World Health Day: Cardiovascular Health For All

Health is a basic human right. In its constitution, the World Health Organization (WHO) states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being” (1). The 1948 United Nations Universal Declaration of Human Rights explicitly recognized health as an element of the right to an adequate standard of living (2). The WHO organizes World Health Day every year as a global health awareness day on April 7, the day on which, in 1948, the WHO was founded. 

In 2023, the WHO is celebrating its seventy-fifth anniversary, making World Health Day more important than ever before. This year’s theme is “Health For All,” aligned with the political, socioeconomic, and biomedical advances in recent decades that have built the foundation for ever-increasing life expectancies, but also in response to perpetual structures that have created, maintained, or even exacerbated disparities within and between countries.

Health, Social Determinants of Health, and Cardiovascular Health

The WHO defines health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity” (1). In its Constitution, the WHO further states that “the enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition.” 

However, the reality is soberingly different: while life expectancies have increased across the globe, people in low-income countries have life expectancies of at least ten years lower than those living in high-income countries (3). Stratifying populations between and within countries shows that discrepancies are even worse: there is a spread of nearly fifty years in life expectancies between countries and twenty years within countries (4). Today, two billion people still lack access to safely managed drinking water services, 99 percent of the world's population lives in areas with unhealthy concentrations of fine particulate matter and nitrogen dioxide, and one in eight people spend over 10 percent of their household budgets on out-of-pocket health spending (3). 

The COVID-19 pandemic further illustrated the grave global inequities in health, ranging from inequitable vaccine distributions to personal protective equipment and testing availability, intensive care capacity, and socioeconomic safety nets (5–7). All of these inequities have been driven by social and political determinants of health (4,8). Social determinants are “the conditions in which people are born, grow, work, live, and age, and the wider set of forces and systems shaping the conditions of daily life” (9). Dissecting these conditions, which extend beyond the operating rooms and hospitals and into the communities, is necessary to truly understand patients’ health, risks, and outcomes.

Cardiovascular health is indeed no less affected by social determinants of health and perhaps one of the most vulnerable conditions thereof. Cardiovascular diseases intersect with fifteen of the seventeen United Nations Sustainable Development Goals, illustrating the mutual relationship between cardiovascular health and human development, inclusive of health systems and our environments (10). This relationship is reflected in individual- and community-level social determinants of health, which are associated with differential cardiovascular disease burdens and outcomes (11). Cardiovascular diseases present the leading cause of morbidity and mortality worldwide, causing approximately 18 million deaths each year, of which 80 percent take place in low- and middle-income countries (12). Addressing this large and growing burden will require more than advances in medical and surgical treatments and technologies.

Cardiovascular Care Disparities

Despite the developments observed in cardiovascular medicine and surgery in recent decades, numerous disparities prevail. Globally, six billion people lack access to safe, timely, and affordable cardiac surgical care when needed (13). High-income countries have 7.15 cardiac surgeons per million population, whereas low-income countries have only 0.04 per million population; worse, over 100 countries and territories do not have a single local cardiac surgeon (14,13). Gaps in access are also not homogenous and affect different populations in different ways. 

Women more commonly present later, suffer from greater acuity, and experience operative mortality and adverse outcomes for cardiac surgery compared to men (15–17). Similarly, nonwhite patients have regularly been established to have higher peri- and post-operative risks when undergoing cardiac surgery compared to white patients as a result of a multitude of factors, including preventable and addressable systemic factors (18,19). Women and individuals from minority populations remain underrepresented in cardiac surgical trials, resulting in skewed and nonrepresentative evidence generation in cardiac surgery (20). 

Moreover, Indigenous Peoples make up approximately 6 percent of the world’s population, yet access to and outcomes after cardiac surgery are often poorer compared to non-Indigenous individuals (21–23). Meanwhile, socioeconomic status, whether in terms of income level, educational attainment, employment status, or neighborhood socioeconomic factors, has been consistently established as a determinant of cardiovascular disease burdens and surgical outcomes (24,25). Lastly, every patient has a unique and complex combination of intersecting identities; however, intersectionality research and approaches remain largely absent in cardiac surgical research and clinical care delivery (26,27). 

