Africa’s Cardiovascular Burden: A Silent Cry for Attention

Amidst the vibrant rhythms of Africa, a less audible rhythm beats – an alarming rise in cardiovascular diseases (CVDs) and non-communicable diseases (NCDs). Between 50% and 88% of deaths in at least seven African countries are due to NCDs, according to the 2022 World Health Organization (WHO) Noncommunicable Disease Progress Monitor. Yet, the realm of research has yet to fully recognize the magnitude of this symphony. 

The cacophony of these diseases is not confined to developed nations; Africa bears witness to their increasing impact, largely unseen by the global research community. Against this backdrop, we stand resolute in our commitment to shifting the focus to the African narrative in cardiovascular medicine.

Closing research disparities: Unravelling the findings 

We are two young cardiologists, both graduates of Egypt’s esteemed medical schools. One of us went on to pursue his career in the United States, where he is now a rising researcher at the Department of Internal Medicine at Yale School of Medicine in New Haven, Connecticut. The other, determined to make a difference in his country, dedicated himself to the demanding work of a physician-scientist in Egypt.

Our paths converged when we decided to address the striking lack of randomized clinical trials (RCTs) in Africa. This scarcity robs the continent of vital disease-specific and population-specific data, which stalls progress in clinical outcomes. This deficiency has global implications, as it dampens cardiology research on a global scale by preventing researchers from tapping into a vast, diverse, and treatment-naive population.

Our journey led us to a comprehensive evaluation of African-led clinical trials in cardiovascular medicine over the past three decades. We recently published our findings in a research letter in the journal Circulation: Cardiovascular Quality and Outcomes.

About 80% of RCTs came from 3 countries (Egypt, Nigeria, and South Africa). Yet, 37 African countries didn’t produce a single RCT.

Our analysis revealed a stark reality: only approximately 2% of published and registered clinical trials in cardiovascular medicine originated from Africa. However, within this fraction, we found a tale of perseverance and determination.

We examined a total of 179 trials from African countries from 1990 to 2019. Egypt, South Africa and Nigeria were the most notable contributors, with Egypt leading the way. The number of African-led trials surged over the past decade, with 2010 to 2019 witnessing a remarkable increase.

The primary outcomes assessed in the trials included biochemical and cardio-metabolic markers, hemodynamic outcomes, clinical events, and patient-related outcomes. African trials often had small sample sizes, few participating centers and short follow-up periods.

The impact of published trials from different countries was measured using the H-index, a metric that gauges the impact of scientific research by tracking how many times a published paper is cited by other researchers. South African publications had the highest impact score, followed by Egypt and Nigeria. A significant number of trials were not published as open access, and risk of bias assessment showed that a significant number of studies had unclear or high risks of bias.

It is estimated that only 2000 cardiologists practice in Africa (≈1 cardiologist for 600,000 individuals)

Collaborations transcended borders, as African centres actively participated in 45 multinational trials, contributing valuable insights to global research endeavors. On the issue of funding, the researchers noted that 91 trials did not disclose their funding sources, while 20 disclosed no external funding. Of the remaining 68 trials, 35.7% had funding from private sources, 28.6% from academic sources, 28.6% from governmental sources, and 7.1% from non-governmental sources.

Our research letter underscores several critical points. First, there is a need for increased investment in training cardiovascular researchers, beyond just cardiologists, to strengthen the research workforce in Africa. Second, it is important to allocate more resources for research and development in African countries, in line with the local disease burden and international recommendations.

Third, initiatives like the Clinical Trials Community platform and the Pan-African Clinical Trials Registry have the potential to improve research infrastructure and collaboration. Lastly, there is a need for multifaceted interventions to address barriers to clinical research in Africa, including regulatory frameworks, electronic medical records adoption, and institutional partnerships.

Forging a new path: Towards inclusivity and impact

Of the 179 trials included, 54 (30.2%) were performed in collaboration with another African (n=42) or non-African center (n=33), most commonly in Europe and the USA.

Together, we can overcome the disparities impeding Africa’s research progress. Our findings have revealed challenges that, once addressed, could amplify the continent’s contributions. Trials across the continent often have limited sample sizes, are conducted at a small number of participating centres, and have short follow-up periods. The intricate dance of collaboration also extended beyond African borders, with European and North American centers partnering to enhance the scope and impact of research.

To unleash the true potential of African-led clinical trials, key changes are needed. Increased investment in training for cardiovascular researchers, beyond just cardiologists, would enrich the research landscape. Clinical research is a cornerstone of sustainable progress, and local governments must invest more in it.

A symphony of change 

As the curtain falls on our story, the call for change echoes. To harmonise Africa’s cardiovascular research and amplify its impact on the world, we need multifaceted interventions. Expanding clinical research sites, standardising regulatory frameworks, and widely adopting electronic medical records will strengthen Africa’s research infrastructure.

Open-access publishing and robust institutional partnerships are our allies in the journey towards progress. The song of African science, once muted, now crescendos as we work to break down barriers and illuminate a path toward equitable cardiovascular knowledge. In this rhythm of change, we are architects of transformation, orchestrating a symphony of research that resonates far beyond the boundaries of continents and borders.

Dr Ahmed Bendary is Associate Professor in the Cardiology Department at Benha University, a member of the Egyptian Society of Cardiology and a Fellow of the European Society of Cardiology (FESC). He also serves on the Board of the Egyptian Association of Vascular Biology and Atherosclerosis (EAVA), is part of the abstract reviewing committee for the European Society of Cardiology (ESC) Congress and serves as associate editor for The Egyptian Heart Journal (TEHJ).

Dr Abdelrahman Abushouk is an Internal Medicine Resident at Yale-New Haven Hospital. He earned his medical degree from Ain Shams University.

Image Credits: CC.

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