- Email: [email protected]
Argentina and argentine cardiology
FROM
THE EDITOR
Argentina
and Argentine
orge L. (Figure), a 44-year-old Assistant Professor of Medicine at the University of Buenos Aires, is in charge of the exercise laboratory of the hospital of the University of Buenos Aires (Hospital de Clinicas). Each morning with his 3 assistants he performs about 10 exercise stress tests and makes consultations to the 4 general medical services for the Division of Cardiology. After lunch he goes to his private office only a few blocks away and there he seesprivate patients until about 9 P.M. He then goes home except for 1 night a week when he lectures at a cardiac society meeting. Dinner with his wife and 2 daughters is usually about 10 P.M. and he retires to bed at midnight. On Saturdays and Sundays he usually makes hospital ward rounds to see his private patients. For his services at the University Hospital he receives $200 (US dollars) a month. Jorge R. (Figure) is a 40-year-old cardiologist in the echocardiography laboratory at the same hospital. He also arises about 7 A.M. and arrives at the hospital about 8:30 A.M. He and the other 3 echocardiographic cardiologists perform about 15 echocardiograms each morning. (It is cost effective to the hospital for physicians to perform echocardiograms. There are no technicians.) He drives 30 minutes home to have lunch with his family, and, at 3 P.M., goes to his private office a block from home. There he seespatients until 7 or 8 P.M., and then home for dinner with his wife and 3 children at 9 P.M. For his work in the echocardiographic laboratory at the hospital he is paid $100 a month. In contrast to Jorge L., Jorge R. does not have a professional position in the medical schooalthough he teaches in the school-because he chose not to take the 4 years of courses on teaching required by the university for professional rank. Neither his pay nor his duties at the hospital, however, are affected by his not fulfilling the course work in techniques of teaching. The lack of professional rank prevents him from ever becoming chief of the cardiology division, but he says that position is of no interest to him. I met Jorge L. and Jorge R. during a 2-day visit to Buenos Aires in May 1988. It was my fourth trip to Argentina and I will return as often as I am invited. Buenos Aires is one of the great cities on this planet, but it is a long way from the USA. Moscow is closer to New York City than is Buenos Aires, which is on the same latitude (35O South) as Capetown, South Africa, Sidney, Australia, and Auckland, New Zealand. Argentina has the potential to be one of the earth’s great countries. Its land area is extensive, 1,OOO,OOO square miles, one-third the size of the USA, and its soil is as fertile as any in the world.‘-3 Despite its being the eighth largest country in the world, Argentina’s population is relatively small, only
J
Cardiology
33 million, 10 million of whom live in the Buenos Aires area and 2 million of whom live abroad.4*5 The population is relatively homogenous; 97% are of European origin.2 The average Argentine is said to be “an Italian who speaks Spanish and thinks British.” 2 Over 90% of the population is Catholic. Growth rate is low, only 1% a year, and literacy rate is high, >90%.4*5 Life expectancy for men is 67 years and for women, 73 years. The birth rate is 25/ 1,000, death rate 9/1,000 and infant mortality is 50/ 1,000 births.4*5 The northern portion of Argentina is heavily wooded and swampy (Gran Chaco); the central portion, where most of the people and cows live, is treeless and wheat or grass covered (6 feet thick topsoil) (pampas) and the southern portion is bleak, arid, cool (Patagonia) and contains millions of penguins and sheep.3 Its western portion is mountainous and contains some of the best ski slopes and most spectacular scenery in the world. One snowy peak is nearly 23,000 feet high. The country produces enough oil for its own needs including enough for its 5 million motorized vehicles, and its agricultural output at one time was so great that Argentina was called “the breadbasket of the world.” Buenos Aires is a cosmopolitan city with 42 theaters, 200 movie houses, numerous museums and galleries and 150 parks. Its residents, called Porte&w (of the port) are as educated, sophisticated and urbane as any on earth.3 The classy tulle Florida, a fashionable shopping street, competes well with those of Florence, Paris, London