart disease. For example, in Kampala, Uganda, the WHO Centre has emphasized the striking differences which are found in the fibrinolytic (clot-dissolving) system of subjects prone to coronary heart disease compared with subjects who are not. The African community in Kampala have no coronary heart disease, and at all ages have an active system for the breakdown of blood clots. The Indian minority in Kam- pala, with an incidence of coronary heart disease similar to any "affluent" group, have a very poor clot-dissolving system when they reach middle age (40-60 years), and this inability to break down blood clots is significantly associated with body fatness, blood cholesterol levels and a ten- dency to diabetes. This may be a pheno- menon of fundamental importance in the development of atherosclerosis and coro- nary heart disease, and furnishes another example of how the absence of a disease in a community may lead to the better understanding of the mechanisms of the disease elsewhere. Food habits may play an important part in determing whether a community does or does not suffer from coronary heart disease. In Singapore, where three-quar- ters of the population are Chinese and one quarter Malay and Indian, the Indian sec- tion of the community, whose eating ha- bits are quite special, is the one most commonly affected. In Fiji, coronary heart disease is not seen in the native Fijians, but is commonly diagnosed among resident Indians. In Ceylon, where coronary heart disease is commonly diagnosed in relatively poor people on low-fat diets, considerable interest focuses on the fact that, although the total amount of fat consumed is low, it takes the form of coconut oil, a substance similar in certain ways to butter, i.e. highly saturated. Clearly, the nutritional peculiarities of tropical countries are of considerable con- cern to those involved in unravelling the mysteries of atherosclerosis and coronary heart disease. rheumatic fever A small proportion of those who suffer from certain streptococcal throat infec- tions experience inflammation of the heart and swelling of the joints which may go io So young and yet he may have a heart lesion. 7 unrecognized if symptoms are not striking: this is acute rheumatic fever. However, though the acute phase soon passes, per- manent injury to the heart in the form of a thickening of the heart valves may result; this is chronic rheumatic heart disease. There has been a remarkable decline in the incidence of rheumatic fever in highly developed communities in recent years through the treatment of streptococcal infections with sulphonamides and peni- cillin. Moreover, preventive regimens have considerably prolonged the life of subjects with chronic rheumatic heart disease, and surgical correction of the valvular defor- mities has become a well-established treat- ment. In many developing countries, particu- larly in the tropical and subtropical regions, the reverse situation can be seen. Severe rheumatic heart disease is being recognized with increasing frequency and it is the most important chronic heart disease in children and young adults. Poor socio-economic conditions, inadequate hygienic and the- rapeutic measures as well as increasing urbanization appear to be far more impor- tant than climate. The high proportion of children in the population and the rapid progression from onset of the disease to severe permanent damage of the heart valves and irreversible heart failure make this a serious problem. Tropical physicians and pathologists are familiar with the presence of advanced rheumatic heart disease in children below the age of ten, and considerable evidence indicates that the prevalence of chronic heart disease is increasing in many tropical countries. Despite the frequency of chronic rheu- matic heart disease in the tropics and sub- tropics, surprisingly little acute rheumatic fever is diagnosed in these areas. Surveys carried out by WHO consultants suggest that the clinical features of acute rheumatic fever may be different in the tropical coun- tries and that the natural history of rheu- matic heart disease may be modified by environmental factors. It is widely accepted that acute rheumatic fever is caused by streptococcal infection, usually manifested as a sore throat, and that treatment of the infection can prevent rheumatic fever. A question which requires study in the tro- pical situation is whether streptococcal skin infections, which are very common and often precede acute kidney disease, may also result in rheumatic fever. At the WHO seminar on cardiovascular diseases due to infections, held in Manila in November 1968, the preventive aspects of rheumatic fever and rheumatic heart disease were fully discussed. In Malaysia, Singapore, Cambodia, Hong Kong, the Philippines, Australia and New Guinea, A specialist scrutinizes heart x -rays at the University of Makerere in Kampala, Uganda. 8 For mothers, heart disease is difficult to understand since there are few ► visible signs of illness. The scene is in Mulago Hospital, Kampala, Uganda.
* 4* there is a significant amount of rheumatic fever and particularly rheumatic heart disease. The severity of streptococcal in- fection and the degree of the immune response to streptococci are factors in- fluencing a high rheumatic disease inci- dence. Reports from countries in the Western Pacific Region showed a wide range in the magnitude of the problem; according to some reports, the situation may be considered under control, for example among the European population of Australia and New Zealand; elsewhere a severe problem is recognized, for exam- ple in the Philippines, Hong Kong and Singapore. Persons who have recovered from an attack of rheumatic fever remain suscepti- ble throughout their lives and thus require continual medical supervision. However, if their infections are promptly treated with antibiotics, serious damage "to the heart can be prevented. In most of the Western Pacific Region, existing health services are able to dispense long-acting penicillin to those already suf- fering from rheumatic fever in order to prevent