The State of Global Cardiovascular Health in sub-Saharan Africa

July 23, 2014

Gerald S. Bloomfield, assistant professor of medicine and global health at Duke, is a pioneer in the field of global cardiovascular health. When he came to Duke in 2007, he was one of the first medical trainees whose career focus was to understand and promote cardiovascular health in Africa. Today, he is credited with launching a clinical research program at Moi University in Eldoret, Kenya to determine the causes of heart failure and other cardiovascular diseases among East Africans. He is leading the charge to understand the complexities of the disease in African populations, with an eye toward treatment and prevention. He joined the faculty in 2011. Prior, he completed the Duke Cardiovascular Medicine Fellowship, the Duke Clinical Research Institute's Cardiovascular Clinical Research Fellowship, the Duke Global Health Residency/Fellowship and a Fogarty International Clinical Research Fellowship.

Tell us about your global cardiology journey at Duke and what keeps you here.

Arriving at Duke as a cardiology fellow in 2007, a career pathway in 'global cardiovascular health' did not exist.  Based on prior work and experiences as a medical missionary in Kenya, I was convinced that cardiovascular diseases were a major problem for Kenya and the systems needed to combat them were not in place.  As a fellow, I met with leadership and faculty from across the campus and ultimately formed an amazing mentorship team.  My primary mentors are Drs. John Bartlett, Eric Peterson and Eric Velazquez, and I have also benefitted from the support and guidance of other faculty from The Duke Global Health Institute, Duke Clinical Research Institute, Department of Medicine and Hubert-Yeargan Center for Global Health.  Global health is a team sport, and it is because of the input from many players that global cardiovascular health is a thriving area at Duke.

What led you to pursue work in Africa?

Serendipity. I had never worked in Africa before a good friend and exceptional clinician, Dr. Jon Fielder, invited me to work alongside him in Kenya for a month while I was an internal medicine resident.  While I did have an interest in the worldwide diversity of how medicine was practiced, there was no clear link between public health, cardiovascular medicine and global health at the time. What I saw in Kenya during that visit was remarkable for two reasons.  First, there was a large burden of non-communicable diseases like hypertension, heart failure, diabetes and stroke; larger than I had read about before this time.  Second, the affected patients were poor and could not afford treatment in most cases.  This poverty extended into the medical system where infrastructure, testing and even knowledge among clinicians was lacking on the importance of non-communicable diseases and how to treat them.  I thought I had stumbled upon something that would be worth exploring further.  And so I did.  I deferred my cardiovascular medicine fellowship training for a year to return to Kenya for a longer period of time and test whether my initial impressions were correct.  It was at that time that I decided to focus my work on understanding cardiovascular disease in Africa, improving knowledge regarding cardiovascular disease among patients and clinicians, and developing approaches to cardiovascular health promotion and disease treatment that are accessible to the poor.

What are some of the key questions you are exploring in your global cardiology research and why is this important to study?

Heart failure has historically been thought to be due to infections, malnutrition or other idiopathic (or "unknown") causes in Africa.  Our team’s experiences suggest otherwise.  In fact, we have seen a number of cases of heart failure over the years that are due to the same problems we see in the United States, such as coronary artery disease due to atherosclerosis.  We wanted to find out how common atherosclerosis is among Kenyan patients with heart failure.  This study is important because in order to call for change in practice or policy, you need data on which to make the case.  We expect to be able to convey the message about the importance of non-communicable cardiovascular diseases to clinicians and policymakers in Kenya based on country data.

Many believe HIV/AIDS and other infectious diseases are most common in Africa. To what extent is this changing?

HIV/AIDS remains an important priority for Africa.  At the same time, chronic non-communicable cardiovascular diseases are becoming more common and are projected to be the highest contributors to disease burden in Africa by 2030.  Africa, particularly sub-Saharan Africa, faces multiple burdens of disease simultaneously.  As opposed to a "siloed" approach to health, health systems in Africa need to consider the dual disease burden in order to respond to the needs of today and prevent the projected epidemics.

What have you learned about cardiovascular disease and other chronic diseases in Africa? In Kenya?

Unfortunately, clinician education and health systems design have not kept up with the transitions in epidemiology or demographics in Africa.  Therefore, a concerted effort that describes epidemiology and identifies cost-effective methods to diagnose, treat and prevent cardiovascular disease must go hand-in-hand with educating clinicians about cardiovascular disease and developing sustainable models of healthcare that are affordable.  This seemingly insurmountable task, I have learned, is best approached in partnership with passionate individuals from the around the globe, each bringing their strengths to the table to improve cardiovascular health in Africa.  Forming, developing and nurturing such partnerships takes time and that may be the most important lesson I have learned thus far.

How is Duke leading the way in global cardiology?

Duke is serious and passionate about tackling the global burden of cardiovascular disease.  Cardiovascular disease is a research priority area for the Duke Global Health Institute.  Within the Division of Cardiology, we have instituted a global cardiovascular health training pathway for cardiology fellows passionate about global health.  To my knowledge, we have begun the first section of Global Cardiovascular Health within a cardiology division in the U.S.  This section aims to heighten awareness of global cardiovascular health at Duke, foster global health training for cardiology fellows and strengthen partnerships between Duke and other institutions in global cardiovascular health research.

What do you believe are the biggest challenges ahead that need attention and consideration in the field?

The biggest challenges in the field today relate to understanding the determinants of cardiovascular disease in sub-Saharan Africa.  Specifically, there is important overlap between HIV and cardiovascular disease that warrants further exploration.  Seventy percent of the world's HIV population lives in sub-Saharan Africa, and this region is expected to witness a dramatic increase in cardiovascular disease and cardiovascular disease risk factors in the near future.  There is much work to be done in order to understand how these diseases express themselves, how they are treated and how to leverage the investment and infrastructure for HIV/AIDS for other chronic diseases. 

Tell us what inspires you most about your work.

 I am inspired by the opportunities to improve the health of populations on the cusp of an epidemic of cardiovascular disease.  This important work, done in partnership with local clinicians and investigators, will take time. But I am encouraged by the Africa proverb that says: "Walk alone, walk fast.  Walk together, walk far". We have a long way to go, but I am convinced that it’s going to be an exciting and productive journey.

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