Global Cardiac Surgery: The Tipping Point for Universal Cardiovascular Health Equity?

Background

Six billion people lack access to safe, timely, and affordable cardiac surgical care (1). More than thirty million people live with rheumatic heart disease (RHD) worldwide (2). Congenital heart defects (CHD) affect more than one million births each year yet remain untreated in more than 90 percent of cases in low- and middle-income countries (LMICs) (3, 4). Ischemic heart disease burdens are rapidly rising in LMICs, affecting younger populations to a larger degree compared with high-income countries (5). Neglected cardiovascular diseases such as endomyocardial fibrosis and Chagas cardiomyopathy further affect the world’s poorest billion individuals, with little research and political attention being paid to such diseases (6).

Furthermore, the COVID-19 pandemic has shed further light on global health inequities. LMICs have trailed high-income countries in obtaining COVID-19 vaccines, with low-income countries’ vaccination rates continuing in the single digits nearly two years after the first vaccines were distributed. These inequities reflect the limited political prioritization toward health systems issues, including COVID-19 and the care for chronic conditions such as cardiovascular diseases and surgical conditions (7, 8, 9).

Despite these gaps and persistent disparities, recent developments have enabled a growing momentum for the field of global cardiac surgery. This articledescribes recent developments in the field of global cardiac surgery, with a particular emphasis on academic, societal, and political momentum. Additionally, the article presents an overview of the global surgery and cardiovascular health discourse that took place at the 75th World Health Assembly and looks ahead toward future opportunities to move the needle toward universal access to cardiovascular healthcare.

Societal Efforts

In 2018, the Cardiac Surgery Intersociety Alliance (CSIA) was established as a collaborative effort among most regional professional cardiac surgical societies, including the American Association for Thoracic Surgery (AATS), Asian Society for Cardiovascular & Thoracic Surgery (ASCVTS), European Association for Cardio-Thoracic Surgery (EACTS), Society of Thoracic Surgeons (STS), and the World Heart Federation (10). The CSIA has selected two low volume cardiac surgery centers in LMICs, the Maputo Heart Center in Mozambique and the King Faisal Hospital in Rwanda, with the goal of supporting them to grow to medium- and—eventually—high-volume programs (11).

Before 2021, attention to global cardiac surgery at societal meetings was limited. Beyond the 99th Annual Meeting of the AATS in 2019, where a dedicated session and plenary talk took place, the discourse surrounding cardiac surgery in variable-resource contexts was limited to local meetings or singular abstract presentations in non-global health sessions. Between October 2021 and May 2022, the African Association of Thoracic and Cardio-Vascular Surgeons (AATCVS), AATS, Canadian Cardiovascular Society (CCS), EACTS, and STS have hosted dedicated global cardiac surgery sessions at their respective annual meetings.

Furthermore, the Cardiothoracic Surgery Network (CTSNet) recently launched the “CTSNet Global” portal with great visibility on their website (12). The portal provides a platform for individuals to share their insights and experiences on an open-access platform without being exposed to traditional publishing barriers (13).

Recent “Wins”

In addition to the societies’ growing leadership in the global cardiac surgery discourse, several major developments have occurred in recent years.

The Global Cardiac Surgery Initiative (GCSI) was founded in 2018 as a platform for advocacy and open-access resource-sharing pertaining to global cardiac surgery. Since 2020, the GCSI has expanded to become an active social network of trainees interested in or training within cardiac surgery, with most members in and/or from LMICs. Today, the GCSI works on engaging individuals from across the globe through advocacy, education, and research efforts. This is done with the goal of fostering the next generation of global cardiac surgeons.

In November 2021, the National Institutes of Health’s ‘National Heart, Lung, and Blood Institute’ (NHLBI) hosted a three-day workshop on rheumatic heart disease (RHD) to identify research gaps and opportunities pertaining to RHD. Topics discussed ranged from primordial prevention to tertiary care, ultimately recognizing the important need for cardiac surgical care in managing the global burden of RHD. Recent research has shown that the socioeconomic benefit of scaling access to tertiary care for RHD is enormous. For example, the African Union would receive a net benefit of approximately US$2.6 billion upon scaling secondary and tertiary care for RHD (14, 15).

