Doctor Proves that Quality Health Care is Possible in the Third World

Cardiologist Ernest Madu sits in his office in Kingston, Jamaica. The walls are lined with framed diplomas and certificates. He hands me a leaflet showing a 4-month-old baby girl born with a disrupted valve in her aorta. The poster advertises a community campaign to raise $60,000 to fly her to Miami, Florida, for surgery. "I heard that she died," Madu says, a sombre look overtaking the usual brightness in his eyes. "If that child had been born in the U.S. instead of Jamaica," he adds, "she would have grown up to do what she wanted to do in life: Go to school, get married, have children, have a career. She died because she was Jamaican.

"Every life is valuable. A person in Indonesia is as important as one in Germany. Unfortunately, we live in a world now where if a person lives in a poor country, it's okay that their health is not as good. We need to find ways so that health and survival are equitable around the world."

For Madu, who is from Nigeria but practiced medicine for years in the southern U.S., access to medical care in the developing world is not simply an abstract issue of fate and fairness. It is a matter of life and death, which he faces every day in his work as CEO of the Heart Institute of the Caribbean (HIC). He and his wife Dainia Baugh, an internist, founded the HIC four years ago to prove it's possible to provide high-quality health care in a poor country like Jamaica. It's their hope that the hospital will become a model that spawns similar facilities throughout the global South.

This is a hugely ambitious goal. But when shaking hands with Madu, a powerfully built man with an even more powerful presence, you sense he possesses the charisma, determination and first-hand experience to make it happen.

People in developing nations die needlessly, Madu explains, because their countries lack basic medical services that patients in even the most impoverished or remote communities in North America and Europe take for granted. Before the HIC opened in Jamaica, there was no chance of receiving routine cardiology procedures like stress tests, electrocardiograms (ECGs or EKGs) or angioplasty.

"People have been indoctrinated to believe that good medical care can't happen in a place like Jamaica," Madu says. "It's simply assumed that ill people must go abroad for good treatment -- that is, if they can afford it and live long enough to make the trip. It's a mindset we have to get beyond if we want to improve health. Fifty percent of people having heart attacks die within 24 hours without the proper medical treatment. Even if you are rich enough to own a plane, it may be too late."

Patrick Walsh, a 47-year-old Kingston resident, declares he would not be alive today if not for the Heart Institute of the Caribbean. "I've come back from sudden cardiac arrest twice because of the defibrillator they implanted in me. It shocked me back to life." Complaining of swollen legs and shortness of breath, Walsh was referred to the HIC by his doctor. He was diagnosed with congestive heart failure and surgically outfitted with a defibrillator, a device incorporating a pacemaker that responds to a rapid or arrhythmic heartbeat with a shock so the pacemaker can continue to work. Such surgery was not available in Jamaica until the HIC opened.

"Dr. Madu assisted me by knocking off a balance of $9,000 from the bill," Walsh adds. "I am very grateful for that."

The hospital treats many poor patients, with a policy of not turning away anyone who needs help. "We charge only what they can afford to pay," Madu says. "Jamaicans are proud people, so many times the whole family -- the brother who is a cab driver in Los Angeles -- will send us money." Madu notes that the HIC provides more than $1 million a year in free or reduced-rate care.

The HIC does not yet have the capacity for pediatric cardiac operations, such as replacing the faulty valve in the little girl's heart, but Madu estimates that with the proper equipment and medical expertise, the operation could be performed in Jamaica for less than $10,000, increasing the chances for that little girl and others to live.

Another reason people in developing countries die needlessly is that medical authorities overlook the rising tide of so-called modern diseases -- such as heart disease and diabetes -- in these societies. It's assumed that malnutrition and infectious diseases like malaria or AIDS are the real threats. "Hypertension is a growing problem in Africa," notes Seyi Oyesola, a London anesthesiologist who regularly travels home to Nigeria on a volunteer open-heart surgery team. "Doctors don't detect hypertension when they are told it's not a problem and that they need to focus on malaria."

Fifty-six percent of hospital deaths in Jamaica are caused by cardiovascular disease, says Madu. Throughout the Caribbean and Latin America, it accounted for 31 percent of all deaths, a number that is expected to rise to 38 percent by 2020, according to a 2006 report from the World Bank's Disease Priorities Control Project. The report notes that cardiovascular disease is the second leading cause of death in sub-Saharan Africa after HIV/AIDS, and the leading cause for people over 30. "Africa made a huge mistake not responding quickly enough to AIDS," Madu says, "and I am afraid that is happening again with cardiovascular disease."

Reporting on the rise of cardiovascular disease in Africa with colleagues from Vanderbilt University in the journal Ethnicity and Disease in 2003, he concluded, "Unfortunately, at a time when Africa is dealing with an epidemic of infectious and communicable diseases, another pandemic is looming ... facilitated by the Westernization of indigenous cultures, increasingly sedentary lifestyles, high-fat Western diets, tobacco abuse and psychosocial stress from urbanization."

