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Abstract

  1. Top of page
  2. Abstract
  3. Stroke, Salt, and Social Determinant Challenges
  4. The Challenge of Best Possible Practice
  5. Conclusions
  6. Acknowledgments
  7. Disclosures
  8. References

On the fourth anniversary, it is impossible to discuss hypertension in Haiti without acknowledging the almost incalculable negative impact of the January 12, 2010 earthquake. It was catastrophic not only in terms of death and physical injury, but also the widespread destruction of a tenuous infrastructure and public health system. Yet, paradoxically, this virtual blank slate could be an opportunity to develop an innovative pragmatic approach to the equally devastating problem of hypertension as the most common contributing cause of death in Haiti. Rising Phoenix-like literally from the ashes and rubble, there are lessons to be learned from the Haiti experience, as a potential model for the management of hypertension in the community in low resource venues in the Caribbean and beyond. Haiti has very poor comparative outcomes, and specific challenges related to high prevalence stroke, renal failure, and heart failure as negative prognostic consequences of undiagnosed and uncontrolled hypertension. There are severe public health challenges related to salt education, as well as societal challenges related to negative social determinants of health and disease, and the structural violence of overwhelming poverty. Pragmatism is necessary as we attempt to combine the tenets of evidence based medicine with reality based medicine restrictions imposed by low resource. It is through the generation of Best Possible Practice (BPP) models of care that colleagues can develop systems of mutual knowledge sharing, service, and support. This approach extends to screening and diagnosis, where there is no electricity for semi- or automatic manometric devices and requisite need to train in manual/ auscultatory technique, to education and curricula built specifically around a flexible hypertension community management guideline as the accepted standard to aspire to. A successful approach requires solid guiding principles, including a commitment to best attainable quality and value(s). It also requires standing together as a community of dedicated medical professionals.

Nobody hears the cry of the poor, or the sound of a wooden bell

—Haitian Proverb

The harsh reality for the rural destitute poor is that of anonymous death with nonexistent or inadequate treatment, and often without the human dignity of even being recognized as a statistic.

Yet, there are statistics, and they paint a troubling picture. The global burden of hypertension is growing, with a projected increase in prevalence to 29.2%, or 1.56 billion, by the year 2025. There is an asymmetric distribution of the estimated 972 million adults with hypertension worldwide, as 333 million are in economically developed countries and 639 million are in developing countries.[1] Unfortunately, there is also an asymmetric relationship of hypertension-related morbidity, mortality, and global expenditures on health. The International Society of Hypertension in 2001 estimated that hypertension was responsible for almost 8 million deaths annually worldwide, contributed to, if not causal for 54% of stroke, 47% of ischemic heart disease, 75% of hypertensive heart and renal disease, and 25% of “other cardiovascular disease.” Low- and middle-income countries shouldered 80% of the burden of hypertension-attributable disease.[2]

An inverse asymmetric funding relationship also exists, as 90% of global expenditures exist in high-income countries. Although low- and middle-income countries have a commanding majority interest in the hypertension disease burden, they have access to only 10% of the global resources to effectively manage the disease and its associated complications.[3]

As this global noncommunicable disease perspective frames the question, it is important to define the scope of the problem regionally in the Caribbean, where hypertension prevalence may approach the 45% level observed in African Americans,[4] and specifically in Haiti, a severely challenged low-income country. In the French Caribbean region of Martinique, French Guyana, and Guadeloupe, the prevalence of hypertension is 46.9% in men and 42.6% in women older than 50 years,[5] whereas Barbados showed an age averaged overall prevalence of 55%.[6] Of interest, with an overall prevalence of 44%, Cuba had only a narrow gap between those of African (46%) vs Spanish (43%) ancestry.[7] Limited data on Haiti prevalence confirm hypertension to be the most frequent diagnosis in outpatient rural clinics,[8] ranging up to 39% of men and 45% of women.[9] Published data from a Port au Prince clinic suggested a rural to urban and expected age-related gradient, with a prevalence of 69% in men and 67% in women older than 40 years.[10] Unpublished data suggest an even higher prevalence of complicated hypertension in the Internal Medicine University Hospital service (Table 1).

