Professor (Mrs.) Janet Ajuluchukwu is a professor of Medicine, Department of Medicine, College of Medicine, (CMUL) University of Lagos, a Consultant Cardiologist, Department of Medicine, Lagos University Teaching Hospital, (LUTH), immediate past Head of Department of Medicine CMUL and LUTH, Head Department of Cardiology Unit B, LUTH and Chairman LCP Program (Open Heart Surgery Program) with over 35 years of medical experience. She has practically toured the world in search of knowledge and is highly acclaimed in the cardiology world. In this interview she talks with passion about matters of the heart.
HOW DID THE JOURNEY TO BECOMING A DOCTOR AND A CARDIOLOGIST BEGIN
If I think back to my primary four, I would say that was the first time I had the inclination that I may be a doctor because I use it to remember my father. If he wants to caution or correct me, he would say, that not how a doctor would do. But where the interest came from, whether it was from those words or from me, I cannot really say but I remember that was how he used to caution me in my Primary four. So I began to do things I thought a doctor would do. Even in our play groups we used to operate on grasshoppers and see how they fed because we felt that was how doctors would behave.
SO WE CAN INFER THAT YOUR FATHER WAS A GREAT INFLUENCE ON YOU BECOMING A DOCTOR
Yes, he was.
DID THAT NOT SURPRISE YOU, BECAUSE I AM QUESSING THAT AT THAT WOMEN WERE EXPECTED TO BE IN MORE TRADITIONAL JOBS SUCH AS TEACHING, NURSING OR SIMPLY HOUSEWIVES
I am the last born in my home, my eldest sister is a nurse who went as far as sub specializing in ENT nursing in Scotland. My father was a British trained nurse. I do not think there was any time a role assignment was there according to what prevailed. Everybody was encouraged to do their best.
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YOU SAID THAT YOU USED TO PERFORM SURGERY ON GRASSHOPPERS IN YOUR PRIMARY SCHOOL, SO HOW COME YOU ARE A CARDIOLOGIST NOW AND NOT A SURGEON
When I went to Secondary School, still trying to answer the first question, I still was not very sure that I wanted to be a doctor. I would say that I felt strongly that I wanted to be a doctor in my primary school rather than in my secondary school. I even left it to fate that when my WAEC result would be out, I would see how I would fare. But funnily, I had the same marks in my science subjects as in my arts subjects and so in trying to go to higher school, it was the medical subjects, Chemistry, Physics, Biology that I applied for and I got it so that removed my other interest. At that time, I was very interested in French and my French teacher used to say I was the best French student she had ever taught.
Coming to why I am a Cardiologist and not a Surgeon, even at the point of the undergraduate class I got one of the prices, in surgery. In the final year, I got the Ali Idowu price for surgery for my class and everybody thought I would be a Surgeon.
After Youth Service, I had a chance to work at the Medical Emergency room in preparation for doing the requisite exams for Residency. My exposure to that emergency room experience made me keep an interest and a senior colleague made some comments that got me attracted to that aspect of medicine more than surgery. So that kept me on the side of Medicine called medicine, that is internal medicine.
Cardiology just seem to come naturally to me. It is very technical and mathematical. So I think that is how my pathway was arranged for me. I have been a Cardiologist since 1993.
HOW HAS IT BEEN FOR YOU THESE 24 YEARS AS A CARDIOLOGIST
It has been very interesting. We have a varied array of different health issues in Nigeria. Cardiology is thought to be a disease guided by westernization and industrialization. Africa, is currently being described as a double burden continent. We have not finished clearing our infective agents, malaria, tuberculosis, HIV, and now we are being burdened with the problems of civilization. So, if you take a typical place like England, America or Sweden, they would have a very minimal rate of infectious disease. For instance, if they record say ten tuberculosis infection for the whole country, it would be news while these infective problems are still in Nigeria. We have not cleared these infections like the white man has before their westernization and industrialization introduced the type of problems they are seeing. So we are still grappling with our infective problems and some of them affect the heart like tuberculosis. Therefore, we have patients with double prevalence, double co-existence of infections and what we call emerging diseases. And it is really interesting trying to deal with such caeses.