serious relapse and heart damage. But the main obstacles to actually doing it are lack of specific formulation of the pro- gramme, lack of free medicine, and lack of awareness by the public. Despite the fact that rheumatic fever is a recognized clinical problem, it is not given high prior- ity by public authorities. The treatment of rheumatic fever is often accepted in prin- ciple but not carried out in practice. Al- though clinicians are interested in medical and surgical treatment of rheumatic heart disease, there is a lack of enthusiasm about starting preventive measures against rheu- matic fever, though this should prove far cheaper in the long run than corrective surgery. parasites of the heart Of the many parasites which may da- mage the heart, the most serious is Trypa- nosoma cruzi which is responsible for Cha- gas' heart disease. Carlos Chagas, a Bra- zilian physician, described this condition for the first time in 1909 as being common in central Brazil although the disease had been locally recognized in many regions well before this time. Chagas' heart disease can be regarded as one of the plagues in several countries of Latin America and there are areas in which as much as half of the population is infected. The parasite is transmitted to man by a biting bug; the acute phase of the illness occurs within two weeks of the entry of the parasite. Apart from fever and typical signs at the site of entry of the parasite, there may be acute myocarditis (inflammation of the heart muscle) with enlargement of the heart and heart failure. In most cases, this phase passes unrecog- nized and the first symptoms appear many years later when the damage has been done and the disease has become chronic. Although the heart is the most frequently damaged organ, in some endemic areas, particularly in Argentina and Brazil, cha- racteristic disturbances in the digestive tract are also common. The basic problem of chronic Chagas' heart disease is a disturbance in the con- duction system of the electrical impulses which are responsible for the harmonious pumping activity of the heart. Various types of rhythm irregularities and even interruption of impulse conduction and heart block are common, and may lead to stoppage of the heart beat in an apparently healthy subject. In other subjects, damage to the heart muscle is gradual and pro- gressive, sometimes resulting in decreased pumping ability of the heart and enormous dilatation, and ending in heart failure. There is no specific treatment for Cha- gas' heart disease. Prevention, however, is possible by interrupting the transmission of the parasite by the proper use of insec- ticides and especially by the improvement of housing and living conditions. These are vital tasks for the public health author- ities in the endemic areas. cardiomyopathies At a meeting of the British Cardiac Society held in Oxford in 1946, Drs Bed- ford and Konstam described a most un- usual form of heart failure in African the large and the small of It Africa, a continent of rich resource, has many lessons for those studying the heart. A tiny bird's quivering pulsations contrast with the slow throb of a buffalo's or an elephant's mighty heart nearby. All three are worth studying and, as regards the elephant, size makes the research worker's task easier: nature has provided a large-scale model on which to work. In East Africa, the long drought has made it necess- ary in the interests of conservation to destroy a number of elephants in some areas so that a proper balance can be maintained between food resources and animal popula- tions. As a result, there is an ample supply of elephant hearts for research purposes. Africa is helping to provide answers to a number of questions that plague the rest of the world. 41 Tapioca root is cut in discs and boiled, and replaces rice as the staple food in Kerala State, India. A tapioca-based diet is believed to be at least partially responsible for endomyocardial fibrosis in which a fibrous growth blocks the heart ventricles. 11 ' .,„tr troops serving in Asia. The soldiers were mostly from West Africa, their average age was 20-30 years, and they all presented heart failure with very large hearts. Seven- teen of forty patients under observations died and came to autopsy. The description of these hearts stimulated widespread inte- rest in unusual forms of heart disease in the tropics. In the more common forms of heart disease, the heart's function is impaired by damaged valves, or by an increased load on the heart due to hypertension or disease of the coronary arteries. There are, how- ever, disorders in which the main feature is a disease of the heart muscle itself; these conditions are now widely known by the collective term `cardiomyopathies'. Many of the hearts described by Bedford and Konstam were of this kind, and subsequent reports have contributed greatly to the recognition of heart-muscle disease in the rest of the world. In the more affluent societies, a diseased heart muscle usually goes with poor blood supply, and the true cardiomyopathies have only recently been sorted out from the coronary heart disea- ses. Damage to the heart muscle may be produced by a wide variety of agents, some infective, some toxic, and even by nutri- tional deficiencies, hormonal upsets and metabolic disorders. Frequently, however, the cause of the damaged heart muscle is uncertain or unknown. Apart from alcohol, certain food addi- tives and preservatives are now known to damage the heart muscle cells. Outbreaks of cardiomyopathies with high mortality have occurred recently in heavy beer drinkers in Canada. The beer had been treated with cobalt and papain ; such un- foreseen cardiac accidents are a warning of our need for a deeper knowledge of the normal mechanisms of the heart muscle cells. In comparison with the incidence of rheumatic heart disease or arterial hyper- tension, the cardiomyopathies occur with relative infrequency, although in some areas they are of considerable importance. In Ibadan, Nigeria, and among the African population of Johannesburg, South Africa, about one-third of the