Table 1. Haiti Hypertension Prevalence With Pertinent Regional and International Comparative Data
RegionOverall Prevalence, %Women, %Men, %Age, yReferenceYear
US African American 45.743 [4] 2012
UK      
Afro-Caribbean 3431 [85] 2002
French Caribbean 42.646.9>50 [5] 2005
Cuba44    [7] 1998
Rural Haiti 4539  [9] 2010
Port au Prince 6769>40 [10] 2006

Remarkably, only 3.2% of the population reported in the literature had an increased body mass index (BMI),[11] compatible with the World Health Organization (WHO) Global Infobase data estimate of 4% in Haiti. This represents a substantial difference from African Americans,[12] as well as Afro-Europeans,[13] and is consistent with previous 1997 data across the African, Afro-Caribbean, and African American diaspora continuum that represents a “westernization” gradient with associated increased BMI and salt intake from developing to developed countries.[14]

Comparative international data on Haitian life expectancy, slowly inching from 50 towards 60 years, is still a substantially lagging indicator in this country of 10.4 million with a median age of 22 (http://www.lambifund.org/news_HaitiStats.shtml). Hypertension is directly responsible for 5.4% of all Haitian deaths and contributes to 3.9% of deaths caused by coronary artery disease, mitigated by low life expectancy before maximum coronary-prone age (http://www.worldlifeexpectancy.com/country-health-profile/haiti). There are very few data related to hypertensive renal failure in a country with minimal dialysis capacity. As a surrogate metric for severe hypertension, the 2002 reported stroke rate was 176 per 100,000 (10.3% of deaths). This was the highest in North America, and one of the highest in the world[15] (Table 2).

Table 2. Mortality Data for Haiti
Disease DiagnosisNumber of DeathsTotal Deaths, %
Hypertension82/100,0005.4
Coronary artery disease55/100,0003.9
Stroke176/100,00010.3

One might make the argument that hypertension and hypertension-related disease may be responsible for up to 20% of deaths in Haiti, driven in large part by excessive stroke and presumed renal mortality. Indeed, the State of Population Health MSPP (Ministry of Public Health and Population) annual statistics report in 2010 confirmed that hypertension is the leading cause of death in Haiti (http://www.nhaha.org/2012topics/2012018.pdf).

Stroke, Salt, and Social Determinant Challenges

  1. Top of page
  2. Abstract
  3. Stroke, Salt, and Social Determinant Challenges
  4. The Challenge of Best Possible Practice
  5. Conclusions
  6. Acknowledgments
  7. Disclosures
  8. References

To understand hypertension in Haiti is to understand the primacy of the “3 S's”: stroke, salt, and extremely adverse social determinants of disease.

Stroke

Life in Haiti is challenging, even for the able-bodied. For individuals disabled by stroke, further challenged by limited to no support resources, it is hellacious. Yet, they are the fortunate survivors.

It is a familiar saga. Stroke is the highest global cause of disability and second most common cause of death, with 67% (The Global Stroke Initiative) to 80% (Global Burden of Disease and WHO 2005 analysis) of deaths occurring in low- to middle-income countries, and 15 years younger than elsewhere in the world.[16, 17] The American Stroke Association International Stroke Conference 2009 showed a 10-fold difference in stroke mortality from high- to low-income countries. In a 3-strike judgment against Haiti, the strongest overall predictors of mortality were national per capita income, elevated mean systolic blood pressure (BP), and low BMI.[18] Specific age-adjusted stroke death rates in the Caribbean and Latin America show that at 176 per 100,000, Haiti is the highest, with only Guyana close; it is more than double the 81 per 100,000 rate of Hispaniola island neighbor, the Dominican Republic. As is the case for many developing countries, transitioning epidemiologically from deaths caused by infectious disease and malnutrition, hemorrhagic stroke leads the way.[19] The overall case fatality rate is best estimated at approximately 30%, with only 20% to 30% of stroke patients hospitalized in a country with only 0.8 hospital beds per 1000 patients compared with 3.2 in the US and a robust 4.9 in Cuba.[20]

The high prevalence rates make stroke a very palpable and powerful surrogate for the discussion of hypertension in a population intimately familiar with stroke-induced death and disability and an appropriate focus of Haiti public education intervention efforts.