Cardiovascular Health For All?

Although the disparities in cardiovascular health and access to cardiovascular care are vast, multidisciplinary and concurrent efforts are ongoing to improve healthcare delivery.

Academic efforts such as those led by the Lancet Commission on Global Surgery, the Lancet Women and Cardiovascular Disease Commission, and the Lancet NCDI Poverty Commission, among others, have been pivotal in uniting multidisciplinary experts and developing a comprehensive overview of access to surgical care, cardiovascular care for women, and noncommunicable disease care for the world’s poorest billion (28–30). Similarly, the field of global cardiac surgery, although still nascent, is rapidly growing in terms of academic output, conference discourse, and trainee engagement across the globe (31, 32). Further efforts to support and ethically grow health services and global health research, knowledge translation, and community engagement are necessary for sustainable change in cardiovascular research.

Societal efforts have complemented these academic developments. The major cardiac surgical societies increasingly support trainees and surgeons by providing opportunities for education (e.g., fixing the leaky pipeline and training surgeons from lower-resource settings), research (e.g., research on cardiac surgery in underserved populations), and policy (e.g., advocacy and leadership training) (33,34). These efforts are laudable and should be supported by societies and the cardiothoracic surgical community to ensure their sustainability and continued growth.

Policy efforts can address disparities from a systemic level by prioritizing the training of a specialized workforce, providing coverage for healthcare services, expanding infrastructural capacity, and targeting gaps in the prevention or care of cardiovascular diseases. Although cardiac surgery has not adequately been reflected in international health policy, national health plans, or the policy prioritization process at large, recent developments are encouraging (35–37). In 2018, the WHO and Ministries of Health adopted a World Health Assembly resolution on rheumatic fever and rheumatic heart disease (RHD), serving as a strong political statement to address the neglected burden of RHD (38). Such a statement reframes the discourse surrounding RHD, which affects over 30 million people globally, from a neglected condition to a highly pressing global health challenge (39–41). Further, since 2011, the United Nations General Assembly has held three high-level meetings on the prevention and control of noncommunicable diseases with a fourth one planned for the 2025 General Assembly (42). These meetings serve as critical political events during which nation leaders commit to acting upon noncommunicable disease policies and actions in their respective countries. This is essential considering the stagnation of the implementation of noncommunicable disease policies (43).

Lastly, from a surgical perspective, more and more countries are committing to, developing, and launching national surgical, obstetric, and anesthesia plans, which are strategic policy plans embedded within countries’ national health plans serving to strengthen surgical health systems (44). Moving forward, the integration of cardiovascular services within these plans will be pivotal to meet the vast global unmet need and concurrently strengthen systems through spillover effects that result from cardiovascular care capacity (36, 45).
 
Every child born deserves to live life to their fullest potential, and people’s access to life-saving or life-changing cardiovascular care should not be determined by where they are born, who they identify as or with, or the resources they have. World Health Day is a first and important reminder that our work—as clinicians, researchers, health advocates, families of patients, and even patients ourselves—serves the ultimate purpose of improving the cardiovascular health of the communities in which we work. Efforts should extend far beyond a single awareness day to ensure that no patient is left behind and we can truly commit to cardiovascular health for all.