patients with clinical heart disease are considered to have heart muscle disease, while in Kampala, Uganda, only about 10% are included in this cate- gory. At autopsy examination, about 4% of hearts in Kampala, Jamaica and Japan have this form of cardiomyopathy, while in Cali, Colombia, it runs as high as 12%. Studies in many parts of Africa, in South America and in South-East Asia all indi- cate that unexplained enlarged hearts are a significant health problem; reports from Jamaica also point to a high prevalence of cardiac enlargement which is not due to coronary artery disease. Endomyocardial fibrosis (EMF), in which a fibrous thickening constricts the cavities of the heart, particularly the ven- tricles, is a tropical cardiomyopathy in the true sense of the term; its occurrence as an endemic problem is confined to the tropic- al parts of the world. The disease has been intensively studied in Nigeria, Uganda and other countries within the tropical belt of the African continent, and in southern India, Ceylon, Malaysia, Brazil and Co- lombia. The occurrence of EMF in Euro- peans who have lived for long periods in West Africa and the very occasional re- port of EMF in subjects who have never lived in or visited the tropics are impor- tant clues whose meaning has not yet been grasped. The disease apparently begins in child- hood but, by the time a diagnosis is made, heart damage is usually already serious and the patient is in heart failure. Predominant- ly a disease of children and young adults, it is found in all age groups. There is no specific treatment beyond the general ma- nagement of heart failure and, as the cause is unknown, prevention is not yet possible. In many ways, EMF appears to have a natural history similar to that of rheumatic heart disease. Studies in Kampala have also demonstrated a very significant con- currence of EMF and rheumatic heart dis- ease in patients coming to autopsy, which has lead to the hypothesis that EMF may be a disorder similar to rheumatic heart disease, another hypersensitivity disorder of the heart. Streptococcus, filariasis and malaria may also be factors in the devel- opment of this disease. using mankind's diversity There is a scientific philosophy accord- ing to which many problems of the highly developed world can best be solved away from the complexity and confusion of modern industrial societies; it may be as important to study communities apparent- ly free from a disorder as those in which almost everyone is prone to it. As the pre- ceding examples have shown, there may be something in the African or Asian diet, or way of life, which has some protective influence against the major killing heart diseases of Europe and North America. If the factor lacking in the one or present in the other proves to be decisive, then ways of preventing some common causes of death will be found. This type of com- parative study is a way in which mankind can make use of its diversity for the common good. ■ There may be something in the African or Asian diet, or way of life, which has some protective influence against the major killing heart diseases of Europe and America. 13 pyramid clinic by Didier Henrioud Rheumatic fever is a serious problem in the United Arab Republic, espe- cially among young people. The Pyra- mid Clinic near Cairo has developed into an ultra-modern hospital concen- trating on the treatment and rehabili- tation of children in the 6 to 14 age- group suffering from heart and joint disabilities resulting from rheumatic fever. The massive bulk and straight lines of the three historic pyramids of Cheops, Chephren and Mykerinos rise into the pure blue sky of Gizeh on the outskirts of Cairo Almost in the shadow of these huge stone struc- tures erected nearly four thousand years ago are the modern buildings of a hospital devoted to the special care of children with heart conditions caused by rheumatic fever. Dr Zahira Abdine, paediatrician and director of the Pyramid Clinic, says : "We began quite modestly, but thanks to private grants and govern- mental aid the clinic has grown, and today we are able to provide com- plete care. "My greatest ambition is to extend the work we are doing here to the whole of Egypt; rheumatic heart disease is a serious problem in every part of the country, particularly among younger children." The incidence of heart and joint disabilities resulting from rheumatic fever is indeed high in the United Arab Republic, especially among the poorer classes. This is particularly true in those regions where popula- tion density and overcrowding en- courage the spread of streptococcal infections. The country's hospitals have diffi- culty in coping with this situation, which seems to be worsening, and in any case there are insufficient beds to hospitalize patients whose condition demands surveillance and possibly long-term treatment. In 1958, the extent and seriousness of the problem stimulated the launch- ing of a nation-wide voluntary cam- paign promoted by a charitable ins- titution which took the name "The Society of Friends of Children with Rheumatic Heart Diseases". Thanks to the efforts of this orga- nization and financial contributions from governmental and private sour- ces, the Pyramid Clinic was able within a year to take 28 young pa- tients, who soon made progress in the dry, healthy climate of the Libyan desert that stretches away beyond the pyramids to the west. Ten years have passed since its foundation, and now the Clinic has 240 beds, 80 of which are set aside for particularly serious cases and for convalescents who require hospita- lization for three to six months. The remaining 160 beds are for other young patients, who benefit from continuous medical supervision and attend classes at a primary school attached to the Clinic or, if they are older, follow courses given in a small annex where they work or learn a trade according to their physical and intellectual capacities. The workshops operate throughout the year under the guidance of professional teachers who encourage the children to sew, weave rugs, do leather work and carry out certain administrative tasks. The 14 ..• On the terrace of the hospital. At the table in the background, Dr Zahira Abdine, Directress of the clinic, examines the file of a young patient. Rest for young patients. 15