Race and Ethnicity vs Ancestry

As one looks at the trans-diaspora position of Afro-Caribbeans in the African to African American continuum, and attempt to dissect relative genetic vs environmental contributions, accurate categorization becomes difficult. Unfortunately, the often co-mingled common terms “race” and “ethnicity” offer no simple answers, as self- reported race may simply be a proxy for a matrix of factors.[21] Given this complexity, many experts have begun to consider ancestry as a better loose fit.[22, 23] The slavery hypertension hypothesis,[24] as a salt-avid natural selection genetic bottleneck theory, has been effectively challenged on both a historic[25] and a genetic basis.[26, 27] Indeed, human genome data have shown as much or greater intra-variation than inter-variation among “racial”[28, 29] or geographic continental groups.[30]

The Science and Culture of Salt

With the realization that hypertension is a complex ecogenic disease, we are nevertheless left with the fact that people of African ancestry certainly have a high incidence of sodium-sensitive hypertension, with lower levels of plasma renin. As the main extracellular cation, sodium has received scrutiny as a presumptive conductor of the hypertension symphony. It is now appreciated that potassium has a critical role in hypertension and cardiovascular complications, especially damaging in the dietary setting of high sodium and low potassium intake. Dietary potassium has a strong and dose-dependent sodium sensitivity inhibitory effect,[31] and a blunting effect that has been noted particularly in those of African ancestry,[32] with altered homeostasis potential related to endothelium-dependent vasodilation.[33]

While discussing the “salt conundrum,” Frolich has determined that chronic salt loading, independent of BP-raising activity, may have direct toxic effects on the heart (eg, left ventricular hypertrophy), vascular integrity, and both renal structure and function.[34, 35] Other harmful or toxic effects of salt include osteoporosis, asthma, nephrolithiasis, and gastric cancer.[36] Not surprising as another part of the Haitian salt culture, there is clearly a very high prevalence of asthma and gastric cancer in Haiti.

Salt and Diet

The sodium chloride content of the Haitian diet has historically been difficult to measure. It has been subject to a wide range of assumptions, from high to astounding, compounded by low potassium intake. Haiti is different from developed countries where the majority (80%) of sodium is through passive ingestion in processed foods.[37-40] In Haiti, salt has been used as a food preservative, given the continued lack of consistent sources of electrical power and refrigeration. Along with charcoal preparation, salt is also a significant component of acquired taste, confirmed in a random sampling of Creole cooking recipes, all of which call for a minimum of a teaspoon to tablespoon of salt in the recipe. Salt is culturally associated with vitality and strength beyond the obvious pragmatic beneficial effects of protection from dehydration in hot environments. There are also certain folklore beliefs such as “salt added to any beverage can help purify blood tainted by strong emotion,”[41] or even the voodoo belief that eating salt could be curative and bring zombies back to full life.

It therefore will be critical to objectively evaluate sodium dietary intake using the standards such as those of the Pan American Health Organization (PAHO) Cardiovascular Disease Prevention Through Dietary Salt Reduction Group. Presumably this will include monitoring and evaluation activities using standard protocols for research into population levels of sodium intake determined from 24-hour urine samples, and a determination of the main sources of salt in the diet.[42]

Another cultural aspect of salt is the fact that salt harvesting remains a small cottage industry, using traditional techniques of simply placing dried bushes over salt pools. The rock salt product then requires vigorous washing to give a more culturally accepted coloration, which is problematic related to a high incidence of iodine deficiency syndrome in Haiti.[43, 44] Iodine fortification, as well as the use of salt as a vector for the drug diethylcarbamazine to treat lymphatic filiariasis,[45] is sometimes met by confusion and perception of mixed messages by the public.

Salt and Food: Cultural Realities

It is difficult to lecture people about salt in a real world of nutritional insecurity. Nutritional insecurity is defined as more than simple food insecurity, bringing in aspects of access to basic elements of a nutritious diet, a safe environment, and adequate health care. A 2010 World Bank study looked at nutritional insecurity in Haiti, pre- and post-earthquake, making the clear-cut observation that poverty is the basic and most proximate cause of malnutrition. Pre-earthquake, it was estimated that 58% of the population was chronically undernourished, with an estimated average caloric intake per person per day of 1840 kcal, with a cultural expectation of one meal per day.[46-48] Food insecurity and a challenged livelihood have represented a chronic background in rural Haiti.[49] Post-earthquake, 52% of the population suddenly became severely food insecure on an acute, superimposed on chronic, deficiency basis. Fortunately, there has been some improvement noted between the 2006 and 2012 USAID Demographic and Health Surveys.

