Uncovering Bangladesh’s Hidden Heart Disease Crisis

When Aftab Ahmed (not his real name) suffered a heart attack, the doctors attending him in Dhaka were puzzled. Unlike many typical heart disease patients, Aftab was in his 20s, he did not have high blood pressure, diabetes or high levels of blood fats and had never smoked (classical factors commonly found in cardiovascular diseases/ CVD). Young and healthy patients like Aftab have now become increasingly common in the cardiology hospitals across Bangladesh.

Apart from unusual patient profiles, the country has also recorded some of the highest rates of CVD in South Asia in recent times and yet it remains the least studied population. In the late 1990s it was estimated that there would be a 100% increase in CVD across South Asia by 2020. But, when one looks at Bangladesh, there has already been a 3,500% increase. This high vascular burden in the local population seems consistent with Bangladeshis living abroad. In England, for example, Bangladeshis have the highest mortality from both heart attack and stroke events among all immigrant groups.

Although the ‘classic’ CVD risk factors apply to Bangladeshis, it seems likely that they may be affected by additional, as yet unrecognised, factors. The combination of atypical clinical patterns, a severely high burden of disease and absence of powerful studies to discover novel genetic, biochemical or lifestyle risk factors of CVD affecting this population prompted me to set up a case-control study called the “Bangladesh Risk of Acute Vascular Events (BRAVE)“.

Initiated in 2011 as a pilot study in Dhaka (with part support from my own personal stipends from my Gates Cambridge Scholarship), this first-ever comprehensive cardiology research in Bangladesh has so far enrolled nearly 4,000 heart attack patients and healthy controls – exceeding any previous Bangladeshi study in scale. The initial results of BRAVE are already showing promising findings, with several environmental contaminants (eg arsenic in the blood) and nutritional elements (eg zinc deficiency) emerging as important drivers for heart attacks in this population.

Several genetic and biochemical analyses are also currently under way. These results are significant as they show that the CVD risk profile in low-income countries might be different from that in higher income countries and may potentially be reinforced by local factors which are largely preventable with appropriate public health strategies.

BRAVE aims to recruit 20,000 participants over the next few years (depending on further funding from leading health charities), making this one of the largest epidemiological studies in the region. Information and bioresources collected in BRAVE will then be used to test novel hypotheses relating to potential risk factors to help shape local and global cardiopreventive policies.

 *Rajiv Chowdhury is the first Gates Cambridge scholar from Bangladesh, and is a final-year PhD student at Cambridge University. BRAVE is a collaborative study between the Department of Public Health and Primary Care at Cambridge and leading clinical and research institutes in Bangladesh. The author is the lead PI of this study.

 

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Talented Law Graduate Faces Uncertain Future

I still remember the first time I met Jose Manuel Godinez Samperio. He was one of a handful of first-year law students who dropped everything to assist me in representing dozens of former workers from the Postville Iowa Meatpacking Plant disaster. These workers were undocumented immigrants from rural places in Central and Latin America, many of whom were abused in the workplace, and en route to deportation unless we were able to find that they qualified for a humanitarian visa.

Though the events occurred in Iowa, these workers somehow ended up in federal prison in Tallahassee, Florida, the last stop before they headed home. An attorney with a national immigration organisation contacted me under the assumption that I was the only immigration lawyer in all of Tallahassee. This was an exaggeration, but I was the only attorney tasked with representing immigrants in “humanitarian” immigration cases.

Jose Manuel was interested in learning about this type of law, which focuses on immigration visas for unaccompanied immigrant children, asylum seekers, and victims of crime, and came to help me translate statements from the incarcerated female workers. Jose Manuel went on to become an exemplary a student in several classes I taught at Florida State University College of Law. He was engaged, proactive, thoughtful and always prepared with challenging questions. He made me a better teacher and a more informed advocate. I knew about his undocumented status while he was my student, only because of the challenges with ensuring lawful summer employment or securing enough funding for Jose Manuel to continue his legal studies, but he never complained or asked for anything. I saw him riding around campus on his bike, pin attached to his poncho on the cold days declaring “no one is illegal.” I agree.

While I taught Jose Manuel, I simultaneously represented a DREAM Act eligible 17-year-old girl who fled gang violence in Honduras to rejoin her mother in North Florida. She became a member of Junior ROTC and dreamt of joining the US Army and fighting for the country that had given her a place to live without fear. We pursued an asylum claim and failed, and the dreaded “bag and baggage” letter followed: “Marisa” was to report on a certain day in June with no more than 40 pounds of luggage to head back to Honduras, a country where she had no living relatives and a city she fled when she was eight.

The Obama administration announced a change in its deportation priorities, declaring it would no longer prioritise deporting non-violent criminals like Marisa or Jose Manuel. Due to this policy change, we were granted prosecutorial discretion for Marisa after we amassed the necessary paperwork and affidavits from friends and family. In short, the Department of Homeland Security will not be deporting her at the moment. Still, every year, we must reapply for prosecutorial discretion for Marisa.

Hopefully, every year, the government will continue to believe that it is better for her to stay here in the US, work, contribute to her community, and assist her mother and step-father with the care and support of her two little sisters, all of whom are U.S. citizens now. While teaching Jose Manuel, I talked to him about Marisa’s situation. He has since helped to educate young people like Marisa about their rights and has even involved Marisa in some of his advocacy efforts as he continued to pursue a law degree.

One year ago, I watched Jose Manuel graduate from law school with distinction. He successfully petitioned the Florida Board of Bar Examiners to waive the requirement that he have documented immigration status (California’s bar exam is immigration status-blind, and other states are considering this as well). Jose Manuel studied for the bar, took the bar, and passed the bar, but he still does not have his license to practice law. The Florida Board has certified this question as one of great importance before the Supreme Court of Florida: can the Florida Bar issue a bar license to an undocumented immigrant and Eagle Scout who has graduated at the top of his class from a Florida law school and passed the bar? While we wait for the Florida Supreme Court to decide his case, Jose Manuel and others in his position are left suspended in uncertainty and unable to fulfill their potential to contribute to our communities and our country.

*Wendi Adelson is an attorney in Florida, a 2002 Gates Scholar, and the author of This is Our Story, a novel about her clients and what it means to represent them, available on amazon kindle, , or paperback here