or New York. Few populations read more than do the Argentines. Philosophizing and flirting are said to be their 2 most popular activities, with soccer a close third. Argentina won its independence from Spain in 18 10. By 1880 it had killed nearly all Indians living in Argentina and the victorious military officers were rewarded by the government with huge parcels of land, commonly > 100,000 acres. The country then began seeking immigrants from Europe and during the next decade about 1.5 million Spanish, Italians and some Germans and English settled in Argentina. The British built their railroads and later their telephone system, which facilitated rapid movement of their produce and cattle to port. By the early 20th century, Argentina was one of the 10 richest countries on earth.’ Today, Argentina-educated, sophisticated, homogenous and captivating-is broke. She is the third most
THE AMERICAN
JOURNAL
OF CARDIOLOGY
JULY 1,1988
167
indebted nation in the world, owing $54 billion (US) dollars, and the interest on the debts takes 50% of her export income. What happened? Many blame the rule and residue of Juan Per& who came to power in 1946. He spent far more money than his government collected. Strong labor unions were established and output per worker fell. Per&r was gone by 1955 but not his influence. His brief return in 1973 was as devastating as his earlier regime, and subsequent military regimes were just as corrupt and harsher. Democracy returned in 1983 but it will probably be many years before stable growth reap pears. The annual inflation rate was nearly 700% in 1984 (about 2% a day) and down to 175% in 1987. The unstable government and economy of Argentina during the past 50 years have had devastating effects on its medicine.6 Argentina has 6 medical schools. The largest is the University of Buenos Aires, which has an open admission policy and free tuition and as a result its freshman class now contains about 5,000 students. (During Per&i’s last year in office [ 19741, the freshman medical school class at the University of Buenos Aires had 17,000 students, and 6 years later 2,500 graduated.) Now, by the beginning of the second year, the class size is down to 3,ooO, by the beginning of the fourth year (the first of the 3 clinical years), the class is down to 2,000, and after the sixth year, the number of graduates is about 1,500. Students are allowed to take the final examination for graduation up to 3 times. The other 5 medical schools have smaller graduating classes, each about 200 students, so that Argentina is producing each year about 2,500 new physicians. There are residency (no internships) slots in Argentina for only about 30% of its medical school graduates. Thus, 70% of the graduates go into practice directly from medical school, nearly always as salaried employees of 1 or several state or private health care institutions. The residency slots are awarded by scores on examinations and 1 interview and the training positions are usually in public hospitals. One such hospital is that of the University of Buenos Aires, officially called Hospital de Clinicas Jo& de San 166
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
62
Martin. This hospital has a capacity for > 1,000 beds but presently only 400 are used because of severe budgetary restrictions. With a few exceptions, equipment in the hospital is old. The exercise laboratory, which Jorge L. directs, has 2 treadmills. The echocardiographic laboratory, where Jorge R. works, has 2 machines doing both M-mode and cross-sectional echocardiography. The number of outpatients at this public hospital is large. In the hospital’s cardiac catheterization laboratory about 15 procedures are done weekly and 2 to 3 open heart surgical procedures are performed weekly. The faculty at the University of Buenos Aires hospital is an A.M. one in that the faculty physicians are at the hospital from roughly 8 A.M. to 12 noon and then they go to their private offices after lunch. About half of the faculty have taken the necessary courses in teaching so that they have professional rank; the other half, who have equal teaching and service responsibilities, have not taken the courses in teaching and therefore they do not have professional rank. The faculty, professional rank or not, is paid $100 to $300 a month for work at the public hospital, after initially having worked for 5 or more years without pay. The large numbers of medical students