HYPERTENSION IN LOW-RESOURCE VENUES:
A MULTI-LEVEL COMPREHENSIVE REFERENCE FOR FAITH-BASED AND NON-GOVERNMENTAL ORGANIZATION MEDICAL MISSION PROGRAMS
BOOK ONE: INTRODUCTION: THE WHY, THE WHAT, AND THE WHO, AND WHERE ARE YOU?
MODULE #I. CIC/WHAG: THE WHY QUESTIONS
IA. WHY DID WE DO THIS?
A TALE OF TWO COUNTRIES:
THE COMMON BOND OF FAMILY SUFFERING
In the Boston (U.S.) area, the father of the primary author was working at his computer when noticed difficulty moving his hand. He then fell when trying to stand up, and was unable to speak. Fortunately, his wife heard the fall, rapidly identified it as a stroke, and called 911. Emergency Medical Services (EMS) responded immediately and he was quickly transported to the Emergency Room of a local hospital where he was identified as high risk for Large Vessel Occlusion (LVO) of the Middle Cerebral Artery (MCA), and was transported by helicopter to a world-renowned Boston hospital high level stroke center. Mistakenly, completely out of protocol, he received heparin in the ER at time of transport, so that was deemed not to be a candidate for either “clot-busting” fibrinolytic (rtPA) Rx or an attempt at thrombectomy or direct removal of clot. Fortunately, the weakness did improve but the dense aphasia (inability to speak) as a silver bullet in one so articulate was devastating and permanent. While technology and higher-income in the developed world has obvious benefits, one of the costs is the geographic dispersion of the nuclear family where a simple telephone (before facetime) was insufficient form of communication for those who could not physically be there. There was suffering.
In Baptiste Haiti, a leader of the small and moderately illiterate community was a regular participant in morning mass as a lector reading by the morning sunlight in the absence of electrical power, respected and beloved by all. At a community BP screening he was noted to have severe hypertension, to the point that he was immediately taken down the mountain to a small local hospital to have treatment initiated. Apparently, when that supply of medicine ran out, he did not return for follow up. At the time of our next visit, we were told he had died at home from stroke. There was suffering.
In Baptiste Haiti, a leader of the small and moderately illiterate community was a regular participant in morning mass as a lector reading by the morning sunlight in the absence of electrical power, respected and beloved by all. At a community BP screening he was noted to have severe hypertension, to the point that he was immediately taken down the mountain to a small local hospital to have treatment initiated. Apparently, when that supply of medicine ran out, he did not return for follow up. At the time of our next visit, we were told he had died at home from stroke. There was suffering.
At the local hospital outpatient clinic in Belladere Haiti, there seemed to be an endless parade of people being brought in by family members after change in status at home, many without a clear understanding that the change was due to a recent stroke. One memorable male patient was brought in relatively early by his son (that is 24-48 hours) with a clear understanding that there was a stroke with new and dense hemiparesis (one sided weakness)and difficulty speaking.
Blood Pressure (BP) was on the relatively low side of normal, with counselling that the BP be followed closely in follow-up. As a physician, all one could do is make best judgement that the deficit had stabilized over 48 hours and maybe not hemorrhagic, and maybe evidence might suggest that giving aspirin in another day might not be completely outrageous. While seemingly trivial acute phase intervention, it might at least alleviate the guilt that otherwise there was absolutely nothing to do beyond the empathetic statement that you understand and are really sorry, and in the difficult days of recovery ahead “take care of your dad”. There was suffering, and it was palpable, and it was bilaterally shared. That therapeutic quandary and desire to go beyond nihilism has led to the CIC/WHAG approach.
Our experience in urban hospitals in Port au Prince Haiti, observing many acute stroke related deaths, especially in young people, was a very different experience from the rural areas where hearing about stroke related death was often anecdotal after the event. We discuss the connection of passion and suffering, independent of statistics. We do not know how many of these mostly anonymous deaths of the rural destitute poor souls even had the basic human dignity of being recognized as a hypertension/stroke statistic.
These personal stories represent our motivation, and why we are so passionate about what we do, especially focused on hypertension, stroke and families. Our efforts are dedicated to our families, those families in Haiti, and their affected brothers and sisters worldwide. It is all with the recognition that though the burden of grief for stroke mortality is a family and community experience, the major burden of stroke morbidity is borne by families and caregivers, as well as the stroke survivor. This is especially the case in areas of low-resource without rehabilitation services. Hypertension is described as the silent killer. In reality, it is so much more, and the carnage is very real.
It is our passion to alleviate suffering from stroke by controlling hypertension in the community, and supporting healthy families. That is what this whole comprehensive effort is about, and we hope you will share that passion. We hope you will share our optimism and enthusiasm for the large effort to have a positive impact on families worldwide, manifest as the avoidance of preventable suffering.
This is also why we continue to tell the family story using coloring books for children. It is factual family folklore in areas with high levels of illiteracy, because that is where the real prevention intervention will take place for future generations! The data has clearly shown that knowledge of stroke risk factors and warning signs are most limited in older adults (>65 years), with low levels of education, and people living in rural areas. Culturally appropriate learning about hypertension and stroke is a game the whole family can play!
We have all heard the sometimes incessant “why” questions of an inquisitive child. It is a binding and shared universal experience. Children tend to reduce complexity to the basics, and reflect the immediate world around them. So, in the gradient from high- to low- income countries the corollary questions might range from the simple “why bother?” reflective of contentment, to the more profound “why doesn’t anybody care enough to do anything to help me and my family?” reflective of loss. Family and community suffering due to hypertension related catastrophic illness, especially from cardiovascular disease and stroke, is also a binding and shared universal experience.
Our experience in urban hospitals in Port au Prince Haiti, observing many acute stroke related deaths, especially in young people, was a very different experience from the rural areas where hearing about stroke related death was often anecdotal after the event. We discuss the connection of passion and suffering, independent of statistics. We do not know how many of these mostly anonymous deaths of the rural destitute poor souls even had the basic human dignity of being recognized as a hypertension/stroke statistic.
These personal stories represent our motivation, and why we are so passionate about what we do, especially focused on hypertension, stroke and families. Our efforts are dedicated to our families, those families in Haiti, and their affected brothers and sisters worldwide. It is all with the recognition that though the burden of grief for stroke mortality is a family and community experience, the major burden of stroke morbidity is borne by families and caregivers, as well as the stroke survivor. This is especially the case in areas of low-resource without rehabilitation services. Hypertension is described as the silent killer. In reality, it is so much more, and the carnage is very real.
What are Knowledge Points?
WHY CERTIFICATION?
BP Measurement is a foundational skill that must be done with a high level of accuracy
#1
It has been clearly established that on average BP measurement is not generally done with optimal accuracy according to established criteria
#2
Being able to perform and teach BP measurement according to defined standards is of critical importance and the best way to document that competence is through certification
#3
The ability to perform high quality public and personal education on hypertension and overall cardiovascular risk is also a critically important function that may also lend itself to the certification approach
#4
Higher-level basic hypertension management activities, as well as knowledge and management of hypertension as related to advanced clinical problems builds on the basic foundation of BP measurement expertise