- Education and games are part of rehabilitation. Children are under constant medical super- vision. staff of the Clinic are always busy and the facilities are used to capacity; during the last few years more than 8,000 children between the ages of six and fourteen have been taken in and treated, all of them free of charge. The Clinic also treats children in its out-patient department, and provides a medical examination for healthy children as part of a forward- looking campaign for the prevention of disease. Encouraged by Dr Abdine, who is also Professor of Paediatrics at the Cairo Medical School, the society that built the Clinic has recently ex- tended its activities to all the children of Cairo and of certain parts of the province; it now covers an enormous area, which follows the course of the Nile from Alexandria on the coast to Assiut, three hundred kilometres south of the capital. The seriousness of the problem was dramatically shown in a recent study of schoolchildren. 4,000 children from 15 schools in the Qalyub area were examined. The results : 40 children already showed signs of organic lesions of the heart and another 160 were suspect. Not only were respira- tory infections common throughout the group but many children were harbouring the very group of strep- tococci that may cause rheumatic fever. These serious findings were confirmed in other studies carried out in Aswan, Alexandria and Cairo among children six to twelve years old. In the interests of the country's future, children at risk should be protected. ■ 17 hearts that fail in their teens by J.-M. van Gindertael On the brink of adulthood when life should be faced with a will and a smile, many young people in tropical countries are held back by a crippled heart. The teenager playing on the beach or poring over his schoolbooks may need a heart operation to repair or replace a defective valve. This article tells of a visit to a group of young patients in Ceylon. Cardiovascular diseases are com- mon in Ceylon; in the Colombo General Hospital almost 40 % of the patients suffer from heart diseases. These illnesses strike all classes of society, and usually display one pro- minent characteristic: appearing as early as adolescence, they develop rapidly within a few years, in con- trast to the slower development ob- served among patients in economic- ally advanced countries. Ceylon presents an array of car- diovascular diseases. There are those which are common in the highly devel- oped countries : coronaries, hyper- tension; those which are disappear- ing there, like rheumatic fever; others common in developing countries, par- ticularly in Africa, like the cardio- myopathies. One of these, idiopathic cardiomegaly, occurs frequently in Ceylon and is characterized by an abnormally large and heavy heart. At sunrise, the General Hospital was already crowded. Erected in 1904, the main building is no longer large enough and a number of bar- racks have now been added. In one of these are the heart patients, divided into groups of thirty or forty accord- ing to sex. in the ward Dr Wickremsinghe, who is in charge of the hospital, explained that the sheer number of cardiovascular patients will require the construction of a separate building. Two floors will be equipped immediately to ac- commodate 60 patients. Two other floors will be added later, bringing the total number of beds to 120. What is most important, modern diagnostic and monitoring facilities, including new catheterization equipment and closed-circuit television will be instal- led to help understand the causes and development of these diseases ; in other words, there will be more than routine care and there will be scope for research. At present, the number of cardiac patients is limited to 40. Dr I. Obey- sekere, who is in charge of the cardio- logy unit, brought me to one of his two big wards. Cases which might be unusual elsewhere are frequent here. However, the physician has very little time aside from his clinical work to go into questions of theory and dis- cover a pattern in what he sees. As we went into the men's ward, the heat rushed out to meet us. Inside it must have been about 25 to 30° C; large openings in the walls high up around the room allowed the damp outside air to penetrate. In spite of the heat, the large fans fixed to the ceiling had stopped. The patients smiled at us, partly because it is a national trait in Cey- lon, but also because the physician's presence is reassuring and creates an atmosphere of confidence. "This man of thirty-six is suffering from coronary heart disease. Wear on the tissues has reached a point barely imaginable in the more devel- oped countries. In this particular case, the heart damage actually led to the perforation of the wall sepa- rating the left ventricle from the right." There was not a single old person in the ward. Young faces were everywhere. We approached one of them. "He is fifteen—the youngest in the ward at present; but unfortunately I can't say that such cases are rare. On the contrary, in Ceylon rheumatic fever often strikes young people of fourteen and fifteen, and these are not mild cases, since we often have to replace the cardiac valve. Can you imagine replacing a valve at that age? The substitute will last four or five years, and then we have to begin all over again. What is more, this is an operation which, here at least, still presents a great deal of risk." The doctor asked me to put my hand on the heart of another patient, who was only a little older than the preceding one. His whole chest shook with every beat of his heart. "A typ- ical case of cardiomegaly," Dr Obey- sekere pointed out. 18 1 Dr I. Obeysekere visiting the women's cardiology ward. The heart function of this patient is monitored. 2