Lastly, the Thoracic Surgery Foundation (TSF), a philanthropic effort largely supported by the STS, has increasingly supported global cardiac surgery efforts. Through the Every Heartbeat Matters Award, in collaboration with Edwards Lifesciences, the TSF has supported multiple initiatives to care for and train healthcare professionals to manage valvular heart disease in variable-resource contexts. Furthermore, the foundation provides multiple travel scholarships for trainees and surgeons to attend cardiothoracic surgery meetings and pursue mini- or full fellowships in centers abroad.

75th World Health Assembly

In May 2022, the 75th World Health Assembly (WHA) took place in Geneva, Switzerland, representing a time where Ministries of Health, intergovernmental and nongovernmental organizations, and other notable global health-related organizations convened to discuss and define health priorities. Global cardiac surgery, however, was notably absent from the agenda (16). This reflects the ongoing sentiment that cardiac surgery is too isolated, specialized, and unscalable to have a role in current global health endeavors. These myths have held back the field as part of broader global surgery and global health efforts (17). These ongoing misconceptions are driven by fragmentation of the global surgical and cardiovascular community, disagreement on best methods of approach, no unifying leadership, few comprehensive advocacy efforts, and limited constructive political engagement (7, 8). In 2018, the “Rheumatic fever and rheumatic heart disease” Resolution was passed at WHA71, indicating some global prioritization of the prevention, control, and treatment of RHD (18). However, like the discussion surrounding global cardiac surgery at WHA75, emphasis was given to prevention and improvement in underlying socioeconomic factors instead of broader tertiary care capacity, including cardiac surgical and interventional cardiology care.

Despite the lack of inclusion of global surgery in the main agenda, numerous global surgical societies hosted widely popular side events. The Global Alliance for Surgical, Obstetrics, Trauma & Anesthesia Care (G4 Alliance) (19), Global Surgery Foundation (20), World Federation of Societies of Anesthesiologists (WFSA) (21), and International Federation for Spina Bifida and Hydrocephalus (IFSBH) (22), and other organizations captured attention for global surgical care and provided for a discourse. Although perhaps not explicitly mentioned in surgical side events, global cardiac surgery is now uniquely positioned for incorporation into the surgical systems strengthening agenda as the global neurosurgery community becomes integral to the global surgical framework shortly after the passage of the Resolution WHA68.15. The resolution recognized the role of surgical and anesthesia care as part of universal health coverage in 2015 (23, 24).

The World Heart Federation’s 2022 World Heart Summit also took place in Geneva, just days before WHA75. Themes of partnership, equity, and universal cardiovascular care were emphasized throughout the event. The event hosted sessions covering topics such as trends in global heart health, upscaling systems during and post-COVID-19, and the role of governments in promoting universal cardiac health—among other themes (25). The World Heart Federation and Permanent Mission of Brazil also hosted the WHA side event, “Time to End RHD: From Promises to Action.” The event gave voice to the challenges patients and Ministries of Health confront in resource-limited settings (26). The speakers also highlighted experiences in implementing the 2018 RHD Resolution and financing in global cardiac surgery.

Future Opportunities

Contrary to historical perceptions, cardiac surgery in variable-resource contexts has been effectively introduced and scaled, is favorably cost-effective, can be implemented at low costs and high volumes, and can be performed with excellent surgical outcomes (17,27,28). Thus, an opportunity exists to incorporate cardiovascular care within existing universal health coverage commitments, national health plans, and National Surgical, Obstetrics, and Anesthesia Plans (NSOAPs) (29).

As similarly emphasized during many WHA side events for global surgery at large, partnerships are key in advancing global cardiac surgery. The list of organizations allied with the G4 Alliance—a common advocacy platform for global surgical organizations and stakeholders—is steadily growing. The list of member organizations encompasses surgery, trauma, obstetrics and gynecology, neurosurgery, pediatric surgery, plastic surgery, and other surgical disciplines. However, cardiac surgical organizations have yet to join the Alliance (30). The Global Surgery Foundation provides a platform through which multiple stakeholders can collaborate to strengthen surgical systems and engage in collaborative research (31). Such organizations include Ministries of Health and other governmental stakeholders, organizations and academic institutions worldwide, industry partners, and patient-family groups. These organizations are united to further surgery as a key component of universal health coverage (20). Collaboration with said organizations would enable advocacy for patients who lack cardiac surgical care and promote the inclusion of global cardiac surgery as a critical component of all surgical systems.

