The 4th All-Africa Workshop on Acute Rheumatic Fever and Rheumatic Heart Disease (RHD)
was held in Addis Ababa from March 4-6, 2016, hosted by the Pan-African Society of
Cardiology (PASCAR) and the African Union Commission (AUC). This was a conference
of expert cardiologists and cardiac surgeons who are leading RHD efforts, and included
delegates from 22 African countries (Figure 1). There were also representatives from
major international stakeholders, such as the World Health Organization (WHO), the
World Heart Federation (WHF), as well as the philanthropic arms of the Novartis and
Medtronic, both of which have active programs targeting RHD.
10.7717/gcsp.201612/fig-1
Figure 1.
Front row left-to-right: Liesl Zuhlke, Mabvuto Kango, Ana-Olga Mocumbi, Oyere Onuma,
AU Commissioner Dr Mustapha Sidiki Kaloko (Sierra Leone), Bongani Mayosi, Magdi Yacoub,
John Musuku, Alaaeldin Elghamrawy.
Remainder in alphabetical order: Azza Abul-Fadl; Ahmed Afifi, Sulafa Ali, Marvin Allen,
Lori Allen, Michael Awoke, Fidelia Bode-Thomas, Rex Clements, Albertino Damasceno,
Rezeen Daniels, Frank Edwin, Ahmed Elsayed, Mark Engel, Mario Fernandes, Paradzai
Gapu, Elizabth Gatumia, Ahmed El Guindy, Prasanga Hiniduma-Lokuge, Chris Hugo-Hamman,
Ali Ibrahim Toure, Neil Kennedy, Peter Lwabi, Zongezile Makrexeni, Joanna Markbreiter,
Duncan Matheka, John Meda, Lwazi Mhlanti, Jeremia Mwangi, Julius Mwita, Robert Neely,
George Nel, Alassane Ngaide, Shanti Nulu, Stephen Ogendo, Emmy Okello, John Omagino,
Susan Perkins, Lumilla Reina, Emmanuel Rusingiza, Steven Shongwe, Maylene Shung King,
Renae Stafford, Brigitta Tadmor, Zeina Tawakol, Wubaye Walegne, David Watkins and
Dejuma Yadeta.
The conference commenced with an opening statement by Dr. Mustapha Sidiki Kalako,
the AU Commissioner for Social Affairs, followed by presentations by the international
delegates, each expounding on their current levels of engagement and resources for
RHD. Next, delegates from each of the 22 countries were tasked with reporting on the
status of their progress toward the “7 key actions” for intervention on RHD in Africa
which were laid out a year prior, during the 3rd AUC RHD conference (Table 1).
10.7717/gcsp.201612/table-1
Table 1
The Addis Ababa communiqué; seven key actions to eradicate rheumatic heart disease.
1. Establish prospective RHD registries at sentinel sites in order to monitor RHD-related
health outcomes, including the achievement of a 25% reduction in mortality from RHD
by the year 2025
2. Ensure adequate supplies of high-quality benzathine penicillin that can be administered
in the most effective manner, in order to achieve primary and secondary prevention
of RHD
3. Guarantee universal access to reproductive health services for women with RHD and
other NCDs
4. Decentralize technical expertise to the primary and district levels
5. Establish centres of excellence for cardiac surgery, which will deliver state-of-the-art
surgical care, train African cardiac practitioners, and conduct research on cardiovascular
diseases, including RHD
6. Foster multi-sectoral and integrated national RHD control programs led by the Ministry
of Health, which will oversee the implementation of national RHD action plans
7. Cultivate, through a strong communication framework, partnerships with relevant
stakeholders, in order to ensure the implementation of the aforementioned actions,
and the connection of African RHD control measures with the emerging global movement
towards RHD control
Notes.
ARF
Acute rheumatic fever
RHD
Rheumatic heart disease
NCD
non-communicable diseases
These aims are directly derived from the 7 key barriers to RHD eradication that were
identified during previous workshops, and include some structural barriers such as
lack of surveillance programs, over-centralization of services, and lack of national
RHD programs, as well as specific deficits, such as the supply of quality Benzathine
Penicillin (BPG), poor integration with reproductive health services, and a lack of
access to cardiac surgical services
1
.
This conference represents a unique moment not only for RHD, but also for global health
in general. It was evident that African health leaders, working on the front lines,
are in the process of reclaiming a health agenda for their own, one that reflects
the actual needs of their respective populations, and one that resists the imposition
of an external agenda driven by donor priorities and perceived needs. This was best
represented by the key themes that emerged from this meeting, which are discussed
below.
Almost all the delegates noted resistance to the RHD agenda at the government or ministry
level. Many noted how competing priorities, even within the category of non-communicable
diseases (NCDs), often prevailed in the funding battles of national ministries. Delegates
cited two major reasons for this.
First, the lack of robust data on RHD prevalence and economic burden was suggested
as a cause for its exclusion in national health agendas. Comparisons were made to
other NCDs such as diabetes, where there is more data to support its urgency as a
health priority. While global estimates point to a relatively low prevalence of disease,
these estimates are largely statistical extrapolations from decades-old data, which
relied primarily on clinical diagnostic criteria. The recent adoption of echocardiography-based
screening with higher sensitivity to detect subclinical disease
2
has shown much higher prevalence rates with the inclusion of asymptomatic children
3-5
. Given the potential economic burden from premature mortality associated with RHD
among the young, the delegates uniformly agreed that further investment in research
may elevate RHD as a major priority.