On the threshold of their adult life many of these Ceylonese youngsters may have damaged hearts. This disease seems to be particu- larly frequent among poor people whose only food may be the rice dis- tributed free of charge by the Govern- ment. Though poor nutrition seems to be the immediate cause of the disease, other factors such as viral infections may play a part. Another patient presented pulmon- ary hypertension, which is a cardio- vascular disease common to Ceylon. Whole families may be stricken with the disease, which is sometimes ac- companied by diabetes, raising the question of a possible hereditary component. As he studied a patient suffering from a heart attack as a result of coronary heart disease, Dr Obeyse- kere wondered aloud about all that remains to be explained and the little of which he is sure. "Another inexplicable case. You can see for yourself that this patient does not belong to the affluent Amer- ican or European society—of which this disease is supposed to be typical. He probably does not weigh more than 55 kilos or earn more than 100 rupees, about $15, a month." Cardiologists like those at work in Ceylon are trying to solve problems that confront doctors all over the world. Even today there is much that can be done. Rheumatic fever, the cause of so much heart disease, is preventable. If a number of acute cases of sore throat could be treated with penicillin, or long-term preven- tive measures for individuals under- taken, many hearts could be saved from serious damage. In countries at widely different levels of development, coronary heart disease has begun to strike ever- younger members of society. An understanding of the causes of this disease would benefit not just a por- tion but all of mankind to some degree. ■ 21 the long watch by Prof. Michael Davies* Is it possible in a community to prevent rheumatic fever and its consequences by rapid diagnosis and treatment of upper respiratory infections? The city of Jerusalem has many advantages for research on primary prevention of the disease. First results are summarized here by the Director of the research study. * Professor of Human Ecology, Hebrew University, Jerusalem. Jerusalem has many advantages for a study of primary prevention of rheumatic fever. Universal public education and a good school health service assure adequate health sur- veillance of all school-age children, the group most susceptible to rheu- matic fever. The boys and girls come from a wide range of socio-economic conditions, and their parents may have immigrated from any of 100 different countries. Rheumatic fever was frequent in the past; one survey even reported 4.2 % of schoolchildren with signs of rheumatic heart disease. However, medical services are well organized and readily available thus enabling our team to detect every new case of rheumatic fever. Rheumatic fever is, in fact, a com- mon disease in many of the warm countries of the world, although for decades experts had thought other- wise. For a variety of reasons, the first attack may go unrecognized, but may nevertheless lead to rheumatic heart disease. The treatment of estab- lished rheumatic heart disease is prolonged and expensive requiring sophisticated medical services. Is it possible to prevent the disease; to prevent attacks of rheumatic fever and, thereby, cardiac involvement? That was our basic question when the Jerusalem primary prevention study was started in 1965. We wanted to find out if such an approach could prove effective, using school health services. Theoretically, there should be no difficulty in preventing rheumatic fe- ver. It has been recognized as a spe- cific, exaggerated reaction to a strep- tococcal sore throat and comes on two to three weeks after the infection. Controlling the streptococcus bacte- rium should then control the rheu- matic fever: this is certainly true for secondary attacks. Children who have had rheumatic fever are particularly susceptible to further bouts but, as long as they receive regular doses of penicillin, streptococcal sore throats and their rheumatic consequences can be avoided. Experience from military camps and crowded schools has con- firmed that mass treatment with peni- cillin will stop an epidemic of strep- tococcal sore throat and prevent new cases of rheumatic fever. Our object, however, was to delve deeper into the problem. What can science do to prevent the first attack of rheumatic fever in the individual schoolchild ? every school absence recorded For a start we set out to gauge the extent of streptococcal infection among schoolchildren and then to plan our strategy. We decided to follow 821 children, aged 8 to 11, in four schools. We re- corded every absence from school, and every sore throat so as to chart the spread of streptococci. A nurse visited the home of each child absent from school and recorded the reason. If the child had any sign of sore throat she took a throat swab for laboratory examination. Not all streptococci produce rheu- matic fever. Those that do also pro- duce a toxin known as streptolysin, which separates haemoglobin from blood, permitting them to be easily recognized in the laboratory. They belong, moreover, to a single group, group A, which can be identified by further tests. The standard practice, in most lab- oratories, is to smear the swab on agar and incubate at blood heat. Colonies of bacteria can readily be isolated after a day or two and their group identified. But this procedure is time consuming and expensive. In fact, it is estimated that surveillance of 9,000 schoolchildren would mean examining from 80 to 100 throat swabs a day. This would require the services of three to four technicians for laboratory work alone, which includes the preparation of ten litres 22 In this Jerusalem school, a daily roll-call is taken in the presence of a nurse. All pupils absent for more than 48 hours will have their throats examined by her at home. 23 of culture medium each week, as well as the maintenance of at least four sheep to be bled in rotation. On the other hand, the adaptation of modern fluorescent antibody tech- niques of staining bacteria saves both time and money. By this method, streptococci incubated for only a few hours are treated with antiserum