ARE YOU SAYING THAT THERE IS A RELATIONSHIP BETWEEN WESTERNIZATION, INDUSTIALIZATION, URBANIZATION AND THE HEART PROBLEMS WE SEE IN THE AFRICAN CONTINENT AND IN NIGERIA IN PARTICULAR
Yes. The profile of the medical problems that the world has been encountering, have been noticed to be in phases. Most communities or countries would have to go through what is called diseases of pestilence. These are diseases like malnutrition, infection, malaria, cholera, undernutrition etc. But as man got better and more scientific and started using implements, cooking food, having stable families, our lifestyle changed. Now our mode of movement ambulation has changed. Instead of walking to the farms my 5am and working in the farm and returning home by 7pm, we drive or at the worst okada or keke will carry you wherever you want to go. Nobody is in the farms, so our lifestyle has changed from being very physical to sedentary and without gainsaying, it has been noticed that the diseases have also changed pattern. We are now having problems of degeneration so those illnesses of poverty and poor nutrition and infections have kind of moved away. If you go the Western countries, nobody is talking about malaria, rather the profile of diseases has moved to these newer diseases like hypertension, diabetes, arthritis, strokes, diseases that do not have an infective process. These new diseases are multi factorial. If a mosquito bites you, you get a disease called malaria, but for these new diseases it is a conglomeration of behavioural risk factors that tend to cause these new illnesses. So the industrialized worlds are having hypertension, heart attacks, strokes, diabetes etc, they do not have infections or hardly ever. But Africa is the seat of all infections and for many reasons such as policy and poverty we have not cleared them but we are also acquiring the lifestyle of the Western world and now having the diseases of pestilence and the diseases of affluence coexisting at the same time. Most of our lifestyle changes are from industrialization, westernization and what we are eating.
THERE IS A SAYING THAT WHEN DIET IS WRONG, MEDICINE IS OF NO USE AND WHEN DIET IS RIGHT, MEDICINE IS OF NO USE. DO YOU AGREE WITH THAT
Yes. The saying may be a paraphrasing of what Hippocrates, Father of Medicine said a long time ago, ‘let food be your medicine.’ Some people have taken it one step further to say you are what you eat. I don’t really believe that but if you go through what we call the risk factors of cardiovascular diseases, there are those we say are non-modifiable and those that are modifiable. The non-modifiable factors include genetics, age and gender while the modifiable ones are behvioural for instance you would want to smoke a cigarette or not smoke, then your salt intake. Salt as we know is a preservative and the more already made or imported food you take especially in the cities, the more salt you eat from the preservative. It has already been proven that when people move from the rural area to the urban areas, within three months their blood pressure will shoot up and this is traceable to what they eat until the time perhaps they have a more stable home and begin to cook their own food. Lack of fruit and vegetable intake is also a factor. Fruits and vegetables are rich in Potassium which tends to neutralize the effects of sodium (salt).
LET’S ZERO IN ON HYPERTENSION HERE. YOU DESCRIBED GENDER AND GENETICS AS RISK FACTORS FOR CARDIOVASCULAR DIESASES, IS ANY GENDER MORE PRONE TO HYPERTENSION THAN THE OTHER
Well, the male gender is a risk factor. Through many studies and researches we know that the male sex is a risk factor for hypertension. In the Nigerian data, in most of the geographical zones where tests were done, it was seen that men would have blood pressure prevalence higher than the women but in certain places you see it coming closer together. But in test books, the male gender is supposed to be more prone to hypertension.
IS THERE ANYTHING IN THE MALE ANATOMY THAT YOU CAN SAY MAKES THEM MORE PRONE TO HYPERTENSION
Generally, we think that the female hormones are protective. Even for certain problems to afflict man and woman, especially the heart attack type of story, the women appear to be highly protected. However, after the natural menstruation ceases or somebody has what is called a surgical termination of menstruation, their risk factors come up. So there is evidence that the female hormones are protective. So does it mean that the male testosterone is adverse, there is a lot of debate about that.
DOES IT THEN MEAN THAT EVERY MAN WILL AT SOME POINT BE HYPERTENSIVE
No it is not invariable. We have the interaction of gene, behavior and the environment. In the koma people who didn’t eat salt at the time of discovery, nobody had hypertension. But we learnt that since they were exposed to eating bread, biscuits, using cooking salt, their profile has changed.
LOOKING AT GENETIC MAKE UP, CAN WE SAY THAT HYPERTENSION IS HEREDITORY
Yes, it is hereditary but we call it Lock and key Model. Even though the genes are there, if you don’t eat the salt, you don’t smoke or you don’t allow yourself to get obese, you may not necessarily manifest.