He calls this "the double burden of disease in poor countries," where the medical consequences of underdevelopment and overdevelopment coexist. Finding a solution to this impending crisis is what prompted Madu, 47, and Baugh, 38, to give up rewarding, comfortable lives as professors at Vanderbilt University Medical Center in Nashville, Tennessee, and come to Jamaica (Baugh's homeland) to become health-care entrepreneurs.

Skepticism was high in Jamaica about the possibility of receiving first-class cardiac care at home, but in just three years, the HIC has won a steady clientele of middle-class Jamaicans who don't want to travel to Miami for medical services, and poor ones who can't afford it. The HIC offers cardiovascular treatment for 5,000 to 12,000 patients a year at a fraction of what it costs in the U.S., due to lower expenses as well as donations from medical firms such as Medtronic.

Kenneth Baugh, a surgeon serving as Jamaica's deputy prime minister (as well as a distant cousin of Dainia Baugh's), says, "We are dealing with the common ailments of the past but now we have more chronic diseases as people live longer, so I am happy to see this kind of specialized health clinic in Jamaica, which shows we can create centers of excellence throughout the developing world."

New HIC branches now receive patients in Mandeville, Jamaica, and the Cayman Islands, with another institute set to open in Montego Bay, Jamaica, in 2008. The following year, his Heart Institute of West Africa in Port Harcourt, Nigeria, is scheduled to open. The facility will also offer dialysis treatment, a diabetes clinic, nutrition counseling and a birthing center -- an acute need in a country with one of the highest maternal morality rates in the world. Madu envisions the day when hospitals in less wealthy countries will offer state-of-the-art care for other emerging diseases such as cancer and asthma.

Paying customers, including "medical tourists" from Europe and North America seeking high-quality medical care at affordable prices, will be the financial backbone of these institutions, making it possible to treat indigent patients for low or no fees. "The globalization of health care will eventually force medical costs down," Madu predicts.

"We've learned a lesson in Jamaica that we want to apply in Africa too," he adds. "If you improve the standards in a country, everyone else will eventually move up. We are already training a lot of technicians from other hospitals. When you show what's possible, you empower other health professionals to do what they do better. That's part of the plan."

Madu is also exploring offers to set up heart hospitals in Tanzania and the Democratic Republic of the Congo. Madu is forthright in explaining that he became a doctor to save the world. His life has been shaped by childhood experiences in Biafra, a region of Nigeria that declared a short-lived independence in 1967, setting off a three-year civil war in which as many as a million people died.

"Most of my memories start with that war," he explains. "In school, we had bunkers where we had to go during bombings. Some students were killed. I wondered even then how responsible adults could throw bombs at kids. Seeing that violence and tragedy has driven my life. I have always felt that I should try to do whatever good I could in the world."

He was trained as a physician and surgeon at the University of Nigeria and moved to New York City for his residency, during which he volunteered at a hospital in Harlem. "What I saw there -- patients without access to care, with no insurance, who came to see doctors only at the late stages of an illness -- was a shock in such a rich country. It still doesn't make any sense to me."

Specializing in echocardiography and nuclear medicine, fields that employ cutting-edge technology to monitor heart health, Madu worked in U.S. hospitals for more than 15 years and taught in medical schools at U.S. universities in Tennessee and Florida, and at Vanderbilt. But he always maintained a keen interest in global health-care issues, and would return to Nigeria every year on medical missions to provide cardiac treatments that were unavailable in that country.

Madu's smile fades as he tells a story from one of these trips. A man suffering congestive heart failure was brought to see Madu in a wheelbarrow. Madu prescribed some medication. The man returned three days later, walking on his own, to say thanks. With a rueful pause, Madu says, "Without any follow-up treatment, I'm not sure he lived. These medical missions felt like putting a band-aid on a big wound."

Madu beams as he shows me around his hospital, a renovated office building in suburban Kingston, and points out equipment for procedures rarely performed in developing nations: echocardiography, electrocardiography, cardiac imaging, electrophysiology, radiofrequency ablations, carotid Doppler ultrasound scanning, stress lab testing, peripheral vascular interventions and percutaneous transluminal angioplasty. He's equally proud of his staff of 21 full-time and consulting physicians, many of whom trained in the U.S. or Canada. Jamaica saw a 75 percent leap in the number of cardiologists on the island when the hospital opened in 2005.

Even with all this up-to-date technology -- including a telemedicine platform that enables HIC staff to consult electronically with medical experts abroad -- there's an agreeably relaxed atmosphere to the place. The waiting room is furnished with cushy sofas from which patients and their families cheer on the Nigerian team in a soccer match with Germany on TV.