to group A organisms which has been "labelled" with fluorescein. If the streptococcus from the throat swab belongs to group A, the anti- serum combines with it and under the ultraviolet microscope it fluores- ces brightly. After testing and adaptation to "production line" use, we adopted this fluorescent antibody technique. Only the positive swabs are cultured in the usual way for further identi- fication of the organisms. Of the children in the pilot study, 5 % were found to have group A streptococci in their throats, even when healthy; when all the children returned to school in October, the proportion of those infected had increased to 13 %. Colds, sore throats, influenza and other upper respiratory infections we found to be most common in the winter months, as opposed to sore throats due to streptococci, which occur most frequently in October. From this and other information, our team calculated that it would be nec- essary to follow up about 9,000 children for several years to obtain a definite answer to the question : "Can rheumatic fever be prevented?" In October 1966, we registered all children in the 7 to 11 age group in 40 Jerusalem schools; they totalled 8,717 in all. The same procedures of recording absences, home visits and laboratory tests were instituted. Ar- rangements were made for our re- search team to treat 3,500 of the children whenever they suffered from a streptococcal sore throat, while the remainder were tested and referred to their doctors for treatment. In all cases, however, the treatment given 24 was recorded and a second throat swab taken 10 days after the first positive swab to verify that the strep- tococci were killed. In addition, a blood sample was taken at the time of the infection and three weeks later, in order to measure the child's anti- body response to the streptococcus. Some idea of the magnitude of the study is given by the fact that an average of over 20,000 absences from school are listed during the school year, which lasts eight and a half months. Upper respiratory infections are the cause of over half the absences, making a total of 39,000 schooldays lost from this cause. Our laboratory processes over 24,000 throat swabs (two from each patient) annually. A record was bro- ken in February 1968 when, work- ing overtime, the laboratory exam- ined 460 swabs in one single day. Such a work load would have been well nigh impossible if we had kept to classical bacteriological methods. a device that "listens" to the heart We found that 11 % of the sore throats yielded group A streptococci and, as before, the peak was reached in October with 17.5 %. Special sero- logical techniques permitted the iden- tification of 14 different types among 1,139 cultures investigated in one year. Over one third of the children had already experienced several strepto- coccal infections, both apparent and otherwise, as evinced by a high level of antibodies to streptolysin when first tested, and 20 % showed an in- crease of this antibody response as a result of the new infection. Obviously, all children with sore throats were carefully examined by physicians of our research team while they were ill and after their recovery. In order to be certain that children in whom rheumatic heart disease was detected were, in fact, new cases and Streptococcal culture being examined. had definitely not been affected be- fore, we found it necessary to examine all the children in the study. For this purpose we made use of an electronic device which is programmed with the characteristics of normal heart sounds. When operated by a techni- cian, the machine "listens" to the heart; it can identify sounds as "within" or "outside" normal limits and suspect cases are then examined by three physicians. This is done because early tests with the machine showed it to be oversensitive, diag- nosing the heart sounds of 7 % of children as "outside normal limits" whereas only 1 % or so had actual heart disease. It was clearly impracticable to have all 9,000 children examined by a sin- gle cardiologist but even had this been possible it would not have been desirable. We found that the possi- bility of subjective diagnosis in mild forms of heart disease is reduced to a minimum if each child under study is examined by three cardiologists. The machine is therefore used only to screen out children who are com- pletely normal. During the two years of our full study, 43 study children were sus- pected of having rheumatic fever but several were found to have other diseases; some of the cases were not typical and only 18 could be con- firmed as "definite" or "probable" cases. The disappointing aspect of our study to date is the fact that, of the 18 patients, 12 either fell ill in the school holiday period or did not show an upper respiratory infection before the rheumatic attack. It is therefore too soon for us to answer the main question, namely whether we can prevent first attacks of rheumatic fever by surveillance of schoolchildren. It is already clear, however, that this approach will have to be com- bined with others if it is to have a significant effect in the prevention of rheumatic fever. ■ An electronic device which "listens" to heart sounds. This school girl is at home with a sore throat and the doctor checks her heart. 