CARDIOVASCULAR JOURNAL OF AFRICA • Vol 24, No 4, May 2013
AFRICA
145
and income (Fig. 9) and child mortality (Fig. 10) suggest that
reduction in fertility would be more effective than any other
intervention we could make at present.
For example, if it were possible to reduce fertility in Niger
from eight to four children per woman, the incidence of
congenital heart disease would be reduced by one-half, and if
each woman had only two children, the incidence would be
reduced by 75%. This is a dramatically greater reduction than
possible with any form of treatment; it comes at little cost to
the medical services and has the added benefit that it may be
associated with an increased per capita income.
16
In Mali, a country with a very high fertility rate (before
the coup), with the cooperation of imams who understood the
problems, the fertility rate dropped from 7.29 in 2009 to 6.35 in
2012. Once such a change starts, the gains accumulate so that
there is more money available to treat congenital heart disease in
the remaining children.
Reductions in fertility rate with improvement in the national
economy have been demonstrated in China, Vietnam and many
other countries, even though multiple factors were probably
involved. Hans Rosling, an epidemiologist who has worked in
this field for many years, made a superb YouTube presentation
that demonstrates these changes.
17
It is well worth looking at it.
Improvement in treating congenital heart disease is a long-
range enterprise. In keeping with the notion that preventing
disease is often cheaper than treating it, reducing the fertility
rate is perhaps the most important approach and one that has
many benefits beyond reducing the incidence of the disease.
Second, investing resources in preventing or treating diseases
such as malnutrition, malaria, diarrhoea, measles, pneumonia
and rheumatic fever would greatly reduce the child mortality
rate, and would then free up money for other purposes, such
as establishing regional centres for treating congenital heart
disease.
One way of achieving these goals with the least expenditure
might be for governments in Africa and Asia to invest in local
clinical centres where people have access to health education,
diagnosis and treatment for common illnesses. Experience in
countries such as China and the former southern Rhodesia,
now Zimbabwe, have shown that it is possible to train nurses
or nurses’ aides for relatively short periods and have them
work in local centres where they can diagnose and treat the
simple common illnesses. If this were done after consulting the
local population and their leaders, whether these be chieftains,
sangomas, ngangas, shamans or imams, this would secure their
cooperation and reduce resistance from the population to a
government structure imposed on them.
Conclusion
The burden of congenital heart disease falls most heavily on
countries with the lowest incomes and the highest fertility
rates. Strategies for improvement include preventing excessive
numbers of births of children with congenital heart disease by
lowering the fertility rate. Money for treating chronic diseases,
such as congenital heart disease is always in short supply but can
be freed up if more easily preventable acute diseases, such as
malnutrition, measles, rotavirus infections or rheumatic fever are
made the targets for concerted action. Finally, establishing local
health centres with the support of the local population may make
it easier to give advice about health and nutrition, administer
vaccines and treat streptococcal infections early.
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