USAID has noted poor dietary diversity with predominant starches and oil-based foods (staple of rice and red beans “Riz et Pois Rouges”) and little protein, fruits, and vegetables in the average Haitian diet. The Kempner Rice diet notwithstanding, the major nonpharmacologic dietary intervention focus is on the Dietary Approaches to Stop Hypertension (DASH) and DASH-sodium studies.[50] Given the observation that African Americans have heightened salt sensitivity, data from the DASH diet intervention importantly showed that the biggest change in systolic BP occurred in the black hypertensive group with low sodium intake modification of the DASH diet.[51, 52] Solid measurable outcomes beyond change in BP have been a challenge.[53] While this dietary intervention is presumed to have important implications for the Haitian population, it potentially may not be the whole story. One practical key issue that is difficult to measure is that of the affordability of the DASH diet. This is an important factor even when it is presumed that access to fresh produce is not a significant issue between high and low socioeconomic groups.[54] Making fruits and vegetables readily available in urban neighborhoods may constitute a challenge.[55, 56]

Sodium and Potassium: The Tale of Two Salts

The American Society of Hypertension Position Paper on dietary approaches to lower BP focused on the specific concerns of high sodium intake in the setting of low potassium intake.[57] The National Health and Nutrition Examination Survey (NHANES III) showed the average intake of potassium to be 2.9 to 3.2 g/d for adult men and 2.1 to 2.3 g/d for adult women, with only 10% of men and <1% of women consuming the assumed reasonable target level of 4.7 g/d of dietary potassium in the United States.[58] There is a consistent message that potassium, magnesium, and calcium have roles in the prevention and potential nonpharmacologic treatment of hypertension.[59, 60] Dietary sodium/potassium ratio is therefore a major factor in nonpharmacologic dietary recommendations and the second fulcrum leverage point for the Haiti Hypertension program public education training efforts.

Overt cultural dietary change in the nutritionally insecure developing world is a challenge, even more than the successful progressive subtle reductions in sodium content of processed foods in the developed world. Progressive small steps to decrease some of the drivers of excessive sodium intake, and encouragement for the addition of more indigenous produce such as mangoes (320 mg average of potassium) and plantains (average 893 mg of potassium) in the diet would be productive first steps.

Social Determinants of Disease

With respect to lessons learned, both global and local in the developing and developed worlds, it is important that information obtained through the tinted glass of personal experience is processed with a mindset of cross-cultural communication and understanding.[61, 62] One of those filters is an understanding of poverty and the worst-case circumstances of the destitute poor. As one descends down the gradient of inequality of “haves” and “have-nots” to the almost unimaginable realm of the “have even less” reality of Haiti and elsewhere, it is impossible to avoid discussions of healthcare disparities, “class,” and health equity. The unfortunate reality that disease also has a “preferential option for the poor” and that there are too many “stupid deaths” avoidable by simple and inexpensive treatments readily available in the developed world has for many become the clarion call to action.[63]

Not atypical for the “bottom billion,” 75% of the Haitian population lives on <$2 a day and 56% fulfill the definition of extreme poverty, living on <$1 a day. This level of poverty is 5 times the regional Latin America average, with an estimated 4.5 million extreme poor, of whom 66% (or 3.2 million) are considered rural and 1.3 million urban or “metropolitan.” The GINI coefficient is a metric of wealth distribution inequality, the Haiti GINI INDEX of income inequality is one of the highest in the world, reported at 0.6 to 0.66 (range 0, perfect equality vs 1.0, absolute inequality) (http://data.worldbank.org/indicator/SI.POV.GINI). Another common metric is the Human Development Index (HDI), which, as a composite of life expectancy, education, and income indices, is a gross proxy for previously described standards of living or quality-of-life measures. Haiti's HDI ranks 149th of 182 in the world (http://hdrstats.undp.org/en/countries/profiles/HTI.html).