25 Venezuela arms against Chagas' disease Rhodnius prolixus, one of the insect vectors of Chagas' disease Chagas' heart disease is a threat for 35 million people in Latin America where it is responsible for a great number of deaths. In Venezuela there are said to be one million cases, which would amount to one-tenth of the country's population. The main carrier of the disease in Venezuela is the insect Rhodnius prolixus, but various other species have been suspected. The insect fills itself with human blood which has the effect of making it defecate and so the parasite is deposited on the the human skin. If the person then scratches himself the parasite enters the body. Prolixus is a winged insect of variable size and looks like a cockroach with long and slender legs. Its life span is from six to ten months. Its diet consists mostly of other insects rather than blood. The acute phase of Chagas' disease (see descrip- tion on page 11) appears 4 to 15 days after the parasite's entry into the human body. The parasite is frequently absorbed by prolixus from its contact with Didelphis marsupialis, a small forest mammal known as the American opossum. Chagas' disease in Venezuela is nothing short of a national problem. Numerous medical centres have been mobilized to meet the challenge. All information is centralized at the Caracas head- quarters of Dr Humberto Garcia Barrios, who directs the cardiovascular disease division in the Ministry of Health. The centre keeps an impres- sive index listing all known cases of Chagas' disease in the country. Systematic case finding is in fact an important part of the struggle against the disease: both to alleviate the suffering of those affected, to gain a better understanding of the disease and to orient preventive action. Several other institutes in Caracas are co- operating in the fight against the disease. Dr Felix Pifano, Director of the Institute of Tropical Diseases, is at present engaged in research on the possibility of interrupting the transmission of Chagas' disease. Insects which are known not to be carrying the parasite are placed in contact with persons affected by the disease and whose blood contains antibodies, in order to determine under what conditions the insect becomes a parasite carrier. Other tropical diseases are also studied at the Institute, but Dr Pifano points out: "Chagas' disease is our principal concern in view of its importance in our country." Poor housing conditions favour the spread of*. Chagas' disease. 26 At the Institute of Pathological Anatomy directed by Dr Suarez, another aspect of Chagas' disease is investigated. Here the hearts of persons who died as a result of the disease are system- atically studied. There is one fully equipped mobile unit at present in Venezuela to help in the assessment of the problem and in the control of Chagas' disease. Bearing the name of Dr. Bernando Gomez, this air-conditioned vehicle includes space for a physician to examine patients, as well as an X-ray room and laboratory. A tent is attached to the vehicle to serve as a waiting-room for the public. There unfortunately is no known remedy or treatment for Chagas' disease. Efforts to fight the scourge are centred on the use of pesticides against insects known to carry the parasite. The disappearance of poor housing conditions, the interruption of transmission and improved standards of living will be decisive factors in the struggle against Chagas' disease. The American opossum among other animals harbours the parasite responsible for Chagas' disease. 27 Radiologist Umberto Diaz taking an X-ray of a patient suspected of having Chagas' disease. Jamaica Home call in the Lawrence Tavern area. Jamaica, third largest of the Antilles, once a haven for pirates and today a holiday resort for thousands of tourists, also has a problem with heart diseases. Among a total population of close to two million people, 35 % of all deaths are caused by heart diseases such as hypertension and rheumatic heart disease. No correlation has yet been established between the island's abundant sugar cane production and rum consumption on the one hand, and the incidence of heart diseases on the other. Research work is proceeding in several departments of Kingston University. Epidem- iological studies are being directed by Dr William E. Miall, Head of the Medical Research Council, Jamaica, Epidemiological Research Unit. Efforts are centred at present on the population of Lawrence Tavern, 35 kilometres north of Kingston, which is considered to be a good test area since it is representative of Jamaica's traditional rural way of life. Facts and figures are collected in two ways : All persons calling at the Lawrence Tavern health centres are given thorough heart examinations. Specialized nurses visit every home in the area, including isolated mountain farms, recording blood pressure and taking electro- cardiograms of every inhabitant. ■ 29 around the world action on amoebiasis Amoebiasis is known to occur in every part of the globe and is estimated to affect 10% of the world's population. This amoe- bian form of dysentery, which is essentially an intestinal infection, can also cause ab- scesses of the liver, lungs and brain. Clearly this disease presents a public health problem of international importance, and a WHO expert committee was convened to study it. In a recent technical report the Com- mittee noted that amoebiasis, commonly known as a "tropical disease", also exists in industrialized countries where its appar- ently low incidence may be explained in part by the mildness of the symptoms and the lack of relevant laboratory work. In any case, rates are generally much lower in Canada, Europe and the United States of America than they are in the Eastern Mediterranean countries, Mexico, Central America, South America and numerous African countries. There are wide and unexplained differences among the countries of Asia and the Pacific region. In a few instances, exceptionally high rates have been reported for a general population, as for example 57% for Egypt, 52% for Liberia and 56% for Ecuador, but it is somewhat unusual for rates to exceed 30% even in communities with the poorest sanitation. There is, however, a heartening devel- opment; a recently perfected compound, metronidazole, is unique in that it is effective against most forms of amoebiasis. Remarkable progress is also reported in the prevention of certain complications. New drugs like metronidazole are both more effective and less toxic than the ones used until very recently. As is the case with other infectious diseases, yet another reason prompts WHO to take an active part in the work on amoebiasis : in all parts of the world, people are travelling more. Amoebiasis, already a serious threat to public health, could therefore become more harmful still with the increase of tourism, migration and labour exchanges, which facilitate the spread of the