Sitting in an office in Kingston, Jamaica, lined with framed diplomas and certificates, Dr. Ernest Madu hands me a leaflet showing a four-month old baby. She was born with a disrupted valve in her aorta, and the poster advertises a community campaign to raise $60,000 to fly her to Miami for surgery. “I heard that she died,” he says, a somber look overtaking the usual brightness in his eyes.
“If that child had been born in the US instead of Jamaica,” says Madu, who is from Nigeria but practiced medicine for many years in Tennessee, “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,” Madu says, with rising passion in his voice. “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, 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, one that he faces every day in his work as CEO of the Heart Institute of the Caribbean (HIC). He and Dr. Dainia Baugh, his wife, founded HIC four years ago to prove that it’s possible to provide high-quality health care in a poor country like Jamaica. It’s their hope that the hospital becomes a model that spawns similar facilities throughout the global south to save lives.
This is a hugely ambitious goal that powerful figures concerned about global health issues such as Bill Gates, Bono, and Bill Clinton have not dared to propose. 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 Heart Institute of the Caribbean opened there was no chance in Jamaica of receiving routine cardiology procedures like a stress test, an electrocardiogram (ECG or EKG), 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,” he says. “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.
The rising tide of modern diseases
Patrick Walsh, a 47-year-old Kingston resident, declares that 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.” Walsh was referred to HIC from another physician complaining of swollen legs and shortness of breath. He was diagnosed with congestive heart failure and was surgically outfitted with a defibrillator, a device incorporating a pacemaker that responds to a rapid or arrhythmic heartbeat with a shock so that the pacemaker can continue to work. Such surgery was not available in Jamaica until HIC opened.
“Dr. Madu assisted me by knocking a balance of $9,000 off the bill,” Walsh adds. “I am very grateful for that.”
The hospital also treats many poor patients through its policy of not turning anyone away who needs help. “We charge only what they can afford to pay,” Madu says. “Jamaicans are proud people, so many times the whole family, or the brother who is cab driver in Los Angeles, will send us money.” Madu proudly notes they provide more than $1 million a year in free or reduced-rate care.
HIC does not yet have the capacity for pediatric cardiac operations, such as replacing the disrupted aortic 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 because medical authorities overlook the rising tide of heart disease, diabetes, and other so-called modern diseases 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 Dr. Seyi Oyesola, a London anesthesiologist who regularly travels home to Nigeria as part of 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.”
The double burden of disease
Fifty-six percent of hospital deaths in Jamaica are caused by cardiovascular disease, according to 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 also 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 age 30. And, based on his research, Madu says the problem is growing even in Africa. “All the data tells us that within eight years cardiovascular disease will be the leading cause of death in sub-Saharan Africa. Africa made a huge mistake not responding quickly enough to AIDS, and I am afraid that is happening again with cardiovascular disease.”
After studying the rise of cardiovascular disease in Africa with colleagues from Vanderbilt University in the scholarly journal Ethnicity & Disease (Spring 2003), he reported that, “Unfortunately, at a time when Africa is dealing with an epidemic of infectious and communicable diseases, another pandemic is looming [one that is] facilitated by the Westernization of indigenous cultures, increasing 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 entrepreneurs by launching an innovative heart hospital.
Skepticism was high in Jamaica about the possibility of receiving first-class cardiac care at home, but in just three years the Heart Institute of the Caribbean 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. HIC offers cardiovascular treatment for 12,000 to 15,000 patients a year at a fraction of what it costs in the US due to lower expenses and donations from medical firms such as Medtronic.
Dr. Kenneth Baugh, a surgeon and Jamaica’s Deputy Prime Minister for Foreign Affairs and Trade (and a distant cousin of Dr. Dainia Baugh), 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.”
Raising standards in the developing world
New HIC branches are now seeing patients in Mandeville, Jamaica, and the Cayman Islands with another institute set to open in Montego Bay, Jamaica, this year. Madu’s dream of high quality hospitals all over the developing world will come one step closer to reality in 2009, when his Heart Institute of West Africa in Port Harcourt, Nigeria, is scheduled to open. Expanding beyond cardiovascular care, 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. He envisions the day when hospitals in less wealthy countries will eventually 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 little or no fees. “The globalization of health care will eventually force medical costs down,” he predicts.
“We’ve learned a lesson in Jamaica that we want to apply in Africa, too,” Madu 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.”