Much has been written about disparities in US health care including racial and ethnic differences[64, 65] and otherwise.[66, 67] Issacs and Schroeder pointed out the potential conflation of the factors of race and ethnicity with socioeconomic status as related to adverse effects on health,[68] ultimately leading to the composite definition of “class” to describe the wide differences between the “haves and the have-nots.”[69] Social Determinants of Health (SDH) have been examined as the “cause of the causes,” and rather than a bimodal have/have-not distribution, represent a graded change in the level of social advantage generally associated with a parallel change in health.[70, 71]

Whereas we speak of descending down the gradient of health inequality as a somewhat nonjudgmental descriptive term, health equity is more of an ethical construct describing inequitable differences in health care that are unnecessary, unfair, unjust, and avoidable.[72, 73]

Humbled by the Enormity

More than 40 years ago, Harburg described the relationship between socioecological stressor areas and BP in Detroit.[74] In 2010 and beyond, Haiti could be the living laboratory for socioecological stress and health inequity.

As individual-dedicated healthcare practitioners, it is difficult to not be humbled by the enormity. As we reach for shrink-wrapped protocols and guidelines off the shelf, and seek solace in the comfort of a comprehensive fund of knowledge and learned appropriate drug treatment dosage regimens, how do we address the “what if” questions? What if we do not have the appropriate drugs available? What if you reach for the reliable arrows of laboratory diagnostic tests, or even short-term dialysis, and you find that the quiver is empty?

What if you are in Haiti with the lowest comparative Water Poverty Index score in the world,[75] and you are faced with both quantitative chronic severe water insecurity manifested by dehydration, as well as the qualitative water insecurity threat of endemic infectious diarrhea (now including cholera) manifested by acute severe dehydration and hypokalemia? What if you understand that when you mix the ingredients of environmental predilections and pharmacologic intervention, you might alter standard risk/benefit ratios to increase the risk of mortality caused by acute kidney injury or acute hypokalemia-induced dysrhythmia, and potentially violate the “first do no harm” dictum? Finally, what if the “what ifs” are not theoretical conjecture, but a real part of the landscape? This is reality-based medicine, extreme edition.

The Challenge of Best Possible Practice

  1. Top of page
  2. Abstract
  3. Stroke, Salt, and Social Determinant Challenges
  4. The Challenge of Best Possible Practice
  5. Conclusions
  6. Acknowledgments
  7. Disclosures
  8. References

All of this is an appropriate segue to the question, why does hypertension in Haiti have anything to do with how healthcare providers manage hypertension in the community? And the corollary question is: Why is management of hypertension in the community so difficult?

Glocal Lessons Learned

One obvious answer to the posited questions has to do with the operational definition of community as a “glocal,” or global to local, construct that transcends geography across the developed and developing world. Whether country or county, the common thread is the substantial challenge of managing hypertension in the setting of limited resources and limited income. The United States has a 76 million hypertensive target population, and may spend $76 billion in part on downstream complications (related to heart failure, dialysis, stroke, vascular dementia, and peripheral vascular disease) with procedures that are not available to the developing world. It matters not whether it be poor outcomes in urban areas of Port au Prince or Norfolk, Virginia. The basic principles are the same.

Evidence- and Reality-Based Medicine

As we enter the “glocal” circle, we need to not only educate and teach but also to learn. After a decade in Haiti, including the day of the 2010 earthquake (LMH), the cofounders of Colleagues In Care (a volunteer organization of medical professionals) have attempted to balance science, standards, and service in the development of sustainable systems in order to best leverage clinical problems with a double product of high population frequency and substantial negative prognostic impact. By virtue of the marriage of evidence-based medicine with reality-based medicine, tempered by the pragmatic limitations imposed by low resources, “Best Possible Practice” (BPP) models of care have been developed. Our approach has utilized IBM Smart Cloud technology-assisted communication tools to support the primary need for effective communication. In recognition that collaborative education leading to true collaboration, cooperation, and community is a human endeavor requiring adherence to principles of human and organizational learning systems, effective communication is the sine qua non. Technology is a tool.