References

1. World Health Organization. Constitution of the World Health Organization. Published 2023. Accessed March 23, 2023. https://www.who.int/about/governance/constitution
2. United Nations. Universal Declaration of Human Rights | United Nations. Accessed April 2, 2023. https://www.un.org/en/about-us/universal-declaration-of-human-rights
3. World Health Organization. World Health Statistics 2022. World Health Organization; 2022. Accessed April 4, 2023. https://www.who.int/publications/i/item/9789240051157
4. Marmot M. Social determinants of health inequalities. Lancet. 2005;365(9464):1099-1104.
5. Ma X, Vervoort D, Reddy CL, Park KB, Makasa E. Emergency and essential surgical healthcare services during COVID-19 in low- and middle-income countries: A perspective. Int J Surg. 2020;79:43-46.
6. Vervoort D, Ma X, Luc JGY. COVID-19 Pandemic: A Time for Collaboration and A Unified Global Health Front. Int J Qual Health Care. Published online June 27, 2020. doi:10.1093/intqhc/mzaa065
7. Ma X, Vervoort D. Critical care capacity during the COVID-19 pandemic: Global availability of intensive care beds. J Crit Care. 2020;58:96-97.
8. Kickbusch I. The political determinants of health--10 years on. BMJ. 2015;350:h81.
9. World Health Organization. Social Determinants of Health. Published 2023. Accessed April 4, 2023. https://www.who.int/health-topics/social-determinants-of-health
10. Ghandour H, Vervoort D, Ravishankar R, Swain JBD. Cardiac surgery and the sustainable development goals: a review. The Cardiothoracic Surgeon. 2022;30(1):14.
11. Powell-Wiley TM, Baumer Y, Baah FO, et al. Social Determinants of Cardiovascular Disease. Circ Res. 2022;130(5):782-799.
12. Roth Gregory A., Mensah George A., Johnson Catherine O., et al. Global Burden of Cardiovascular Diseases and Risk Factors, 1990–2019. J Am Coll Cardiol. 2020;76(25):2982-3021.
13. Vervoort Dominique, Lee Grace, Lin Yihan, Contreras Reyes Juan Roberto, Kanyepi Kudzai, Tapaua Noah. 6 Billion People Have No Access to Safe, Timely, and Affordable Cardiac Surgical Care. JACC: Advances. 2022;1(3):1-5.
14. 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.
15. Cho L, Kibbe MR, Bakaeen F, et al. Cardiac Surgery in Women in the Current Era: What Are the Gaps in Care? Circulation. 2021;144(14):1172-1185.
16. Gaudino M, Chadow D, Rahouma M, et al. Operative Outcomes of Women Undergoing Coronary Artery Bypass Surgery in the US, 2011 to 2020. JAMA Surg. Published online March 1, 2023. doi:10.1001/jamasurg.2022.8156
17. Chung J, Coutinho T, Chu MWA, Ouzounian M. Sex differences in thoracic aortic disease: A review of the literature and a call to action. J Thorac Cardiovasc Surg. 2020;160(3):656-660.
18. Khera R, Vaughan-Sarrazin M, Rosenthal GE, Girotra S. Racial disparities in outcomes after cardiac surgery: the role of hospital quality. Curr Cardiol Rep. 2015;17(5):29.
19. Rangrass G, Ghaferi AA, Dimick JB. Explaining racial disparities in outcomes after cardiac surgery: the role of hospital quality. JAMA Surg. 2014;149(3):223-227.
20. Preventza O, Critsinelis A, Simpson K, et al. Sex, Racial, and Ethnic Disparities in U.S. Cardiovascular Trials in More Than 230,000 Patients. Ann Thorac Surg. 2021;112(3):726-735.
21. United Nations. Indigenous peoples. Published 2023. Accessed March 29, 2023. https://www.un.org/en/fight-racism/vulnerable-groups/indigenous-peoples
22. Vervoort D, Kimmaliardjuk DM, Ross HJ, Fremes SE, Ouzounian M, Mashford-Pringle A. Access to Cardiovascular Care for Indigenous Peoples in Canada: A Rapid Review. CJC Open. 2022;0(0). doi:10.1016/j.cjco.2022.05.010
23. McVicar JA, Poon A, Caron NR, et al. Postoperative outcomes for Indigenous Peoples in Canada: a systematic review. CMAJ. 2021;193(20):E713-E722.