Madu is not bashful about walking into a physician's office with just a perfunctory knock to show me a new device ("This technology never existed before in the Caribbean. Look at it!") or introduce me to a colleague ("Meet Dr. Aldo Furlani, an electrophysiologist, trained at the Montreal Heart Institute, who is from Argentina."). As we pass one anxious-looking woman hooked up to a monitor, Madu carefully studies the screen and then reassures her in a deep, soft voice. "Your heart looks really good to me."

More than a hospital, the HIC is also an education-and-research facility that conducts medical studies on health factors in the developing world, trains professionals from public hospitals and sponsors public campaigns about healthy lifestyles. While the HIC is run as a private business so staff can be free of interference from bureaucrats or shareholders, a non-profit foundation supports its research-and-training programs and raises money to honor the pledge that no sick person will be denied.

"This is not a business; this is a social movement," notes Edwin Tulloch-Reid, director of clinical services, a Jamaican who came home after working as a cardiologist in Canada and the U.S.. "We make money but that is not our mission. We must be economically self-sustaining to show that this can be done other places around the world."

Madu and his staff are worried that the advance of Western-style development means Jamaicans and other people of the developing world are losing the few health advantages they enjoy compared to wealthier nations -- a way of life with fewer processed foods, lower stress, more exercise and a richer sense of community, all of which have been proven to affect wellness. "Obesity is becoming a problem in Jamaica and it's rising in Africa," Madu reports. "And smoking is rising too as tobacco companies intensify marketing efforts there."

In developing nations, where a desk job seems like a dream come true after generations of back-breaking labor, where cigarettes still appear glamorous and where an overflowing plate of food represents a triumph over malnutrition, people are not naturally inclined to worry about exercise, smoking or overeating. But as Western-style development slowly transforms these societies, unhealthy lifestyles have become a growing problem. The first sight I saw coming into Kingston from the airport was a huge banner strung across the highway advertising Kentucky Fried Chicken, and later when walking back to my hotel from the clinic, I asked directions from a well-dressed young woman on the street. She was shocked that I wanted to go that far on foot. It turned out to be only three blocks, but along a particularly grim stretch of road full of speeding vehicles and exhaust fumes that made me wish I had taken a taxi.

Madu and his colleagues are dedicated to preventing these looming health hazards, not just treating the cardiovascular problems that can result. One HIC study underway looks at the impact of a daily walk on preventing heart disease. "We want to create a new culture of walking in developing nations," Madu declares, "to let people realize it is an important part of the good life, of modern life, just as much as cars or restaurants. Not everyone has the time or money to go to a health club, but everyone can walk. I make sure that people see me walking in the park evenings at 6:30, so they might think: Here's a doctor, from America, and he's walking. I should be walking too."

The HIC has launched an ambitious education campaign in Jamaica to promote healthy living, which includes a weekly 15-minute radio show offering advice on preventing heart disease, a partnership with restaurants and school cafeterias to provide healthier meals and an annual three-kilometre (two-mile) Heart Walk that draws hundreds of participants and gets widespread media coverage. They've enlisted reggae star Rita Marley, Bob Marley's widow, to help spread the word.

Although not Jamaican by birth, Madu is fascinated by reggae music, and he is organizing a campaign to establish a Reggae Hall of Fame in Kingston. "Jamaica, this little island, has pioneered a music loved all over the world. This needs to be celebrated so people here can realize what they are capable of doing. You succeed because you believe. That's the biggest thing we need in Jamaica and developing nations. People need that sense of possibility. That's what Bob Marley accomplished. He started with something that bucked all the trends because he believed in his ideals -- "

His colleague, clinical services director Edwin Tulloch-Reid, cuts him short and with a teasing grin asks, "Say, are you talking about Bob Marley or yourself?"

Find out more:

Is there a doctor in the country?

The medical crisis in poor regions is heightened by an exodus of doctors and nurses who have been trained in developing countries at public expense and now practise in Europe or North America. One out of 10 doctors in Canada, according to Toronto's This Magazine, comes from low-income countries with acute health problems of their own, notably South Africa and India. Sixty percent of doctors graduating from the University of the West Indies in Kingston are not working in the Caribbean, according to the HIC.

"Why do people leave?" asks Madu, who still splits his time between the HIC and Baptist Hospital in Nashville, Tennessee. "For a lot of them, it's because there are no facilities for people to do their jobs well. Everyone wants to feel they are making progress in their field. It's not just the money. People want to feel they are doing some good.

"But if we build good hospital facilities in the developing world, then more nurses and doctors will stay, and health care will improve. If even 10 percent came back from the West, that would make a great difference for people, and encourage more of the next generation to stay."

Yet Madu has discovered, "it's easier to get money from the international community for non-profit groups that go into poor places three times a year to do medical missions than for a hospital that can improve the medical infrastructure in these countries." He and Baugh have raided their retirement accounts to help fund the HIC, Madu says, which is one reason they both still practise part-time in the U.S. "I'm poorer now," he says with a laugh, "but happier."


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