disease and make it more difficult to fight. water quest The world will have to wait for more than 100 years before the community water supply systems of rural areas in developing countries reach a satisfactory level, unless current projects are dramat- ically accelerated. Only one in ten rural dwellers can obtain even a small amount of safe water. The populations of slum areas multi- plying throughout the world live in even more deplorable conditions. The rate of increase of urban populations in devel- oping countries is about two and a half times that of rural populations. Cholera and typhoid fever are the two most serious diseases commonly trans- mitted by water, but there are others, such as dysentery, gastroenteritis and a number of viral infections. Diseases closely linked to a lack of cleanliness could also be avoided if safe water were plentiful enough for bathing and washing clothes. Such is the case for trachoma, louse-borne relaps- ing fever, scabies, louse-borne typhus and yaws, among others. Then there are diseases such as malaria which are associated with water. Artificial lakes, waterways and irrigation ditches can serve as breeding grounds for mosqui- tos and flies transmitting malaria, oncho- cerciasis and filariasis. The same water may provide a habitat for the snails that are intermediate hosts in the spread of schistosomiasis. The provision of safe water supplies for the whole globe therefore sets problems of considerable magnitude. Great resources in manpower, money and supplies will have to be mobilized if the situation is to be effectively improved within a reasonable length of time. A WHO report on this subject lists old and new problems connected with the supply of water to the public and under- lines the fact that the laying down of a supply network is not an end in itself. Maintenance is of utmost importance, since, for example, waste from leakage can amount to as much as 50% of the quantity of water distributed. Twenty recommendations conclude this report in the hope that action undertaken at na- tional and international level will lead to tangible improvements. more medical schools The total number of medical schools in 101 countries reached 782 in 1967, which is 185 more than in 1955. The figures are given in a recent pamphlet that brings up to date the World Directory of Medical Schools published by WHO. Sixteen countries and territories where there was no teaching of medicine in 1955 now have their first school. They are Angola, Ethiopia, Ghana, Guinea, Ivory Coast, Kenya, Liberia, Malaysia, Mon- golia, Morocco, Mozambique, Papua, Southern Rhodesia, Tunisia, Tanzania and Zambia. 30 Water, precious water. Other countries doubled the number of their medical schools since 1955. Thus Brazil went from 23 to 46 schools, and India from 44 to 92. Growth was particularly strong from 1960 onwards: 120 schools were created in 52 countries between 1960 and 1967. In the long-industrialized countries there has been little or no increase, except in the Federal Republic of Germany, where the number of medical schools went up from 19 to 26, the United States of America (from 86 to 90) and the USSR (from 77 to 84). american indians It is traditionally believed that the native populations of the Americas have a genetic susceptibility to certain infectious diseases, such as measles and tuberculosis. Evidence to the contrary was presented at a recent technical meeting held under the auspices of the Pan American Health Organization, where physicians, geneticists, anthropol- ogists and sociologists discussed the bio- medical situation of the American Indian. The report of the meeting also deals with the origin and dispersion of Indians in North and South America, their bio- logical and anthropological subdivisions, goitre and gall-bladder infections in cer- tain native communities, as well as food and nutrition among the Maya before the conquest and at present. better health protection for easter island Scientists from seven countries took part in a medical expedition that spent three months on Easter Island to study the in- fluences of heredity and environment in this comparatively isolated community. The expedition was organized under the auspices of the Canadian Government and WHO. In the past contact with visitors touch- ed off serious epidemics among isolated populations; a serological investigation was made of 82% of the islanders over six photo credits WHO-A.G. SHAPER: Front cover, p. 5 WHO-D. HENRIOUD : Back cover, pp. 15, 16, 17 WHO—E. SCHWAB: pp. 2, 3, 6, 7, 8, 9, 10, 12, 13, 18, 19, 20, 21 LEN SIRMAN PRESS: p. 11 WHO-T. FARKAS : pp. 23, 24, 25 WHO-P. ALMASY : pp. 26, 27, 28, 29 WHO-M. JACOT : p. 31 years of age to study the situation of the major viral infections. The scientists poin- ted to the necessity of protecting islanders against some of these diseases, particularly poliomyelitis, measles and influenza. The Microbiology and Hygiene Institute of the University of Montreal immediately sent sufficient quantities of polio vaccine to immunize all the inhabitants of the island. Isolation, way of life, and actual compo- sition of the population have been consid- erably disturbed since the inauguration, in April 1967, of an air link between Chile, Easter Island and Tahiti. Many of the islanders who lived in Chile have returned, while on the other hand over 500 Chileans have now found work on Easter Island. Tourists also make use of the new air route to visit this wonderland of giant and mysterious statues. A WHO report says that it would be of considerable interest to pursue this study over a period of years in order to follow changes as they occur among the popula- tion, which amounted to approximately 1,000 before 1967. ■ 31 /Z. ::%-t` • • - - 111- . "'''--t„, I, it 'I.. 1,:- Z4,2 ' ..... • i .. - - 1;.-1:.- - ,g.t.'1 ....4 LL :4-1,, '. -, • -IP ,,,,. . t. "4-jr:›":. . .. --4•!- ;.1 t-`.!:. • _ C-1 - • ...frE;Fr, %II- -,..°,‘ --: `• ...z.,1, - - ....,t. __;-t, -..-'4 -yi:'-- r......"? •,i Kii, * *.- 2: - .. . 1 ... 4 , V °eFmli." A young patient with rheumatic Aver terrace of the Pyramid clinic. on the