IN TIMES PAST, HYPERTENSION WAS ASSUMED TO BE AN OLD AGE DISEASE. IS THAT ASSUMPTION STILL CORRECT
Let’s start with why it was called an aging disease. We have a certain amount of blood pressure that we have found useful. Naturally when a baby is born the blood pressure is very low and as the baby grows older the blood pressure goes up. Until 1999, the World Health Organization said that for someone to be said to have hypertension, the partition level for the blood pressure should be 160/95. This of course was an arbitrary cut-off. But in 1999, they changed it to 140/90, and said if we start doing things either with drugs or without drugs to keep our blood pressure lower than 140/90 the world would be a better place. So before 1999 was even accepted that a blood pressure of 170 in a 70-year-old man was normal for him because as you grow older your blood pressure goes up. But with better research and better observation, it was noticed that if you are 70 years and your blood pressure is 140, you are not likely to have a stroke but if you are 70 years and even though nature is pushing your blood pressure up to 170, that status will give you a stroke.
We also have what we call a ‘rule of thumb’ that the systolic blood pressure should be your age plus 100 and we still use it. Now WHO says that for us to characterize somebody as hypertensive, the blood pressure will be 140/90 and above, but if a 30-year-old comes to me with a blood pressure of 135, I will do that 100 plus 35 and I will keep him under surveillance. A 16-year-old should have 116 and below, if he/she come with 120 or 125 blood pressure, even though it has not got to the WHO cut off, I will still keep that person under surveillance and lifestyle modifications might just have to start early.
From some of the studies carried out by the Nigerian government it was seen that about 16 percent of some 15-year-olds were hypertensive, having a blood pressure level higher than what it should be. So hypertension is not an old age disease any more.
SO HOW SERIOUS AN ISSUE IS HYPERTENSION IN NIGERIA
With figures, hypertension is the biggest, most common, most independent risk factor for heart failure, stroke, heart attack, kidney disease/failure and sometimes eyes problem. It is one risk factor that can affect many parts of the body. Coming to the numbers, remember we have said that in 1999, WHO changed its partition from 160/95 to 140/90. The Nigerian government was able to sponsor a very big national study that was published in 1997 using WHO figures of 160/95 and the people that were seen then were 15 years and above and it was seen that 11 per cent of Nigerians using 160/95 had hypertension. It was commoner in the urban centres than in the rural areas. Then when WHO said it was 140/90, they now used the same figure and changed the partition level and we got about 20 percent. However, different people have been doing different studies, the one that was done using Lagos State as a pilot to do another national one, we saw that the prevalence of hypertension in Lagos in 2003 went up to 30 percent and we are still seeing the increases.
IN YOUR INAGURAL LECTURE A FEW YEARS BACK, YOU SAID KANO WAS THE HYPERTENSION CAPITAL OF NIGERIA, CAN YOU EXPLAIN
It is still from this national health survey sponsored by the Federal Government and this was not political or anything since it was done by the Federal Ministry of Health and in different locations in Nigeria, supervised and controlled at a central level. It was seen that Kano town had the highest level of hypertension. At that time, we were still doing 160/95, some towns like Mangu and Malumfasi had 6 to 7 percent, but in certain areas of Kano they were having 30 to 40 percent. So they now used those values and made something like a map and Kano was just there standing by itself.
IS IT KNOWN WHY THE PREVALENCE IS SO IN KANO
We just have conjectures and scientific debates why it might be so not that it has been proven because after you have an observation and/or a scientific thought, you go back and prove it by really doing comparisons to know what is it there that is different. But the things that we have observed are dietary, all the dressing that they put on the meat preparation, the part of meat that is attractive to the man on the street, the high creamy milk dishes that they would have because cholesterol and salt are part of the things that would cause the blood pressure to rise. So with these, we feel it is dietary. I’m sure in the north and around that Kano, the very poor people can have some meat and all those fatty parts that people might throw away may be picked up by the poorer people to eat because socio cultural status also comes into play. The national survey also showed that very rich people and very poor people had hypertension with very little in the middle. We also feel that the suya type of dressings might be highly salted. Again, because of the nomadic kind of living there, we heard that meat is prepared and preserved in such a way that it does not spoil easily. So the question is what are using.