Lastly, the pandemic has shed light on global inequities in access to essential health services, including diagnostics and preventive measures (9, 32). The pandemic has illustrated the need for health systems to strengthen in response to future healthcare crises, which include the continued and new infectious disease outbreaks, economic crises, natural disasters and climate change, war, conflict, and more external influences. This will require sufficient consideration of the role of cardiovascular diseases and their care, considering their large burden worldwide and close link to healthcare crises (33–35). Today’s awareness of global health disparities, in terms of access to cardiac surgical care and its cross-cutting role in achieving the United Nations Sustainable Development Goals (36), ought to serve as a moral imperative to work toward global cardiovascular health equity.

Potential Hurdles

The political commitment to cardiac surgery and cardiovascular health remains limited at the national and international levels (29, 37). For example, only one (Zambia) of seven NSOAPs launched by LMICs has mentioned and addressed the need to expand cardiac surgical care (29). To change this, cardiac surgeons need to grab a seat at the table and become more familiar and comfortable with advocacy, policy, and politics (38, 39). Political prioritization is essential to move the needle in health systems strengthening. Yet inconsistencies in the messaging and lack of multidisciplinary collaboration among the global surgical and cardiovascular community result in lesser prioritization of these issues among policymakers, decisionmakers, and funders (7, 8). This is the case for issues like cardiac surgery; as over 100 countries and territories worldwide lack cardiac surgeons altogether, cardiac surgery may be left behind in national health plans and NSOAPs (40).

Societal efforts are commendable and should be both sustained and expanded. Simultaneously, however, a conscientious effort must be made to avoid neocolonial practices (41). Global surgery and global health have been dominated by high-income country actors (42). Global cardiac surgery, which was historically built on fly-in-fly-out mission trips (43), is at high risk of the same. Inclusion of voices from and in LMICs is critical in the global cardiac surgery discourse, such as sessions held at societal meetings and in global cardiac surgical research. Similarly, bilateral partnerships between institutions must move toward meeting local needs and pursuing local sustainability of cardiac surgical programs. Lastly, barriers to research regarding research training, mentorship, capacity, and finances must be minimized (13, 44).

Conclusion

While the gaps in access to cardiac surgical care across the globe remain enormous, the growing momentum of the field of global cardiac surgery enables cautious optimism for the future. Societal efforts, increasing funding opportunities, and virtual meetings have enabled greater international dialogue within and beyond the cardiovascular community. Achievements by the global surgical and cardiovascular health communities at high-level meetings provide an entry-point for global cardiac surgery toward greater political prioritization that is more aligned with the global burden of cardiovascular surgical disease. Cardiac surgeons, other heart team members, and trainees are critical voices in accelerating momentum toward cardiovascular health equity for all. Together, we can move beyond the tipping point.