Second, the lack of prioritization by the WHO was widely acknowledged to be directly
correlated to the agendas of national health ministries. Indeed, the relationship
of many national health ministries to the WHO was described in paternalistic terms.
While the WHO representative noted the existence of an RHD program within the WHO
dating back to 1954, she also acknowledged the “pause” in its activities during the
early 2000s, a time roughly correlated to the time at which RHD was thought to be
eradicated in the West. This “pause” was essentially its de-prioritization, which
represented the shifting of priorities of Western donors.
In virtually all of the 22 countries represented, the WHO role in RHD efforts by front
line leaders was essentially absent. However, plans for a possible WHO Board Resolution
on RHD for 2017 appear to be underway.
Indeed, there is a clear disconnect between the priorities of international global
health institutions, which are focused primarily on “middle-class” NCDs such as ischemic
heart disease and diabetes, and those of African health leaders who tend to the neglected
diseases of the global poor. The international delegates urged for greater integration
of the “7 key actions” within their own broader NCD agendas.
However a review of the WHO NCD Action Plan and the WHF Global Roadmap suggests a
virtual neglect of RHD. The WHO NCD Action Plan, for instance, focuses entirely on
the “big four” NCDs of cardiovascular disease, diabetes, chronic respiratory disease,
and cancer and their behavioral risk factors—smoking, inactivity, dietary excess and
alcohol. RHD, a disease structurally determined by poverty, inadequate access to healthcare
(and antibiotics), and poor sanitation, cannot be easily integrated into this framework.
As such, adhering to this framework would not address the barriers to RHD eradication
observed by the African delegates.
The PASCAR RHD agenda more broadly addresses the specific structural deficiencies
that have enabled RHD to thrive on the African continent. Rather than integration,
international health organizations should work to elevate this framework and enable
its prioritization in national health agendas. A positive step in this direction is
the establishment of the RHD Action Alliance in 2015 by the WHF, together with RhEACH
and Medtronic Philanthropy, which provides a platform for technical support and policy
advocacy.
Two areas encompassed in the seven actions that are almost universally lacking in
all represented countries are the lack of integration of RHD surveillance and treatment
with reproductive services, and the lack of access to cardiac surgical services. It
is thought that RHD represents an important source of maternal and perinatal mortality
that is vastly under-recognized by reproductive health workers
6
. Many of the delegates who attempted to establish integrative strategies with reproductive
health partners reported on the poor levels of awareness of RHD among maternal health
workers. There was also universally limited access to cardiac surgical services for
RHD patients, especially for those who cannot afford to pay at a private hospital.
In Egypt, the Aswan Heart Centre has served as an example of a donor-funded cardiac
facility, which provides a first-world level of cardiac care free of charge, including
percutaneous and surgical interventions
7
. Indeed, several other countries shared marked progress towards surgical facilities
for RHD. Such examples should not be seen as exceptional cases. It is essential to
keep in mind that the 7 key actions represent the entire spectrum of RHD, from primary
to tertiary care, and this requires bold steps by individuals and organizations aimed
at all points of the continuum.
When comparing the successes and failures of the 22 countries towards RHD eradication
over the past year, countries that made the most progress were those with strong,
African-led leadership. In Malawi, RHD has been included and highlighted in the national
NCD plan. In Egypt, in addition to a national RHD program with 30 decentralized RHD
centers, there is strong support for RHD initiatives through the efforts of the Magdi
Yacoub Foundation and the Aswan Heart Centre, as well as Dr. Alaa Ghamrawy from Mahla
City, whose robust research efforts which have yielded data suggesting a much higher
prevalence of RHD than previously imagined. In Namibia, strong coordination of leadership
at the ministry and academic levels has resulted in a national RHD registry, a national
program for prevention, and outreach and decentralization efforts. Rwanda’s strong
central leadership has led to robust horizontal system strengthening efforts which,
although not specifically targeting RHD, have resulted in stronger resources for RHD
prevention and treatment.
Education remains a vital component of prevention and treatment efforts, and this
requires innovative strategies for reaching the public. The Bienmoyo Foundation in
Tanzania enlisted the help of composer Danielle Williams to teach children the importance
of RHD awareness through the song “Moyo Wetu” or “Our Heart”, which the PASCAR delegates
had the opportunity to learn and sing (Figure 2).
10.7717/gcsp.201612/fig-2
Figure 2.
(a) Delegates sing “Moyo Wetu”, a song about rheumatic heart disease awareness taught
in primary schools in Tanzania. (b) “Moyo Wetu” Lyrics by Peter Mhando, Composed by
Danielle Williams.
All these themes converge to represent the voice of the front-line African health
leader who resists international paternalism and reclaims an agenda that is relevant
for neglected populations. This voice demands a global health equity approach which,
until recently, has been overshadowed by cost-effectiveness rationalities for resource
allocation. The “seven actions” agenda put forth by PASCAR is a contextually-oriented
framework that has real resonance with the prevailing values of today’s global health
value shifts, such as system orientation and health equity. This framework is in need
of elevation by the major international health organizations, and resource prioritization
to help front-line African health leaders. We eagerly anticipate next year’s follow
up conference “Rheumatic Heart Disease Science and Practice—from Molecules to the
Global Community”, which will be held in Cairo January 13-16th, 2017. We expect to
build on the momentum of this year’s conference, sharing progress and emphasizing
specific tasks for African leaders from diverse health care backgrounds to help make
the eradication of RHD a reality.