prevent close supervision of students by the faculty. Ward rounds often consist of 1 faculty physician, 1 resident and 20 medical students. Lectures may be to as many as 1,500 students. Cardiology training consists of 1 year of residency in internal medicine, 3 years of clinical training in cardiology, followed by 2 years of A.M.courses in cardiology at the University. When the clinical training is completed, however, there is no assurance of a faculty post and private practice in all cities in Argentina now is enormously competitive. Argentines who can afford private medicine are hospitalized in private hospitals that are far better equipped than are the public (teaching) hospitals. Most coronary bypass operations are performed at the private hospitals. The top 10 cardiovascular surgeons in Argentina may bill as much as $15,000 (US dollars) for a bypass operation for a private patient. Most patients, however, have some form of health insurance, and some of these
policies pay as little as $700 for a bypass operation. About 5,000 coronary bypass operations and 90,000 percutaneous transluminal coronary angioplasty procedures were performed in Argentina in 1987. The bill to a private patient for coronary angioplasty is about $3,500. Most physicians in Argentina, however, are much poorer today than in the late 1960~;~the government pays only $3.00 for a private patient’s visit to a private physician. Many physicians no longer recommend the medical profession to their children, and it will be many years before their outlook will change significantly either economically or academically. Atherosclerotic coronary artery disease is the leading cause of death in Argentina, and, indeed, Argentine men have one of the highest coronary artery disease mortality rates (604/100,000) in the world.7 The mortality rate for coronary artery disease in women (155/100,000) in Argentina is also one of the highest in the world.7 The mean serum total cholesterol levels of Argentine middleaged adults is high (241 f 53 mg/dl in men and 235 f 45 mg/dl in women).8 Few people eat more beef than do the Argentines-an average of nearly 100 kg/capita/year. The calorie supply per capita in Argentina also is high (about 3,350), similar to that in the USA, West Germany, United Kingdom and Finland.* Systemic hypertension is frequent in Argentines, and only about 15% of its hypertensive patients are having their blood pressure controlled by antihypertensive agents8 Cigarette smoking is the rule among Argentine adults; the average number of cigarettes smoked is about 2,000/adult/year.8 Forty percent of the adult Argentine population is overweight, and a similar percent of adults do not exercise.8 Argentine medicine has been enormously affected by the disruption in the Argentine government and economy. For medicine to return to its pre-1950 glory, the
medical school faculty must be paid sufftciently so that private practice for half the day will be unnecessary; the number of its medical students must be enormously curtailed and stringent admission requirements must be established; modem diagnostic and therapeutic equipment is needed, and a drastic change in eating habits must occur for blood lipid and pressure levels to be drastically lowered. These changes unfortunately appear far away. The cheapest way for Argentina-as for any developed nation-to improve the health of its citizens is to decrease its intake of saturated fat, cholesterol and salt. For a nation raised on beef, butter, milk and cheese, the challenge is a great one.
Wiliam
C. Roberts, MD Editor
ia Chief
1. Swbie JR. Argentina. A City anda Nation, secondedition. New York Oxford Uniwrsity Press, 1971:323. 2. Nelson CB, editor. Fodor’s South America 1982. New York F&w’s Modern Guides, Inc., 1982.630. 3. La Argentina, un pak maravillmo. Buem Aires: Monrique Zago, 1982:1X 4. Johwn 0, executive editor. Intwmation PIeme Almanac Atlas & Yearbook 1988,llst edition. ikxtotr Houghton Mtfjlin, 1988.976. 5. Hoffman MS, editor. World Almanac ana’ Book of Facts 1987. New York World Almanac, 1987.928. 6. Argentina: inflation vs mediim. MedicaI World News 1976 (April IS):81 -84. 7. Hauger-Klevene, Balmsi EC. Coronary heart disease mortality and coronary risk factors in Argentina. Cardiology 1987;74:133-140. 6. Neuman J, de Neuman MP, V&m E, Lindental D. Epidemiology of coronary heart disease risk futors in a f?ee-living population. Prev Med 1979:8:445-446.
To Our Readers.
..
