The symptoms of a heart attack may appear hours before the actual attack. Often subtle in nature, people tend to ignore the discomforts of chest tightening or shortness of breath that eventually develop into cardiac arrest. However, it is when preventive measures are taken during these first crucial minutes that the chances of surviving the impending attack increase significantly. Not recognizing the symptoms, often passing them off as a minor inconvenience such as indigestion, means that when cardiac arrest takes place, some hours later, treatment is more complicated. Fortunately, in Western society defibrillators and healthcare points are widely available. This is not often the case in developing nations, as highlighted by Dr Prahlad Karki and his colleagues. At this year’s Geneva Health Forum (18-20 April 2012) they will present their findings on access to healthcare for patients with Coronary Artery Disease (CAD) in environments that are topologically, financially and politically unaccommodating.

Nepal is one of the poorest and least developed countries in the world, and does not yet have a fully stabilized government. Hospitals are set up in larger cities, but many rural villages still rely on health posts for primary healthcare. Nepal’s vast mountainous landscape often means that villagers live far away from one of the 3129 health posts. The government’s long-term health plan is to ensure that 90% of citizens have access to some form of medical outfit within a travel time of 30 minutes. Yet those needing specialized care from a hospital or tertiary care centre may find themselves traveling for much longer, as health posts are often not equipped or trained for anything out of the ordinary.

The quality of service in remote health posts can vary enormously, as physicians tend to stay in cities where remuneration and opportunities for promotion are substantially better. Unaware of the symptoms, health posts often do not diagnose Acute Coronary Syndrome (ACS) - a result of CAD - and urgently needed care is delayed. In their study, Dr Karki and his colleagues at the B.P. Koirala Institute of Health Sciences, Dharan, found that the time between the onset of symptoms and treatment could be anywhere between 1 and 360 hours, with an average of 32 hours. Surprisingly, even residents living in Dharan still took about 20 hours to go from an initial consultation at a health post to being received at the tertiary health care facility in the same city. This was due to a combination of incorrect diagnoses at local healthcare centres, and car breakdowns on the way to a specialized facility. It is frustrating for the physicians who eventually deal with the patients to know that their suffering is partly due to the developing nature of the country, despite the B.P. Koirala Institute’s modern facilities.

A lack of knowledge from both patient and local care provider is a root cause of delayed care for ACS treatment. The patient may often not be aware of their unhealthy lifestyle, and the caregiver of the symptoms. The study recommends programs on the prevention of heart conditions, including raising general awareness and introducing technical improvements such as equipping all health facilities with electrocardiogram machines. The World Health Organization has a health promotion plan for the region to raise awareness of various diseases; perhaps Dr Karki’s work could contribute towards a better general health policy in Nepal.

Abstract on the 2012 Geneva Health Forum website

(Photo ©  Nepal Health Sector Support Programme)