24. Koch CG, Li L, Shishehbor M, et al. Socioeconomic status and comorbidity as predictors of preoperative quality of life in cardiac surgery. J Thorac Cardiovasc Surg. 2008;136(3):665-672, 672.e1.
25. Schultz WM, Kelli HM, Lisko JC, et al. Socioeconomic Status and Cardiovascular Outcomes. Circulation. 2018;137(20):2166-2178.
26. Chen JC, Obeng-Gyasi S. Intersectionality and the Surgical Patient: Expanding the Surgical Disparities Framework. Ann Surg. 2022;275(1):e3-e5.
27. Patterson KN, Cochran A. Recognizing Intersectionality-The Association of Gender, Gender Identity, Sexual Orientation, and Race With Social Experience. JAMA Surg. 2021;156(10):953.
28. Meara JG, Leather AJM, Hagander L, et al. Global Surgery 2030: evidence and solutions for achieving health, welfare, and economic development. Lancet. 2015;386(9993):569-624.
29. Vogel B, Acevedo M, Appelman Y, et al. The Lancet women and cardiovascular disease Commission: reducing the global burden by 2030. Lancet. 2021;397(10292):2385-2438.
30. Bukhman G, Mocumbi AO, Atun R, et al. The Lancet NCDI Poverty Commission: bridging a gap in universal health coverage for the poorest billion. Lancet. 2020;396(10256):991-1044.
31. Vervoort D. Global cardiac surgery: a wake-up call. Eur J Cardiothorac Surg. 2019;55(5):1022-1023.
32. Vervoort D. Global Cardiac Surgery and the COVID-19 Pandemic: Bouncing Back, Higher Than Before? CTSNet; 2020. doi:10.25373/CTSNET.12702329
33. Wilder FG, Lawton JS. Commentary: Wanted: A reliable, unhindered, and more robust cardiac surgery pipeline. J Thorac Cardiovasc Surg. 2022;163(2):e209-e210.
34. Wang TY. Mentorship and the Leaky Pipeline in Academic Cardiology. Circ Cardiovasc Qual Outcomes. 2022;15(7):e009218.
35. 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.
36. 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
37. Shawar YR, Shiffman J. Generating Global Priority for Addressing Rheumatic Heart Disease: A Qualitative Policy Analysis. J Am Heart Assoc. 2020;9(8):e014800.
38. Vervoort D. Rheumatic Heart Disease: Important steps to tackle a misunderstood disease. CTSNet. Published online February 23, 2023. doi:10.25373/CTSNET.22151729.V1
39. 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.
40. Macleod CK, Bright P, Steer AC, Kim J, Mabey D, Parks T. Neglecting the neglected: the objective evidence of underfunding in rheumatic heart disease. Trans R Soc Trop Med Hyg. 2019;113(5):287-290.
41. Vervoort D, Antunes MJ, Pezzella AT. Rheumatic heart disease: The role of global cardiac surgery. J Card Surg. Published online May 3, 2021. doi:10.1111/jocs.15597
42. Preparatory process leading to the fourth High-level meeting of the General Assembly on the Prevention and Control of Noncommunicable Diseases in 2025. Accessed April 4, 2023. https://www.who.int/news-room/feature-stories/detail/preparatory-process-leading-to-the-fourth-high-level-meeting-of-the-general-assembly-on-theprevention-and-control-of-noncommunicable-diseases-in-2025
43. Allen LN, Wigley S, Holmer H, Barlow P. Non-communicable disease policy implementation from 2014 to 2021: a repeated cross-sectional analysis of global policy data for 194 countries. Lancet Glob Health. 2023;11(4):e525-e533.
44. Albutt K, Sonderman K, Citron I, et al. Healthcare Leaders Develop Strategies for Expanding National Surgical, Obstetric, and Anaesthesia Plans in WHO AFRO and EMRO Regions. World J Surg. 2019;43(2):360-367.
45. Vervoort D, Edwin F. Treating Pediatric and Congenital Heart Disease Abroad? Imperatives for Local Health System Development. International Journal of Cardiology Congenital Heart Disease. Published online January 22, 2021:100082.

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