CORRESPONDENCE: LETTER TO THE EDITOR
Aspirin for the Masses
Fawad Aslam, MD* and
Abdul Waheed, MD
* Baylor College of Medicine, Houston, Texas 77030 (Email: fawadaslam2{at}gmail.com).
The recent article by Joshi et al. (1) stressed the need for a nonphysician workforce in cardiovascular disease (CVD) management in low- and middle-income countries. We believe that there is a need to go one step further, considering the exigency of the situation. The use of aspirin for primary prevention is well established and must be added to this approach at a community level. The combination of nonphysician health care workers (NPHWs) equipped with aspirin can potentially be a very effective strategy. Aspirin is a drug of common social acceptance in developing countries, is often readily available over the counter, and is easily affordable because most payments are out of pocket. Statins and diuretics unfortunately do not share these attributes, at least at present.
A program should be developed to teach the NPHWs the administration of aspirin along with lifestyle modification after the identification of high-risk patients. This will not be easy, and a risk assessment tool would need to incorporate the risk of bleeding with aspirin. Routine availability of cholesterol and glucose evaluation at the community level will remain elusive for years to come, and clinical criteria and clinical risk prediction models will have to be relied upon. The use of a national cholesterol average as a substitute is a decent suggestion in these calculations (2). The World Health Organization CVD risk management package has been successfully practiced by NPHWs (3) and can be useful in this regard.
Compliance, however, will still be the fundamental problem. There is evidence to suggest that although interventions result in improved knowledge, they do not necessarily translate into practice (4). There is anecdotal evidence to suggest that people in these settings do not comply with medicines for which they see no overt benefits. This necessitates that vessels of established trust be used, where available, to spread prevention and proven intervention hand-in-hand to the current epidemic of CVD in developing countries.
There are many examples of effective health care delivery by NPHWs in developing world settings, such as the success of the Integrated Management of Childhood Illness program on an international scale and the Lady Health Visitor program for female health care in Pakistan (4). The latter can also serve to address the gender inequity of health care access more effectively because of its large network, penetration, and reputation.
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1. Joshi R, Jan S, Wu Y, MacMahon S. Global inequalities in cardiovascular health care J Am Coll Cardiol 2008;52:1817-1825.[Abstract/Free Full Text]2. Mendis S. Cardiovascular risk assessment and management in developing countries Vasc Health Risk Manag 2005;1:15-18.[CrossRef][Medline] 3. Abegunde DO, Shengelia B, Luyten A, et al. Can non-physician health-care worker assess and manage cardiovascular risk in primary care? Bull World Health Organ 2007;85:532-540. 4. Nishtar S, Badar A, Kamal MU, et al. The Heartfile Lodhran CVD prevention project—end of project evaluation Promot Educ 2007;15:17-27.
Related Article
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Reply
- Rohina Joshi, Stephen Jan, Yangfeng Wu, and Stephen MacMahon
J. Am. Coll. Cardiol. 2009 54: 91-92.
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