WE HAVE BEEN TALKING ABOUT HIGH BLOOD PRESSURE BUT I KNOW THERE IS ALSO WHAT IS CALLED LOW BLOOD PRESSURE. WHAT CONSTITUTES LOW BLOOD PRESSURE AND IS IT AS DANGEROUS AS HIGH BLOOD PRESSURE
Blood Pressure we know is the force imparted by the heart in its effort to push out blood into the vessels. So if the heart itself does not have a lot of force, it will not push out blood into the vessels. Everybody has a blood pressure though arbitrarily, WHO fixed it at 140/90. So there is also a pressure that would be in the vessels that would not give enough force for the blood to move upwards against gravity to get to the brain and all the other parts of the body, because the heart just pumps once and the blood keeps moving until it finds its way back. We don’t have a very good level for low blood pressure but we would be worried if people have blood pressures that are less than 100/60. And we say any blood pressure that you have that is associated with symptoms is not good. So if your natural blood pressure is 90/60 and you are running marathons and doing all you are supposed to do, then it is not bad. But if you are usually about 120 and then one day you get to 90/60 and you are feeling week, dizzy and your heart is beating, then that blood pressure is a problem and we will it take as low blood pressure. Is it dangerous? Yes. Part of the dying process or state is that the heart gets weaker and the pressure gets lower until there is no blood pressure at all. In a simplistic manner if somebody is vomiting and having diarrhea losing the usual quantity of fluid that should be in the body, it will affect the blood pressure. If somebody is having serious diabetic problem, passing large volume of urine and very frequently, then the BP will drop. Again if the heart itself which is the pumping organ is weak or somebody is having a heart attack, the BP will drop.
IS IT PROPER TO SHARE HYPERTENSION DRUGS
It is not proper at all. People should not share any drugs. With hypertension though, the drugs are targeted at certain problems. For instance, some hypertensive patients have shown proneness to kidney failure, we give them kidney saving drugs. Some have shown proneness to heart enlargement, so we give them specific drugs, some patients are diabetic and they have their own drugs that are more suited to them. So we should not share drugs. The numbers may be the same but the internal arrangement may not be.
IN YOUR INAUGUARAL LECTURE YOU SAID ANTI HYPERTENSIVE DRUGS WORK BETTER WHEN TAKEN AT NIGHT. WHY IS THAT SO
It has been noticed that the different organs of the body and their natural workings have rates that can be up or down depending on the time of the day. So there is an internal clock that the body has that tells your body that night is coming and that you should be preparing to go to sleep and during sleep, the body and its organs are more relaxed. The blood pressure that we have at our work place with stress and everything, is not the blood pressure we have at our house, it goes down a little bit. When you are asleep, your blood pressure must go down 10 units than when you are awake. As we are trying to wake up, certain things happen inside our body to put the body into the process of waking up and it involves adrenaline and certain stress hormones. So people are surprised that when they wake up their blood pressure is up and that is even why people have heart attacks and strokes in the morning.
We have studied it and we have proven it in our own practice that when we gave part or all of the treatment at night because of those night time changes, the drugs worked better and in our own values, the blood pressure went down. We had two groups of people, they had the same blood pressure, the same number of men and women, we checked the level of heart enlargement they have had due to hypertension and we gave them treatment for three months, day time and night, we found good changes consistent with science. We found that some of the physiological activities that are switched on or switched off at night worked well with our drugs at night and we saw those effects. It is called Chrono biology and that is why jobs like shift work can cause certain changes because people are seating down working at night when they should be lying down.
ON A FINAL NOTE
Well nothing beats knowledge. I have observed in these my over 35 years of being a medical doctor, that there is a lot of bravado with ignorance. People make statements like ‘my fore fathers did this or that’, it is very painful. Your fore fathers were not using telephones; they were not flying in planes. They did what they could do and they did well. We are losing a lot of people, young people due to ignorance. I had a patient who came in with a BP 250/190 and this happened because she stopped taking her drugs because she said she had faith that she had been cured. Faith is good but people should check their BP especially if you are already diagnosed. People should also go for regular checkups.
We should use the information and knowledge that our age, this 2017 has given us. We cannot be in 2017 and be having health care of 450BC.
Prevention is important. Prevention is at different levels. At the governmental level they should give us wholesome food, help our agriculture, educate us in school as to the proper and healthy things to eat, minimize the importation of things that are injurious to our health not chasing women in the market when the things are already in the country.
At the individual level, people have to make the conscious effort to know their health status. WHO has started a programme called Knowing your Numbers. Everybody has to know how old they are, because age has an impact on health, your blood pressure, the level of your blood pressure, not that the doctor said it is normal: you must know the value and what it means. People need to know their blood sugar, that it is maybe 88 and normal or that is 150 and not normal and what next to do. They need to know their cholesterol level and finally the measures of obesity: their weight against their age to know if their Body Mass Index is right. Do the little tests for going into secondary school, university or starting a new job. These are important avenues to catch things because the earlier one can pick up these non-communicable diseases and intervene, the better the outcome and the slower would be the processes of damage.
People should invest in their health just as they invest in education. We have said that hypertension is the biggest risk factor for heart failure, stroke, kidney failure etc, so imagine what will happen if we can take out avoidable hypertension.