References

1. Vervoort D, Swain JD, Pezzella AT, Kpodonu J. Cardiac Surgery in Low- and Middle-Income Countries: A State-of-the-Art Review. Ann Thorac Surg. Published online August 6, 2020. doi:10.1016/j.athoracsur.2020.05.181
2. Watkins DA, Johnson CO, Colquhoun SM, et al. Global, Regional, and National Burden of Rheumatic Heart Disease, 1990-2015. N Engl J Med. 2017;377(8):713-722.
3. Zimmerman MS, Smith AGC, Sable CA, et al. Global, regional, and national burden of congenital heart disease, 1990-2017: a systematic analysis for the Global Burden of Disease Study 2017. The Lancet Child & Adolescent Health. 2020;4(3):185-200.
4. Zheleva B, Atwood JB. The invisible child: childhood heart disease in global health. Lancet. 2017;389(10064):16-18.
5. Roth GA, Johnson C, Abajobir A, et al. Global, Regional, and National Burden of Cardiovascular Diseases for 10 Causes, 1990 to 2015. J Am Coll Cardiol. 2017;70(1):1-25
6. Kwan GF, Mayosi BM, Mocumbi AO, et al. Endemic Cardiovascular Diseases of the Poorest Billion. Circulation. 2016;133(24):2561-2575.
7. Shawar YR, Shiffman J. Generating Global Priority for Addressing Rheumatic Heart Disease: A Qualitatie Policy Analysis. J Am Heart Assoc. 2020;9(8):e014800.
8. Shawar YR, Shiffman J, Spiegel DA. Generation of political priority for global surgery: a qualitative policy analysis. Lancet Glob Health. 2015;3(8):e487-e495.
9. Vervoort D, Ma X, Sunderji A, Bookholane H. The internaitonal treaty for pandemic preparedness and response: same story, different times? Future Virol. 2021;0(0). doi:10.2217/fvl-2021-0214
10. Zilla P, Bolman RM, Yacoub MH, et al. The Cape Town Declaration on access to cardiac surgery in the developing world. J Thorac Cardiovasc Surg. 2018;156(6):2206-2209
11. Enumah ZO, Bolman RM, Zilla P, et al. United in earnest: First pilot sites for increased surgical capacity for rheumatic heart disease announced by Cardiac Surgery Intersociety Alliance. J Thorac Cardiovasc Surg. 2021;161(6):2108-2113.
12. Farkas E, Kpodonu J, Vervoort D, Elbatarny M, Dunning J. CTSNet Global. CTSNet. Published online June 27, 2021. https://www.ctsnet.org/article/ctsnet-global
13. Vervoort D, Ma X, Bookholane H. Equitable Open Access Publishing: Changing the Financial Power Dynamics in Academia. Glob Health Sci Pract. 2021;9(4):733-736
14. Coates MM, Sliwa K, Watkins DA, et al. An investment case for the prevention and management of rheumatic heart disease in the African Union 2021–30: a modelling study. The Lancet Global Health. Published online May 10, 2021. doi:10.1016/S2214-109X(21)00199-6
15. Vervoort D, Genetu A, Kpodonu J. Policy prioritisation to address the global burden of rheumatic heart disease. The Lancet Global Health. 2021;9(9):e1212.
16. Vervoort D. Twitter. Published 2022. Accessed July 17, 2022. https://twitter.com/DVervoort94/status/1528325296163807233
17. Vervoort D. The Neglected Component of Cardiovascular Care: Dispelling the Myths. Glob Heart. 2019;14(3):281-283.
18. World Health Assembly. Rheumatic Fever and Rheumatic Heart Disease. World Health Organization; 2018.
19. The G4 Alliance. The Global Alliance for Surgical, Obstetrics, Trauma & Anaesthesia Care. Published 2022. Accessed July 17, 2022. https://www.theg4alliance.org/
20. Global Surgery Foundation. GSF 75th World Health Assembly Side Event. Published 2022. Accessed July 17, 2022. https://www.globalsurgeryfoundation.org/events/wha2022
21. World Federation of Societies of Anaesthesiologists. Safer C-sections-improving maternal health outcomes. Published June 21, 2022. Accessed July 17, 2022. https://wfsahq.org/news/latest-news/safer-c-sections-improve-maternal-health-outcomes/
22. International Federation for Spina Bifida and Hydrocephalus. WHA75 side-event "folic acid fortification to prevent spina bifida." Published May 25, 2022. Accessed July 17, 2022. https://www.ifglobal.org/news/what75-side-event-folic-acid-fortification-to-prevent-spina-bifida/
