EDITORIAL

Public Health at the Center of Debate

La salud pública en el centro del debate

Andres Rosende

Rev Argent Cardiol 2023;91:371-373. http://dx.doi.org/10.7775/rac.v91.i6.20706

SEE RELATED ARTICLE: Rev Argent Cardiol 2023;91:389-394. http://dx.doi.org/10.7775/rac.v91.i6.207068

Declaration: The opinions expressed in this article are sole responsibility of the author and do not necessarily reflect the opinions and policies of the Pan American Health Organization

Cardiovascular diseases continue to be the leading cause of mortality worldwide and Argentina is no exception. (1) Despite significant progress in its reduction observed in the last decades, multiple factors have slowed the trend during recent years (2) In this context, the COVID-19 pandemic broke out at the beginning of 2020, generating great uncertainty about the best policies to apply in order to prevent the collapse of the health system, with the ensuing increase in the number of deaths caused by the virus. Effectively, we have witnessed public discussions and the most diverse opinions, with greater or lesser degree of support. Infectologists, epidemiologists and intensive care specialists strolled along the television sets giving lectures, but also sociologists, anthropologists, political scientists, civil servants and politicians from all sectors exchanged their points of view, often not exempt from interests different from the welfare of the general population. As if this was not enough, journalists turned into “experts in pandemic management”, “opinionologists” of all colors, colorful characters of the television prime time drinking allegedly unfailing beverages against the virus, and many other situations marked a time dominated by confusion and fear
The reader of the study by Charask et al. (3) could jump to conclusions and state that the policies were wrong, impacting on the excess of all-cause mortality recorded by the vital statistics of the National Ministry of Health. (4) However, we will never know the counterfactual scenario of not having implemented them or having done so in a different direction, or with different intensity or duration. Would the same number of people have died? Or maybe less? Or perhaps more? Nobody would dare to predict it. Nevertheless, the association between the COVID-19 outbreak and the 15% increase in mortality due to myocardial infarction found by Charask et al., leaves no room for doubt.
Charask et al. reveal the sudden increase in specific mortality rate for myocardial infarction during the two years of Social, Preventive and Mandatory Isolation (SPMI) and its particular impact on women and subjects < 60 years. At this point, other questions should be posed. Are these two circumstances related? Can we infer causality? Could the pandemic effect on infarct mortality have been avoided or at least mitigated?
Analyzing the causal mechanisms of the relationship between SPMI and the increase in mortality for myocardial infarction opens the gates to a complex and multidimensional scenario. What does this increase in infarct mortality really explain? Could it have been the massification of the COVID infection or the sanitary measures adopted in the SPMI context? Regardless the first option continues to be subject of investigation and debate, (5,6) we have all witnessed, in greater or lesser degree, the collateral damage generated by SPMI on the health system. Delays in consultation for fear of the virus, restrictions in displacement imposed by the authorities, an emergency system dedicated almost exclusively to the care of COVID-19 cases, cancellation of programmed diagnostic or therapeutic procedures, empty intensive care units for weeks, or even months, awaiting COVID-19 patients whose arrival was long delayed, and a marked alteration in ambulatory health services in charge of prevention through the control of risk factors, were among other causes faced.
The COVID-19 pandemic broke out in the midst of a sanitary context with huge structural challenges in multiple areas, and especially in that related to cardiovascular diseases and their risk factors. According to the last 2018 National Risk Factor Survey, carried out in subjects over 18 years of age, in Argentina there is a prevalence of 22.2% smoking, 66.1% overweight or obesity and 10.9% diabetes. In addition, an incidence of 39.5% hypercholesterolemia and 46.6% hypertension, with 32% underdiagnosis and a troubling lack of control in 4 out of 10 diagnosed patients has been encountered. (7) If we specifically approach ST-segment elevation myocardial infarction, we do not find detailed official statistics, though diverse independent studies performed in the country show an alarming reality. Even though early reperfusion therapy has the greatest impact on the reduction of morbidity and mortality in this context, , 4 out of 10 patients do not access it and among those who do through treatment with primary angioplasty or fibrinolytics, more than half are outside the recommended time window. (8-10) This shows not only the urgency to improve networks of care for opportune diagnosis and treatment, but also of strengthening public health policies aimed at controlling their risk factors and thus prevent or delay their emergence. (10,11)
This complex scenario discloses the enormous challenges of the Argentine health system in terms of prevention, diagnosis and opportune treatment of cardiovascular diseases and their risk factors. Thus, public health is placed at the center of the debate, highlighting the importance of health plan policies, which when delineating their objectives contemplate the cost of opportunity, in order to make them more efficient. It is necessary to learn from successes and mistakes made during this pandemic that surprised humanity, and whose real impact we are still understanding, to improve our position at the time of facing a similar health crisis that might occur in the future. (12,13) This implies working in extending population intervention policies to stop the silent pandemic of overweight and obesity, continue to reduce tobacco and alcohol consumption and salt intake, eradicate trans fats and promote environments favoring physical activity. At the same time, it is essential to strengthen primary healthcare, providing the resources and instruments that improve the diagnosis, treatment and control of risk factors such as hypertension, diabetes and hypercholesterolemia. (14) Finally, to work in the development and reinforcement of networks for the care of myocardial infarction with the aim of increasing the timely access to reperfusion therapies, without health coverage limitations, and ensuring an efficient secondary prevention. (11)
All the countries in the world have suffered the consequences of the COVID-19 pandemic and also the collateral damages of the measures adopted to face it. (15) Undeniably, some countries may have done it better than others, and the place Argentina will occupy in this sad ranking is still to be seen. At a time where public services and their management are at the center of debate in the light of a new government, it only rests to defend successful health policies and work to improve those with poor performance. It is imperative to support efficient universal health coverage, supported on data-based sanitary planning and guided by epidemiological priorities in the widest sense, with the purpose of providing more and better healthcare for all the population. The study by Charask et al. is undoubtedly an essential element in this debate, and disregarding its results, or not learn from them, would be a highly costly error for the health of the Argentine population.

Conflicts of interest

None declared. (See authors’ conflict of interests forms on the web/Additional material)

https://creativecommons.org/licenses/by-nc-sa/4.0/

©Revista Argentina de Cardiología

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