Experts Address Challenges of Delivering Critical Care in Resource-Poor Countries

LatestIssue of Global Heart Focuses on Key Issues Impeding Delivery of EffectiveCardiac Care in Resource-Limited Settings

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Criticalcare is defined by life-threatening conditions, which require close evaluation,monitoring, and treatment by appropriately trained health professionals.Cardiovascular care bears these same requirements. In fact, cardiovasculardisease will soon surpass even human immunodeficiency virus (HIV) as theleading cause of mortality in Sub-Saharan Africa. In the latest issue of Global Heart, researchers discuss thechallenges of delivering critical care in resource-limited countries.

Accordingto Guest Editors Vanessa Kerry, MD, MSc, and Sadath Sayeed, MD, JD, "Criticalcare as a clinical discipline in resource-rich settings is associated with highresource (financial, human, technological) intensity. For this reason, amongothers, critical care has received far less investment in resource-poorcountries… Although numerous challenges to scaling up high qualityintensive care services present themselves, even more opportunities tocreatively innovate in this field exist that hold promise to move us closer toequity in global healthcare."They argue that investments in critical care need not be technology orcost intensive, but they should be appropriate and effective.

Criticalcare is an area of needed scale-up. Although the massive influx of effort andfunding of HIV treatment has resulted in significant gains in life expectancyand health system strengthening, a lack of critical care resources indisadvantaged areas remains. Interventions in critical care in these settingsare justified. In resource-limited settings, the majority of criticallyill patients are children and young adults and avoiding preventable death would reducemortality and disease burden as well as have socioeconomic impacts."

Thisissue of Global Heart, "Critical Carein Resource-Limited Settings," includes coverage by a group of internationallyrecognized experts on important topics pertaining to the delivery of healthcareto low-income countries.

Keyconcerns explored include:


  • The definition of sepsis is controversial
  • Standards of treatment in high-income areas differ from low- or medium-income areas and possible areas for intervention and improved care

Acute Respiratory Distress Syndrome (ARDS):

  • Lack of diagnostic resources in resource-limited settings makes it difficult to even identify ARDS
  • Alternate diagnostic methods may allow recognition of ARDS in resource-poor settings
  • Some effective interventions for ARDS may be feasible in resource-poor settings

Pulmonary Vascular Disease (PVD):

  • The vast majority of patients with PVD globally have limited access to diagnosis and therapies
  • PVD is likely underestimated in resource-limited settings but is of risk due to causes such as endemic infectious diseases and environmental factors
  • Disease awareness and prevention will have the greatest effect on PVD incidence in resource-limited countries

Cardiac Care in Resource-Limited Environments:

  • Cardiovascular disease is emerging rapidly in Sub-Saharan Africa
  • Scale up of cardiac care facilities and education should be appropriately triaged to meet broad needs in the community, not just highly focused specialties in a few sites
  • The central importance of medical and nursing education will have to be prioritized in resource-limited countries

Providing ICU Care in a Challenging Case:

  • The application of basic principles of critical care including resuscitation and surgical and critical care management can be applied in a limited resource setting
  • The multiple factors working against the delivery of emergency and intensive care in Sub-Saharan Africa


  • Influenza exerts a great toll in low-income environments where it is the cause of 5% to 27% of all severe acute respiratory infections
  • The lack of access to healthcare and adequate healthcare infrastructure portends a disproportionate burden of influenza disease in resource-constrained environments
  • Improved influenza surveillance is needed to guide resource allocation and basic healthcare infrastructure development

Intensive Care in Low- and Middle-Income Countries:

  • In intensive care units from low- and middle-income countries, there is considerable variation of available infrastructure, training, staffing and processes even as access to intensive care unit resources is reasonable
  • The greatest perceived need for hospitals surveyed was for ICU-specialized healthcare providers

HIV and Critical Care Delivery:

  • Despite progress in enrolling millions of people living with HIV into treatment and care in Sub-Saharan Africa, most individuals with HIV present with advanced disease, which can require critical care
  • Nonphysician-delivered care can be both cost-effective and of high quality

Antimicrobial Resistance:

  • Despite being identified as a worldwide public health priority by WHO and other international organizations, data on and efforts for antimicrobial resistance and hospital-associated infections in low resource settings remain extremely limited
  • Resistance is driven by unfettered access and lack of product regulation and clinical diagnostic tools
  • Antimicrobial stewardship programs (ASP) may need to be modified to work in low- and middle-income environments

Perspective from a Professional Society – How the AmericanThoracic Society has played a role in global health by:

  • Taking a leadership role in health interventions and policy, for example, writing the first international standards for TB diagnosis, treatment, and control
  • Identifying and recruiting doctors for service in resource limited countries
  • Providing formal recognition of volunteers who have provided needed services in resource-limited countries

The Guest Editors would highlight that, "Avoidingpreventable death will not only reduce mortality and disease burden, but itwill help improve life expectancy, decrease birth rates, increase householdproductivity, and even have an impact on gross domestic product. Investments incritical care need not be technology- or cost-intensive, but they should be appropriateand effective. Such investments, though, will have dividends across manyclinical specialties as well as have an impact on the health outcomes of apopulation."


Notes for editors
Critical Care inResource-Limited Settings

Guest Editors:
Vanessa Kerry, MD, MSc
Department of Pulmonary and Critical Care, MassachusettsGeneral Hospital, Center for Global Health, Massachusetts General Hospital,Harvard Medical School, Seed Global Health, Boston, USA

Sadath Sayeed, MD, JD
Harvard Medical School, Seed Global Health, BostonChildren's Hospital, Boston, MA

Global Heart,Volume 9, Issue 3 (October 2014), published by Elsevier. Full table ofcontents at

The full text of these contributions areavailable to credentialed journalists upon request; contact Eileen Leahy at +1732 238 3628 or wishing to interview the Guest Editors or authors should contact VanessaKerry, MD, MSc, at

About Global Heart
Global Heart seeks toprovide a forum for dialogue and education on matters that relate foremost tothe prevention and control of cardiovascular diseases worldwide, with a specialfocus on countries with middle and lower economies. The journal also featuresstudies on cardiovascular surveillance and health policies, professionaleducation, ethical issues, and technological innovations particularly thoserelated to prevention. Global Heart is the official journal of the World HeartFederation ( is affiliated with the Asian Pacific Society of Cardiology (

About Elsevier
Elsevier is a global information analytics business that helps scientists and clinicians to find new answers, reshape human knowledge, and tackle the most urgent human crises. For 140 years, we have partnered with the research world to curate and verify scientific knowledge. Today, we’re committed to bringing that rigor to a new generation of platforms. Elsevier provides digital solutions and tools in the areas of strategic research management, R&D performance, clinical decision support, and professional education; including ScienceDirect, Scopus, SciVal, ClinicalKey and Sherpath. Elsevier publishes over 2,500 digitized journals, including The Lancet and Cell, 39,000 e-book titles and many iconic reference works, including Gray's Anatomy. Elsevier is part of RELX, a global provider of information-based analytics and decision tools for professional and business customers.

Media contact
Eileen Leahy
+1 732 238 3628