23. Vervoort D, Park KB, Swain JD. Global cardiac surgery: lessons learnt from the global neurosurgery movement. Heart Asia. 2019;11(1):e011125.
24. Park KB, Johnson WD, Dempsey RJ. Global Neurosurgery: The Unmet Need. World Neurosurg. 2016;88:32-35.
25. World Heart Federation. World Heart Summit. Published 2022. Accessed July 17, 2022. https://world-heart-federation.org/world-heart-summit-2022/#:~:text=The%207th%20edition%20of%20the,of%20Cardiovascular%20Health%20for%20Everyone
26. World Heart Federation. Time to End RHD: From Promises to Action. Published 2022. Accessed July 17, 2022. https://crm.world-heart-federation.org/civicrm/mailing/view?id=813&reset=1
27. Cardarelli M, Vaikunth S, Mills K, et al. Cost-effectiveness of Humanitarian Pediatric Cardiac Surgery Programs in Low- and Middle-Income COuntries. JAMA Netw Open. 2018;1(7):e184707.
28. Vervoort D, Vinck EE, Tiwari KK, Tapaua N. Cardiac Surgery and Small Island States: A Bridge Too Far? Ann Thorac Surg. Published online July 25, 2020. doi:10.1016/j.athoracsur.2020.05.150
29. Vervoort D. National Surgical, Obstetric, and Anesthesia Plans: Bridging the Cardiac Surgery Gap. Thorac Cardiovasc Surg. Published online March 1, 2020. doi:10.1055/s-0039-1700969
30. G4 Alliance Member Organizations. Accessed June 6, 2020. http://www.theg4alliance.org/about-g4-alliance-member-organizations
31. Global Surgery Foundation. Global Surgery Foundation. Published 2022. Accessed January 28, 2022. https://www.globalsurgeryfoundation.org/
32. Fleming KA, Horton S, WIlson ML, et al. The Lancet Commission on diagnostics: transforming access to diagnostics. Lancet. 2021;398(10315):1997-2050.
33. Chan VF, Vervoort D. The double-edged sword of cardiac surgical care: rethinking sustainability in an ever-growing field. Eur J Cardiothorac Surg. Published online January 22, 2022. doi:10.1093/ejcts/ezab531
34. Roa L, Velin L, Tudravu J, McClain CD, Bernstein A, Meara JG. Climate change: challenges and opportunities to scale up surgical obstetric, and anaesthesia care globally. Lancet Planet Health. 2020;4(11):e538-e543.
35. Jawad M, Vamos EP, Najim M, Roberts B, Millett C. Impact of armed conflict on cardiovascular disease risk: a systematic review. Heart. 2019;105(18):1388-1394.
36. Ghandour H, Vervoort D, Ravishankar R, Swain JBD. Cardiac surgery and the sustainable development goals: a review. The Cardiothoracic Surgeon. 2022;30(1):14.
37. Vervoort D, Parikh UM, Raj A, Swain JD. Global cardiovascular care: an overview of high-level political commitment. Asian Cardiovasc Thorac Ann. Published online May 27, 2020:218492320930844.
38. Vervoort D, Swain JD, Fiedler AG. A Seat at the Table: The Cardiothoracic Surgeon as Surgeon-Advocate. Ann Thorac Surg. 2021;111(3):741-744.
39. Nissen AP, Nguyen TC. Reply: Surgeons and health policy-Claiming our seat at the table. J Thorac Cardiovasc Surg. 2020;159(5):e320.
40. Vervoort D, Meuris B, Meyns B, Verbrugghe P. Global cardiac surgery: Access to cardiac surgical care around the world. J Thorac Cardiovasc Surg. 2020;159(3):987-996.e6.
41. Alayande B, Forbes C, Degu S, et al. Shifting global surgery's center of gravity. Surgery. Published online June 14, 2022. doi:10.1016/j.surg.2022.04.048
42. Abimbola S, Pai M. Will global health survive its decolonisation? Lancet. 2020;396(10263):1627-1628.
43. Vervoort D, Guetter CR, Munyaneza F, et al. Non-Governmental Organizations Delivering Global Cardiac Surgical Care: A Quantitative Impact Assessment. Semin Thorac Cardiovasc Surg. Published online August 15, 2021. doi:10.1053/j.semtcvs.2021.08.010
44. Vervoort D, Lee G, Lin Y, Reyes JRC, Kanyepi K, Tapaua N. Six Billion People Have No Access to Safe, Timely, and Affordable Cardiac Surgical Care. JACC: Advances. Published online 2022, In Press.

Disclaimer

The information and views presented on CTSNet.org represent the views of the authors and contributors of the material and not of CTSNet. Please review our full disclaimer page here.