Cardiac Surgery in Haiti: High Need, Low Support

Haiti is home to over 11 million people and is facing a growing burden of cardiovascular disease (CVD). Currently, about 29 percent of all deaths in Haiti are from CVD, which can often be treated with surgical intervention (10). Despite this, there is no local cardiac surgical capacity to manage patients in need of cardiac surgical care.

Globally, more than 100 countries and territories do not have a single cardiac surgeon, and six billion people lack access to safe, timely, and affordable cardiac surgical care when needed. The situation in Haiti is particularly challenging because the nation has the lowest health index among countries in the Western Hemisphere.

A better understanding of access to care and the need for cardiac surgical care is crucial to enabling more streamlined advocacy and encouraging policymakers in Haiti, as well as national and international non-governmental organizations (NGOs), to accelerate efforts to build capacity for local cardiac surgical care delivery.

What follows is an historical overview of cardiac surgery in Haiti through visiting teams and partnerships and a look ahead at opportunities for Haiti to introduce local cardiovascular services in the near future.

Disparities in Cardiovascular Health 

Cardiovascular diseases (CVD) are the leading cause of death worldwide (1–3). They are responsible for about 17.5 million deaths every year (1), of which 80 percent happen in low- and middle-income countries (LMICs) (4). Nevertheless, 93 percent of people in LMICs lack access to cardiac surgical care (1,5), driven in part by regional cardiac surgery workforce disparities. LMICs possess about 0.04 adult cardiac surgeons per million population, compared to 7.15 adult cardiac surgeons per million population in high-income countries (HIC); the same trend exists for pediatric cardiac surgeons (1). 

With the epidemiologic transition away from communicable and toward noncommunicable disease, global cardiovascular mortality is currently more than five times higher than the mortality of HIV/AIDS, malaria, and tuberculosis combined (6). Furthermore, congenital heart defects (CHDs) are the most common major birth defect and present with some of the highest associated mortality rates (7). The world prevalence and incidence of CHD are 1.8 per 100 live births and 19 to 75 per 1,000 lives, respectively (7,8). Approximately 260,000 people die per year from CHD, of whom two-thirds are children younger than one year old (7–9). Despite these facts, in LMICs, 90 percent of patients with CHD do not receive the care they need (9).

In Haiti, CVD now constitutes the leading cause of death and loss of disability-adjusted life-years among adults in the country (10), and the burden continues to grow (11). The Global Burden of Disease study estimated that CVD was responsible for about one-third of deaths across all ages in Haiti in 2016, and the prevalence of RHD is as high as 5 percent in rural settings (10, 15). Moreover, thousands of Haitian children die from heart disease, and about 2,000 are born with some CHD each year, of whom approximately 50 percent will eventually require surgery or interventional care (16). Thus, because of a lack of pediatric cardiac care, hundreds of Haitian children die of curable heart conditions each year.

It is worth noting, like many LMICs, the true incidence of CVD in Haiti remains unknown largely because of a lack of screening, reporting, and data systems. And though cardiac surgery is, for the most part, a life-saving intervention, very few Haitian institutions or organizations are involved in supporting local access to cardiac surgery. This is largely because the infrastructure, workforce, and financial coverage that are required are currently unavailable there (11). 

Brief Overview of Haiti

Haiti is a Caribbean country of 10,641 square miles and a population of about 11.6 million people (12). It is the poorest country in the Western Hemisphere, with a 2020 gross domestic product (GDP) per capita of $2,925 USD, which is also the lowest in the Latin American and the Caribbean (LAC) region and less than a fifth of the LAC average of $15,092 (11,13). 

Haiti also has the lowest health index (13). The life expectancy of women at birth is 67.2 years and that of men is 62.8 years (12). In comparison, the United States has a life expectancy for women of 79.1 years and 73.2 for men. The infant and maternal mortality in Haiti remain at high levels, and the coverage of prevention measures is currently stagnating or declining (11–13). For example, in 2020, the infant and under-five mortality rate were 48.0 per 1,000 live births and 71.6 per 1,000 live births, respectively (12).

Because of limited public resources and local health infrastructure, more than 70 percent of the health care delivery in the country is provided by NGOs (11). 

In addition, sociopolitical instability and insecurity remain present. In the past two years, more than twenty health care workers, especially physicians, have been kidnapped or killed in Haiti (14). Moreover, the country is extremely vulnerable to natural disasters, to which 90 percent of the population are exposed (13).