The Primacy of Knowledge

Although always evolving and never perfect, knowledge is power, and it is unequivocally most powerful when shared. The key is to leverage knowledge and experience as we build effective transcultural bridges among individual colleagues in the helping and healing profession of medicine. It is a functional requirement that all must be fluently speaking the common language of BPP. Education, training, and BPP clinical care standards can allow expansion of the delivery system to include more nontraditional healthcare workers and volunteers, where the constant is performance and the variable is job title. In this regard, lessons to be learned include contributions of the “Accompagnateur,” who is essentially a task-oriented trained community health worker responsible for accompanying the patient through the system. This has been a successful model of care for infectious disease in Haiti, Boston, and beyond, with obvious implications for chronic noncommunicable disease management, especially hypertension and heart failure.[76]

Values and Value

Clearly, the BPP glue is demonstration of values and value, classically defined as cost for specific outcomes, as modified for appropriateness. De facto, if we are able to maintain quality outcomes at low resource cost, we have attained high value. Using an approach of “value-based collaboration” rather than “value-based competition based on results,”[77, 78] cost will be determined on an interactive basis from the database, determined on a per patient-year of therapy basis driven primarily by pharmacologic decisions. Outcomes can range from standard awareness, treatment, and control comparators of achieved BP targets to the most important measurable impact on stroke events. The continued goal is to minimize unexpected and unexplained clinical variation; with the caveat that protocol noncompliance solely due to resource unavailability is neither unexpected nor unexplained.

Building an effective integrated system requires that the journey must begin by utilizing simple first steps of classic and basic structure and process-quality metrics, documenting the ability to do the right things right.[79]

Haiti Hypertension Program

The Haiti Hypertension Program is a BPP program blueprint that has involved in-country partnerships with Dr Jean Claude Cadet, Dean of the Faculte de Medecine et de Pharmacie de l'Universite d'Etat d'Haiti (FMP UEH), and the leadership of Dr Roger Jean-Charles, Director of Centre Haitien d'Hypertension (CHH). Multi-level certification programs will establish acquisition of a solid fund of knowledge related to both diagnostic and therapeutic levels of hypertension management in the community (Table 3).

Table 3. Haiti Hypertension Program Best Possible Practice Education Model
PhaseCertificationTarget Providers
IABlood pressure measurementStudents, community health worker leaders, nurses, physicians, pharmacists
IBPublic health education providersStudents, community health worker leaders, public health educators, nurses, physicians, pharmacists
IIABasic science of hypertensionMedical students and physicians
IIBHypertension management in community guideline curriculumMedical students and physicians, potentially advanced training nurses and pharmacists
IIILevel II, plus clinical case studies, for postgraduatesFamily practice/internal medicine residents, and physicians in the field
IVHypertension specialist fellowship trainingHypertension leaders

Consistent with the Ministry of Public Health and Population (MSPP) health care delivery continuum from Teaching and Specialty Hospitals to Department Hospitals, Community Hospitals, and Village to Community Health Centers, the integrated hypertension system will go beyond the State University Medical School and urban Port au Prince central hypertension clinic into rural area clinics. Beginning with the Baptiste Clinic on the mountainous Dominican Republic frontier border, BPP models applicable to mobile clinics and community health centers will use standard hypertension protocol management and a defined interactive database. They will be supported by physical and virtual consultation for treatment-resistant hypertension patients who have bubbled up through standard protocol management. The goal is colleague-to-colleague support on the low complexity end of the telemedicine spectrum, potentially using mobile phone technology. From there, strategic nodal hypertension network centers will be added.

The phase IA foundational base of the hypertension program pyramid is focused on resolving well-documented, widespread difficulties in the ability to take an accurate and reproducible BP measurement using manual devices. Incorporating multiple international training and technical standards, the Haiti BP Measurement Specialist Certification Program is based on a successful program utilized by the Virginia Department of Health. The culturally modified course manual has been rewritten in French, Spanish, and Creole, with supportive video including a sights and sounds examination of Korotkoff sounds for testing, and pre-/post-course testing for certification. Documentation of competency for certification is consistent with published guidelines. The BP Measurement Specialist Certification program has begun with medical, nursing, and pharmacy students. They will then become the teachers and become engaged in database collection from BP screening kiosks (specific BP measurement specialist certification-related references available upon request).

A complementary phase IB certification program is being developed for those who wish to be involved in public education. This will focus on stroke and salt sodium/potassium education. The plan is to have a standardized video series to be filmed in Haiti, scripted collaboratively in French, Creole, and Spanish. In order to avoid the pitfalls of a purely folklore method of instruction, public educational material will be standardized, in concert with “teach back” or “show me” techniques utilized for health literacy education.[80, 81]

There is movement to build on phase I certification programs, addressing challenges in low resource areas, and potentially integrating a recommendation for the preferential use of semi-automatic manometric devices as an international standard. This is in recognition of the reality that in many countries such as Haiti with a UNICEF 2002 pre-earthquake reported 0.25 physician/1000 population, with similar nursing personnel challenges, there has to be an option for quality-based expansion of the hypertension outreach screening and diagnosis system with appropriate documented standards enlisting support of community health workers, public health educators, nursing assistants, and pharmacists.