This issue inaugurates a redesign of the Journal. We hope you like it and we welcome your comments. William C. Roberts
THE AMERICAN
JOURNAL
OF CARDIOLOGY
JULY 1.1988
169
THE EDITOR
Argentina
and Argentine
orge L. (Figure), a 44-year-old Assistant Professor of Medicine at the University of Buenos Aires, is in charge of the exercise laboratory of the hospital of the University of Buenos Aires (Hospital de Clinicas). Each morning with his 3 assistants he performs about 10 exercise stress tests and makes consultations to the 4 general medical services for the Division of Cardiology. After lunch he goes to his private office only a few blocks away and there he seesprivate patients until about 9 P.M. He then goes home except for 1 night a week when he lectures at a cardiac society meeting. Dinner with his wife and 2 daughters is usually about 10 P.M. and he retires to bed at midnight. On Saturdays and Sundays he usually makes hospital ward rounds to see his private patients. For his services at the University Hospital he receives $200 (US dollars) a month. Jorge R. (Figure) is a 40-year-old cardiologist in the echocardiography laboratory at the same hospital. He also arises about 7 A.M. and arrives at the hospital about 8:30 A.M. He and the other 3 echocardiographic cardiologists perform about 15 echocardiograms each morning. (It is cost effective to the hospital for physicians to perform echocardiograms. There are no technicians.) He drives 30 minutes home to have lunch with his family, and, at 3 P.M., goes to his private office a block from home. There he seespatients until 7 or 8 P.M., and then home for dinner with his wife and 3 children at 9 P.M. For his work in the echocardiographic laboratory at the hospital he is paid $100 a month. In contrast to Jorge L., Jorge R. does not have a professional position in the medical schooalthough he teaches in the school-because he chose not to take the 4 years of courses on teaching required by the university for professional rank. Neither his pay nor his duties at the hospital, however, are affected by his not fulfilling the course work in techniques of teaching. The lack of professional rank prevents him from ever becoming chief of the cardiology division, but he says that position is of no interest to him. I met Jorge L. and Jorge R. during a 2-day visit to Buenos Aires in May 1988. It was my fourth trip to Argentina and I will return as often as I am invited. Buenos Aires is one of the great cities on this planet, but it is a long way from the USA. Moscow is closer to New York City than is Buenos Aires, which is on the same latitude (35O South) as Capetown, South Africa, Sidney, Australia, and Auckland, New Zealand. Argentina has the potential to be one of the earth’s great countries. Its land area is extensive, 1,OOO,OOO square miles, one-third the size of the USA, and its soil is as fertile as any in the world.‘-3 Despite its being the eighth largest country in the world, Argentina’s population is relatively small, only
J
Cardiology
33 million, 10 million of whom live in the Buenos Aires area and 2 million of whom live abroad.4*5 The population is relatively homogenous; 97% are of European origin.2 The average Argentine is said to be “an Italian who speaks Spanish and thinks British.” 2 Over 90% of the population is Catholic. Growth rate is low, only 1% a year, and literacy rate is high, >90%.4*5 Life expectancy for men is 67 years and for women, 73 years. The birth rate is 25/ 1,000, death rate 9/1,000 and infant mortality is 50/ 1,000 births.4*5 The northern portion of Argentina is heavily wooded and swampy (Gran Chaco); the central portion, where most of the people and cows live, is treeless and wheat or grass covered (6 feet thick topsoil) (pampas) and the southern portion is bleak, arid, cool (Patagonia) and contains millions of penguins and sheep.3 Its western portion is mountainous and contains some of the best ski slopes and most spectacular scenery in the world. One snowy peak is nearly 23,000 feet high. The country produces enough oil for its own needs including enough for its 5 million motorized vehicles, and its agricultural output at one time was so great that Argentina was called “the breadbasket of the world.” Buenos Aires is a cosmopolitan city with 42 theaters, 200 movie houses, numerous museums and galleries and 150 parks. Its residents, called Porte&w (of the port) are as educated, sophisticated and urbane as any on earth.3 The classy tulle Florida, a fashionable shopping street, competes well with those of