After a well-received speech last summer in Tanzania at the prestigious TED conference, where cutting-edge ideas in technology, entertainment, and design are introduced to an invitation-only audience of global movers and shakers, Madu is now exploring offers to set up heart hospitals in Tanzania and the Democratic Republic of the Congo.
Madu is quite 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 independence in 1967, setting off a three-year civil war in which as many as one 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 for his residency, where 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,” he says. “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 has worked in US hospitals for more than 15 years and taught in medical schools at the University of Tennessee, the University of Florida, and Vanderbilt University. 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 treatment unavailable in that country.
Madu’s smile fades as tells a story from one of these trips: A man suffering congestive heart failure was brought to see Madu in a wheelbarrow. Madu prescribed him 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.”
Exodus of talent
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 practice in Europe or North America. One out of 10 doctors in Canada, according to Toronto’s This Magazine, come from low-income countries with acute health problems of their own, notably South Africa and India. Sixty percent of MDs graduating from the University of the West Indies in Kingston are not working in the Caribbean, according to HIC.
“Why do people leave?” asks Madu, who still splits his time between HIC and Baptist Hospital in Nashville. “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 built 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 nonprofit 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 funds to help fund HIC, Madu says, which is one reason they both still practice part-time in the US. “I’m poorer now,” he says with a laugh, “but happier.”
Madu beams as 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, stress labs, peripheral vascular interventions, percutaneous transluminal angioplasty. He’s equally proud of his staff of 21 full-time or consulting physicians, many of who trained in the US 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, which includes 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 another physician’s office with just a perfunctory knock in order to show me a new device (“This technology never existed before in the Caribbean. Look at it!”) or to introduce me to colleague’s (“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.”
A social movement
More than a hospital, 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 HIC is run as a private business so the staff can be free of interference from bureaucrats or shareholders, a nonprofit foundation supports its research and training programs as well as raises money to honor Madu’s and Baugh’s pledge that no sick person will be turned away.
“This is not a business, this is a social movement,” notes Dr. Edwin Tulloch-Reid, director of clinical services, a Jamaican who came home after working in Montreal and Pittsburgh. “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.”
One HIC research study that particularly excites Madu is a project measuring the average size of the heart among people in the Caribbean. It’s known that heart measurements can vary among cultures, but there is no firm data from the Caribbean. “They use simply the heart dimensions that are normative in the US and Europe,” he says. “The average ventricle size is set at 4.2 centimeters, but what if 3.8 is the average in the Caribbean, and 4.0 is actually enlarged? We need to know that.”
Madu himself is investigating the incidence of high blood pressure among Africans who migrate to other countries, compared to those who stay at home. “We already know there is more hypertension among Africans who immigrate and with an earlier onset. Someone who left Africa at 30 has a greater chance of developing hypertension at 40 than someone who stayed in Africa, but we don’t know why. We are pursuing research to measure the effects of stress in the new environment, and the loss of family and community support systems.”
HIC researchers are creating a medical profile of top Jamaican athletes, hoping to explain their exceptional performances and find clues that can boost overall health. With a population of less than 3 million, the island has produced many world-class runners, including Asafa Powell, dubbed “the fastest man in the world” for breaking his own world record in the 100-meter dash in September with a time of 9.74 seconds. “The world wants to know what makes us great athletes,” says HICs staff nutritionist Dr. Garth Officer, who once served as reggae star Peter Tosh’s personal physician. “We don’t have the best equipment, the best coaches, the best training facilities. But it may be that we eat a better diet—a poor man’s diet of complex carbohydrates, not the refined carbohydrates of the American diet.”
Western development/Western disease
Madu and his staff are worried the advance of Western-style development means Jamaicans and other people of the global south 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 health 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 afterwards. One HIC study now under way 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.’”
HIC has launched an ambitious education campaign in Jamaica to promote healthy living that includes a weekly 15-minute radio show offering advice on preventing heart disease, a partnership with restaurants and school cafeterias to offer healthier meals, and an annual 3K Heart Walk that draws hundreds of participants and gains widespread media coverage. It has enlisted reggae star Rita Marley, widow of Bob Marley, to help spread the word.
Although not Jamaican by birth, reggae music holds a particular fascination for Madu, 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,” Madu continues, growing ever more excited. “He started with something that bucked all the trends because he believed in his ideals—”
At that moment, his colleague, Dr. Edwin Tulloch-Reid, cuts him short and with a teasing grin asks, “Say, are you talking about Bob Marley or yourself?”
This article originally appeared in the January/February edition of Ode magazine.