There is an appropriate expanding leadership position for physicians and nurses integrating education, training, and an oversight management role in support of hypertension BPP suggested models of care with appropriate database and protocols. Upper-level clinical management of hypertension in the community will require managing systems as well as individual patients.

The Management of Hypertension in the Community guideline document will serve a dual purpose as both the basis for a hypertension curriculum offering certification in clinical hypertension, as well as suggestions for BPP consideration. For students in training, it begins with basic science review of cardiac, renal, and endocrine aspects of hypertension, collaboratively developed by a coalition of medical school physiologists.

The medical education system in Haiti is such that after medical school there is a compulsory national social service year. This requires working in outreach clinics and hospitals throughout the system, often as the sole primary care medical resource. The goal is to start with all medical students to confirm competence in hypertension management for this year of service. Building on clinical experience, documentation of hypertension management competency could expand to residents in family and internal medicine training. Post graduates out in the trenches in practice could eventually challenge the examination to allow hypertension management certification via a continuing medical education mechanism.

Once a multi-tiered integrated clinical hypertension management team is built from the bottom up, the management of hypertension in the community approach may be eventually adopted as a national standard, with consensus on a national formulary. That is the road map. The ultimate dream is for a hypertension specialist fellowship training program at Faculte de Medecine et de Pharmacie de l'Universite d'Etat d'Haiti (FMP UEH), under the direction of Dr Jean-Charles and colleagues, with aspirations to ultimately achieve the level of a comprehensive hypertension center for education and research at the University Hospital.

System theorists and learning organization leaders have observed that when faced with the challenge of immediately unattainable quality and value goals, there are two options. Successful programs will avoid the symptomatic solution to lower the bar so low that metrics are ignored or are easily attained, and keep the aspirations bar appropriately high with the realistic recognition that while we cannot get there now, it remains the focused goal.[82] This is the philosophy of BPP, that is individual colleagues supporting colleagues, together working towards the “R-7” solution of the right provider doing the right thing, the right way, to the right patient, at the right time, in the right place, and at the right cost, perhaps with an asterisk for human rights access to appropriate levels of medical care, and the medical professional right to knowledge acquisition.

Conclusions

  1. Top of page
  2. Abstract
  3. Stroke, Salt, and Social Determinant Challenges
  4. The Challenge of Best Possible Practice
  5. Conclusions
  6. Acknowledgments
  7. Disclosures
  8. References

By proving proof of concept and process in Haiti, the approach should be replicable in all communities challenged by low resource/income. The 2001 WHO Global capacity assessment has shown that of 167 surveyed countries, 61% did not have national hypertension guidelines. Professionals were not trained to manage hypertension in 45%, and drugs were not affordable in 25%, with many lacking basic equipment.[83] In 2010, there is still room for improvement.[84] Certification standards and a flexible and practical set of BPP recommendations, supported by a defined knowledge base, is a good first step.

Acknowledgments

  1. Top of page
  2. Abstract
  3. Stroke, Salt, and Social Determinant Challenges
  4. The Challenge of Best Possible Practice
  5. Conclusions
  6. Acknowledgments
  7. Disclosures
  8. References

The author would like to sincerely thank all of our international and Haitian colleagues who have volunteered time, effort, and knowledge for the Haiti Hypertension Program collaborative effort. Special recognition for CIC partners cofounder Lisbet Hanson, MD, Marie Kenerson, and Lisa Smith, and our partners in Haiti Jean Claude Cadet, MD, and Roger Jean-Charles, MD. Special thanks also to the superb writing committee of the management of hypertension in the community guidelines and supporting individual members of ISH, ASH, ISHIB, and WHL.

References

  1. Top of page
  2. Abstract
  3. Stroke, Salt, and Social Determinant Challenges
  4. The Challenge of Best Possible Practice
  5. Conclusions
  6. Acknowledgments
  7. Disclosures
  8. References
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