Florence, Paris, London or New York. Few populations read more than do the Argentines. Philosophizing and flirting are said to be their 2 most popular activities, with soccer a close third. Argentina won its independence from Spain in 18 10. By 1880 it had killed nearly all Indians living in Argentina and the victorious military officers were rewarded by the government with huge parcels of land, commonly > 100,000 acres. The country then began seeking immigrants from Europe and during the next decade about 1.5 million Spanish, Italians and some Germans and English settled in Argentina. The British built their railroads and later their telephone system, which facilitated rapid movement of their produce and cattle to port. By the early 20th century, Argentina was one of the 10 richest countries on earth.’ Today, Argentina-educated, sophisticated, homogenous and captivating-is broke. She is the third most
THE AMERICAN
JOURNAL
OF CARDIOLOGY
JULY 1,1988
167
indebted nation in the world, owing $54 billion (US) dollars, and the interest on the debts takes 50% of her export income. What happened? Many blame the rule and residue of Juan Per& who came to power in 1946. He spent far more money than his government collected. Strong labor unions were established and output per worker fell. Per&r was gone by 1955 but not his influence. His brief return in 1973 was as devastating as his earlier regime, and subsequent military regimes were just as corrupt and harsher. Democracy returned in 1983 but it will probably be many years before stable growth reap pears. The annual inflation rate was nearly 700% in 1984 (about 2% a day) and down to 175% in 1987. The unstable government and economy of Argentina during the past 50 years have had devastating effects on its medicine.6 Argentina has 6 medical schools. The largest is the University of Buenos Aires, which has an open admission policy and free tuition and as a result its freshman class now contains about 5,000 students. (During Per&i’s last year in office [ 19741, the freshman medical school class at the University of Buenos Aires had 17,000 students, and 6 years later 2,500 graduated.) Now, by the beginning of the second year, the class size is down to 3,ooO, by the beginning of the fourth year (the first of the 3 clinical years), the class is down to 2,000, and after the sixth year, the number of graduates is about 1,500. Students are allowed to take the final examination for graduation up to 3 times. The other 5 medical schools have smaller graduating classes, each about 200 students, so that Argentina is producing each year about 2,500 new physicians. There are residency (no internships) slots in Argentina for only about 30% of its medical school graduates. Thus, 70% of the graduates go into practice directly from medical school, nearly always as salaried employees of 1 or several state or private health care institutions. The residency slots are awarded by scores on examinations and 1 interview and the training positions are usually in public hospitals. One such hospital is that of the University of Buenos Aires, officially called Hospital de Clinicas Jo& de San 166
THE AMERICAN
JOURNAL
OF CARDIOLOGY
VOLUME
62
Martin. This hospital has a capacity for > 1,000 beds but presently only 400 are used because of severe budgetary restrictions. With a few exceptions, equipment in the hospital is old. The exercise laboratory, which Jorge L. directs, has 2 treadmills. The echocardiographic laboratory, where Jorge R. works, has 2 machines doing both M-mode and cross-sectional echocardiography. The number of outpatients at this public hospital is large. In the hospital’s cardiac catheterization laboratory about 15 procedures are done weekly and 2 to 3 open heart surgical procedures are performed weekly. The faculty at the University of Buenos Aires hospital is an A.M. one in that the faculty physicians are at the hospital from roughly 8 A.M. to 12 noon and then they go to their private offices after lunch. About half of the faculty have taken the necessary courses in teaching so that they have professional rank; the other half, who have equal teaching and service responsibilities, have not taken the courses in teaching and therefore they do not have professional rank. The faculty, professional rank or not, is paid $100 to $300 a month for work at the public hospital, after initially having worked for 5 or more years without pay. The large numbers of medical students prevent close supervision of students by the faculty. Ward rounds often consist