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Cardiac Care

A Physician-Scientist Explores Africa’s Alarming Rates of Heart Failure—Particularly its Connection to HIV

Dr. Justin Kingery. Photo credit: John Abbott

Dr. Justin Kingery grew up in West Virginia coal country, a world away from Tanzania—but he felt at home in the East African nation from the beginning. That may seem surprising, but Dr. Kingery has come to realize that the two places have much in common. Residents of both often struggle with poverty, he notes, but they have a deep sense of community and a willingness to help each other. “Growing up in a coalmining camp in West Virginia is actually very similar to growing up in Tanzania—it’s a very communal upbringing,” says Dr. Kingery, an instructor in medicine in the Division of General Internal Medicine at Weill Cornell Medicine and a hospitalist at NewYork-Presbyterian/Weill Cornell Medical Center. “I think that’s part of why I took to the Tanzanians, because they understand me even though we don’t speak the same language all the time. In Tanzania, everyone takes care of everyone, and that’s exactly how southern West Virginia is. Sometimes it can be a little closed to the outside world, but they’re fiercely protective of people; they want everyone to be OK.”

For nearly three years, Dr. Kingery has been splitting his time between New York and Mwanza, Tanzania, home to the Weill Cornell Medicine-affiliated Weill Bugando School of Medicine. As a research fellow at the Weill Cornell Center for Global Health, Dr. Kingery is partnering with colleagues from Weill Bugando to study the high rates of heart disease in Tanzania. “When I first started going to Africa, I noticed that they have an even higher burden of cardiovascular disease than we do in the West—it’s pretty dramatic,” he says. “In fact, all the literature suggests now that the cardiovascular disease burden in low- and middle-income countries is much, much higher than even in the developed world, and that is going to be a big problem once those countries start to develop more.”

One study that Dr. Kingery conducted found that 20 percent of the patients who come to Weill Bugando Medical Centre are seeking treatment for heart disease—and alarmingly, 60 percent of them die within a year. Dr. Rob Peck, the Tanzania-based director of the Weill Cornell Medicine-Weill Bugando partnership, points out that the drivers of this cardiovascular epidemic reflect the urbanization and westernization that have altered lifestyles throughout the developing world. “Whereas the people of Tanzania used to live and work on the land, farming, many more are moving into the cities, working at desk jobs, getting very little exercise and eating a diet very high in fat and salt,” says Dr. Peck, an assistant professor of medicine and of pediatrics in the Division of Infectious Diseases who is one of Dr. Kingery’s research mentors. “Because of these changes in diet and exercise, obesity is rising at an alarming rate.” But Tanzania’s high incidence of HIV infection—with five percent of adults carrying the virus—has made matters even worse. In a study of 250 HIV-infected patients, Dr. Kingery’s research revealed that 41 percent suffered from a particular kind of heart disease known as diastolic dysfunction, more than double the rate of an uninfected control group.

In diastolic dysfunction—which can progress to heart failure and death—the heart’s lower left chamber doesn’t relax properly and therefore has difficulty filling with blood. In Mwanza, where Dr. Kingery spends about eight months of the year, he has been diagnosing the condition at the bedside through echocardiography, an imaging technology rare in Tanzania due to a lack of equipment and expertise; he has also been teaching Weill Bugando’s students and residents how to use it. And with his background in the role of immunology in heart disease—the subject of his doctoral work at the University of Louisville, where he also earned his medical degree—Dr. Kingery is studying the relationship between HIV and diastolic disease in the laboratory during his time in New York. “The research that Justin is doing is really groundbreaking,” says Dr. Peck. “He is a very bright, dedicated doctor who goes above and beyond to get his patients better. And he’s not only doing research and treating patients—he’s training the next generation of doctors here in Tanzania.”

While the connection between diastolic dysfunction and HIV has previously been observed in the West, it’s more of a threat in Africa, where patients are generally diagnosed with HIV much later, allowing the heart disease to develop as the virus goes unchecked. Fortunately, Dr. Peck says, HIV treatment is free and widely available in Tanzania, so once patients are diagnosed they do well in terms of disease management—and as the antiretroviral drugs strengthen their immune systems, Dr. Kingery can study how and why that impacts cardiac function. “We’ve come up with what we think is one of the central pathways involved,” he says. “I’ve done echocardiography on about 500 patients over the past couple of years, and we have samples from them of blood and serum, both before and after receiving treatment for HIV. This is a unique opportunity, because it would be rare even in the United States to have all of that data and samples in a freezer waiting to be investigated.”

And as Dr. Kingery notes, understanding the immunology of this type of heart disease has potential benefits beyond patients in Tanzania, and even beyond the HIV infected population worldwide. While diastolic disease is uncommon in younger people, he says, “if you’re in the United States and you’re over 60, there’s about a 40 to 50 percent chance you have it. So we could be helping hundreds of thousands of people.” Furthermore, he says, his studies in Tanzania may offer insights into other aspects of heart disease. “There are interesting differences in cardiovascular disease between there and the United States,” he observes. “For example, only 5 percent of people with heart failure in Tanzania have ischemic heart disease [in which the coronary arteries become narrowed or blocked]. If you compare that to the United States, about 50 percent of people with heart failure have ischemic disease. If the Tanzanian diet is as bad as ours, and they’re as sedentary, why are so few having heart attacks? We don’t know.”

For Dr. Kingery, the desire to battle the scourge of cardiovascular disease runs deep; growing up, he saw many members of his West Virginia community succumb to heart attack and stroke, due to such factors as obesity and environmental pollution from coal mining. The first adult male in his family not to work in the mines, Dr. Kingery attended Marshall University on a scholarship funded by famed test pilot Chuck Yeager, an area native. While at the University of Louisville, which he attended on a full scholarship, Dr. Kingery became friends with an elite marathon runner from Kenya who planned to open a medical clinic in his hometown and invited Dr. Kingery to help with a community health assessment, providing his first glimpse of Africa’s cardiovascular disease burden. When he learned about Weill Cornell Medicine’s global health research fellowship after completing his internal medicine residency in Louisville, it seemed the perfect fit—allowing him to contribute to improving health both in the developing world and back home. “The research goes back and forth, and this project is a great example of that,” he says of his work with diastolic disease and HIV. “I’m taking research methods that were developed for the richest people in the world, and I’m using them to help people in a low-income country—but also to help us. It’s a never-ending cycle, going back and forth to help each other. I really love that.”

This story first appeared in Weill Cornell Medicine, Vol. 17. No. 2

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