key: cord-0844419-ntwpzaqr authors: Klassen, Sheila L.; Kwan, Gene F.; Bukhman, Gene title: The COVID-19 Pandemic: A Massive Threat for Those Living With Cardiovascular Disease Among the Poorest Billion date: 2020-09-18 journal: Circulation DOI: 10.1161/circulationaha.120.047969 sha: 7eca2336a91c4b7ffa242b867e865fecc441da42 doc_id: 844419 cord_uid: ntwpzaqr nan November 17, 2020 Circulation. 2020;142:1887-1889. DOI: 10.1161/CIRCULATIONAHA.120.047969 1888 CVD in poorest billion populations predisposes more individuals to severe illness, small health care budgets in many LMICs limit access to health care for these very individuals. Last, the ripple effects of job loss and a global economic recession taking place during the pandemic may make it impossible for poorest billion individuals living with chronic CVD to afford medications and medical care both in the short and long term. 1 However, there are innovative opportunities for the global cardiovascular community to respond to achieve long-lasting health system strengthening during this pandemic. One such response would be to support efforts to decentralize specialized care, such as heart failure care, to more remote communities and install cardiac care units or other high-dependency care units in rural district hospitals, easing the burden on health care systems in high-density centers. These initiatives can promote social distancing, while improving access to care among the rural poor even with concurrent regional lockdown measures. Decentralization requires both investment to extend existing supply chains and tasking shifting: reorganization of training and care models so that tasks usually performed by health care workers with specialized training at referral hospitals are shifted to workers with lower levels of training. Partners In Health in rural Malawi has been successful in adapting preexisting human immunodeficiency virus infrastructure to provide CVD care and this has been described as an effective strategy by other groups. 5 For many years, our group has used the PEN-Plus model of training nurses to lead outpatient clinics for patients with severe chronic disease in rural LMICs (The NCD Synergies PEN-Plus Toolkit can be found at http://ncdsynergies.org/chronic-care-toolkit/). New technology, such as digital disease surveillance systems, teleconferencing via mobile devices, and online training platforms, can facilitate decentralization and task shifting. During the pandemic, our group has conducted virtual training of health care providers to support care of patients with heart failure at several sites in rural Malawi. We are developing and testing an online heart failure teaching module using an open-source learning platform (Moodle Pty Ltd) in rural Rwanda. Our goal is to disseminate these technology-based tools to rural health care providers across sub-Saharan Africa. Through our decentralized clinics, we have also been able to coordinate the distribution of cash transfers to our patients in highest poverty to provide direct economic support. Over the past several months, it has become clear that strong health systems have the ability to adapt in acute crises, whereas underresourced health systems simply shift dwindling supplies from one care environment to another. While high-income and upper middle-income countries continue to lead in COVID-19 case counts at the time of this writing, LMICs may still be waiting to experience their own surge in cases and have already felt the profound ripple effects of the An appeal for practical social justice in the COVID-19 global response in low-income and middle-income countries Endemic cardiovascular diseases of the poorest billion The impact of COVID-19 and strategies for mitigation and suppression in low-and middle-income countries Adult congenital heart disease and the COVID-19 pandemic Noncommunicable diseases and HIV care and treatment: models of integrated service delivery global pandemic. As COVID-19 continues to circulate for many months to come, the global CVD community must be vocal about increasing investments in health care structures that care for the most vulnerable patients. With global support, pandemic response efforts in LMICs such as facilitating access to health care and creating social protection mechanisms can bolster health systems for the poorest billion populations for years to come. None.