of 1 faculty physician, 1 resident and 20 medical students. Lectures may be to as many as 1,500 students. Cardiology training consists of 1 year of residency in internal medicine, 3 years of clinical training in cardiology, followed by 2 years of A.M.courses in cardiology at the University. When the clinical training is completed, however, there is no assurance of a faculty post and private practice in all cities in Argentina now is enormously competitive. Argentines who can afford private medicine are hospitalized in private hospitals that are far better equipped than are the public (teaching) hospitals. Most coronary bypass operations are performed at the private hospitals. The top 10 cardiovascular surgeons in Argentina may bill as much as $15,000 (US dollars) for a bypass operation for a private patient. Most patients, however, have some form of health insurance, and some of these
policies pay as little as $700 for a bypass operation. About 5,000 coronary bypass operations and 90,000 percutaneous transluminal coronary angioplasty procedures were performed in Argentina in 1987. The bill to a private patient for coronary angioplasty is about $3,500. Most physicians in Argentina, however, are much poorer today than in the late 1960~;~the government pays only $3.00 for a private patient’s visit to a private physician. Many physicians no longer recommend the medical profession to their children, and it will be many years before their outlook will change significantly either economically or academically. Atherosclerotic coronary artery disease is the leading cause of death in Argentina, and, indeed, Argentine men have one of the highest coronary artery disease mortality rates (604/100,000) in the world.7 The mortality rate for coronary artery disease in women (155/100,000) in Argentina is also one of the highest in the world.7 The mean serum total cholesterol levels of Argentine middleaged adults is high (241 f 53 mg/dl in men and 235 f 45 mg/dl in women).8 Few people eat more beef than do the Argentines-an average of nearly 100 kg/capita/year. The calorie supply per capita in Argentina also is high (about 3,350), similar to that in the USA, West Germany, United Kingdom and Finland.* Systemic hypertension is frequent in Argentines, and only about 15% of its hypertensive patients are having their blood pressure controlled by antihypertensive agents8 Cigarette smoking is the rule among Argentine adults; the average number of cigarettes smoked is about 2,000/adult/year.8 Forty percent of the adult Argentine population is overweight, and a similar percent of adults do not exercise.8 Argentine medicine has been enormously affected by the disruption in the Argentine government and economy. For medicine to return to its pre-1950 glory, the
medical school faculty must be paid sufftciently so that private practice for half the day will be unnecessary; the number of its medical students must be enormously curtailed and stringent admission requirements must be established; modem diagnostic and therapeutic equipment is needed, and a drastic change in eating habits must occur for blood lipid and pressure levels to be drastically lowered. These changes unfortunately appear far away. The cheapest way for Argentina-as for any developed nation-to improve the health of its citizens is to decrease its intake of saturated fat, cholesterol and salt. For a nation raised on beef, butter, milk and cheese, the challenge is a great one.
Wiliam
C. Roberts, MD Editor
ia Chief
1. Swbie JR. Argentina. A City anda Nation, secondedition. New York Oxford Uniwrsity Press, 1971:323. 2. Nelson CB, editor. Fodor’s South America 1982. New York F&w’s Modern Guides, Inc., 1982.630. 3. La Argentina, un pak maravillmo. Buem Aires: Monrique Zago, 1982:1X 4. Johwn 0, executive editor. Intwmation PIeme Almanac Atlas & Yearbook 1988,llst edition. ikxtotr Houghton Mtfjlin, 1988.976. 5. Hoffman MS, editor. World Almanac ana’ Book of Facts 1987. New York World Almanac, 1987.928. 6. Argentina: inflation vs mediim. MedicaI World News 1976 (April IS):81 -84. 7. Hauger-Klevene, Balmsi EC. Coronary heart disease mortality and coronary risk factors in Argentina. Cardiology 1987;74:133-140. 6. Neuman J, de Neuman MP, V&m E, Lindental D. Epidemiology of coronary heart disease risk futors in a f?ee-living population. Prev Med 1979:8:445-446.
To Our Readers.
..
This issue inaugurates a redesign of the Journal. We hope you like it and we welcome your comments. William C. Roberts
THE AMERICAN
JOURNAL
OF CARDIOLOGY
JULY 1.1988
169