Governance, Financing, and Information Management

In Haiti, there are no national or government sponsored cardiac surgery programs. All the progress in this area so far been made through NGOs (11). The few cardiac interventions that have been held in Haiti were fully funded by the NGOs and supported by private and institutional philanthropic funding (16,22). According to Dr. Samantha Lacossade, lead clinical coordinator at the Haiti Cardiac Alliance, each intervention within the country costs about $2,800 USD. Although this number is among the lowest reported in the world—with cardiac surgery costs ten to one hundred times more expensive in European countries and the United States—the far lower per capita income makes this amount inaccessible for nearly the entire population.

To date, there is no evidence of a governmental, national cardiac surgery database, although some institutions and organizations manage their own databases. A database may make it possible to better understand the impact of CVD in the country and is necessary to clearly identify gaps and needs, and to better advocate for Haitians requiring cardiac surgical care. This issue is the result of the lack of information management infrastructures, qualified workforce to enter and manage the data, budget shortages, and a lack of validation mechanisms (5). As a result, only the hospital or the organization in charge has the patient's medical file. Similarly, research remains very scarce in this field.

History of Cardiac Surgery in Haiti

Throughout the years, cardiothoracic surgery programs in Haiti have always been chaperoned by international organizations to address the country’s challenges with CVD.

In November 1996, the Open Hearts Haiti program was initiated at Hopital Sacre Coeur by Dr. A. Thomas Pezzella and Dr. Ted Dubuque (11, 17). By the second half of 1997, visiting teams equipped the hospital with an operating room and an intensive care unit that was fit for standard open-heart surgery (11). In November 1997, the first two successful open-heart surgery procedures in Haiti were performed—a ventricular septal defect repair in a seven-year-old girl and a mitral valve repair on an eighteen-year-old boy—by a team of six specialists from the University of Massachusetts Medical Center and St. Vincent Hospital. Afterward, the teams made several one-to-two-week trips, through which many patients were screened; some were sent to the Mayo Clinic to have their operations, while about thirty-one received cardiac surgery in Haiti (11). Unfortunately, because of security concerns and political instability, the program was suspended in 2006 and only briefly restarted in 2011, during which only one trip was performed (11).

From 2011 to 2013, Chen Lespwa Ayiti—in partnership with Chaine de l’Espoir (France), Gift of Life International, and Rotary International—performed eleven cardiac surgery visits. During these trips, teams of ten to fifteen people each from France, the United States, and local Haitian health workers came to the Lambert Clinic in Pétion Ville, where they performed about 130 heart surgery interventions over two years (18).

Haiti Cardiac Alliance (HCA) was founded in July 2013 as a United States-based nonprofit organization that works to address the need of life-saving cardiac surgery in Haiti (19–21). From 2013 to 2018, HCA worked with multiple partner organizations to facilitate life-saving cardiac surgery for almost four hundred children and young adults. Approximately one-third of these surgeries took place in Haiti itself, while the remainder took place overseas (22). All in-country surgeries took place through an initiative that began in March 2015 and was led by Gift of Life International (GOLI) in collaboration with Rotary International, Akron Children’s Hospital, St. Damien Children’s Hospital, and other organizations (16). 

In 2018, HCA facilitated heart surgery for seventy-four patients, twenty-six of which were performed in Haiti itself and the remainder in other countries (21). In 2019—a very challenging year because of political instability—sixty-six patients underwent cardiac surgery, although only three of these surgeries were performed in the country (23). Despite tremendous efforts by several cardiac surgery organizations, eighty to one hundred operable patients die on HCA’s waiting list each year while waiting for a cardiac intervention.

Additionally, from 2013 to 2019, HCA has facilitated more than 450 cardiac surgeries both within and outside Haiti, averaging less than seventy for the whole country’s population per year, as well as more than 4,800 cardiac exams at St. Damien Hospital (19, 23, 26). After the cardiac interventions, the team members stay for several additional days to manage potential early complications. After patients are discharged, HCA works with Haitian providers to ensure proper follow-up: patients receive any necessary medications and are asked to visit for echocardiogram and evaluation at one month post-operatively, then three months, six months, one year, two years, and eventually five years, when feasible.

Because of the global travel restrictions brought on by the COVID-19 pandemic, and the following deterioration in security, Haiti has not received visiting teams for open-heart surgery since the pandemic began.

Infrastructure

Lack of infrastructure is a huge hurdle in increasing cardiovascular care in Haiti. Indeed, the country faces challenges in healthcare delivery throughout the system, including basic prevention and primary care services. Thus, it is even more difficult for the most specialized services, such as cardiac surgery, which requires state-of-the-art infrastructure and highly trained specialists to thrive. In 2018, among the fifty-three hospitals listed in Haiti, only fifteen had an intensive care unit (ICU), which contained a total of 124 ICU beds. In hospitals with no ICU, an average of fifty-three beds are available for critically ill patients. About sixty-eight patients can be ventilated within an ICU and six others in other areas of hospitals (25). There is currently no cardiac center that can fully perform cardiovascular interventions or a diagnostic or interventional cardiac catheterization laboratory (11,15). 

However, since 1997, some cardiac surgery interventions have been done within the country by international organizations at the Sacré Cœur Hospital, as teams bring with them the necessary equipment and supplies (11). The Lambert Clinic has hosted several cardiac surgery missions, but most interventions have been done at the St. Damien Pediatric since 2013 (16,18,19,26). In the long-term, the latter might be the first one to have the ability to take care of cardiac surgery patients within Haiti on a continuing basis. As Dr. Jacqueline Gautier, executive director of St. Damien Hospital, said about seven years ago: “We are very excited as we begin the first phase of a project to ensure lifesaving heart surgery to children in Haiti. We are committed to this initiative for the benefit of the children, bringing them hope” (16).

Surgical Workforce and Training

Despite the high burden of CVD in Haiti, no surgeons in Haiti practice cardiothoracic surgery, and there is a complete absence of cardiac and cardiothoracic training programs. Dr. Jude Milcé has been trained as a cardiovascular surgeon at the Geneva University Hospital, and Dr. Pierre Sonson Prince has been trained at the Hospital Veinte de Noviembre in Mexico and Hospital Royal Victoria in Canada, but neither perform cardiothoracic surgery in Haiti outside visiting teams. 

Haiti does have one general surgery training program. The University Hospital of Mirebalais (HUM) has received accreditation from the Accreditation Council for Graduate Medical Education International, and more recently, the International Cardiology Curriculum Accessible by Remote Distance Learning (ICARDs) was also implemented there (15). Built in 2013 by Partners in Health, HUM is one of the largest hospitals in the country, with more than 300 beds. Partners in Health is an NGO cofounded by the late Dr. Paul Farmer, who dedicated himself for more than thirty years to bringing safe and affordable health care to people in need in Haiti (27,28).

Moving Forward

To meet Haiti’s growing cardiovascular disease burden and catalyze a sustainable response to this situation, the Haitian healthcare system needs to step up and understand that CVD burden is real, and that immediate attention is required (10). Necessary actions include expanding Haiti’s upcoming National Surgical, Obstetrics, and Anesthesia Plan (NSOAP) with a cardiac surgery component, investing in cardiac centers—as multiple studies show that cardiac surgery is a cost-effective intervention—and facilitating training of Haitian surgeons to become cardiothoracic surgeons abroad and then reintegrating them in the health system, and later developing a local cardiac surgery training program (5,30,31,32). 

Because of COVID-19 travel restrictions and security issues, two years have passed without any cardiac surgery teams visiting the country, which means two years of lost opportunity to save people with heart conditions from preventable death, except for the few who are lucky enough to travel abroad. 
For about twenty-five years, cardiac surgery in Haiti has been performed by NGOs, which are doing the best they can to bridge part of Haiti’s cardiac surgery gaps. Through their visits, they screen patients, perform operations, and share skills with the local health care professionals. However, more is needed. 

One short-term solution before local cardiac surgery training programs or hiring of cardiac surgeons can be implemented would be to support young doctors and surgeons to enter training abroad. In addition, investment of more time and resources into research is critical to more accurately measure and understand the situation that Haiti is facing, which will help drive policymakers’ actions in the right direction.

Conclusion

Although the lack of cardiac surgery is a major healthcare and quality of life issue in the country, Haiti is far from ready to meet the large—and still-growing—burden of cardiovascular surgical disease. Lack of cardiac surgery teams, institutions, and infrastructure to sustainably perform such interventions locally are key drivers of this difficult truth. 

To make progress toward universal health coverage, Haiti must make cardiac surgery one of its priorities (33,34). Cardiac surgery should not be a luxury of the few who have enough money to travel abroad or those who lucky enough to be part of the seventy cases operated per year by NGOs. 

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