The article in the current issue by Nwafor et alReference Nwafor, Lawn and John ¹ reports the outcomes of cardiac surgery procedures performed for adults with CHD in Nigeria over a period of 5.5 years. There were 18 cases reported, of which 14 underwent surgical repair. The most common pathology was atrial septal defect in five patients, followed by sinus of valsalva aneurysm and patent ductus arteriosus in three patients each. Two patients had tetralogy of Fallot, but were not able to undergo surgical repair because there were no resources available to perform right heart catheterisation. The immediate operative survival was 77.9%, and no follow-up data are provided.

Worldwide, CHD contributes significantly to infant morbidity and mortality, accounting for 7% of all neonatal deaths.Reference Lawn, Cousens and Zupan ² Cardiac surgery services are not available or inadequate in most developing countries, with estimates of only 2500–3000 children accessing heart surgery every year in Africa.Reference Hewitson and Zilla ³ The scarcity of cardiac centres with appropriate diagnostic and surgical capacity on the African continent, combined with widespread poverty, the absence of universal health coverage systems, a high birth rate, and a lack of awareness of the signs and symptoms of CHD, indicates that many children with CHD are never able to be diagnosed and treated. Given low literacy levels in those countries, CHD diagnosis is delayed even more because some children are taken to herbalists and other non-conventional caregivers before seeking conventional care, even if it was available.

Although Nigeria, the most populous nation on the African continent, is among the few countries to have cardiac surgery services since 1974,Reference Eze and Ezemba ⁴ it has no permanent and sustainable cardiac surgery programme for CHD. Some patients with CHD, however, manage to survive to adulthood, provided complications of the underlying lesion(s) do not supervene. These patients form the basis of this report.

The authors describe a situation that is all too common in the developing world. Competing healthcare priorities, primarily communicable diseases, consumes many of the limited resources available for healthcare. As life expectancies increase through improved control of communicable diseases, non-communicable diseases are emerging as major public health challenges. Among non-communicable diseases, cardiovascular diseases, mainly ischaemic heart disease, remain the number one killer worldwide with more than 80% of the estimated 17.3 million annual deaths happening in low- and middle-income countries. ^{5 , 6}

For the patients in the present report, all surgeries were carried out by humanitarian, visiting itinerant teams of surgeons and accompanying caregivers. The authors observe that some of these teams demonstrated a laudable focus on teaching and knowledge and skill transfer and improving the capabilities of the local team. Unfortunately, these teams were the ones who visited less frequently, with the result that the impact of their missions was limited. Other visiting teams, some of which visited more frequently, devoted less time and energy to skill transfer and to teaching the local team. Thus, the impact of these visits was strictly limited to the lives of the patients for whom they provided care. They had virtually no impact on care delivery once they had departed, and contributed in a minimal manner to improve healthcare in the country.

As the authors rightly point out, charitable, intermittent surgical missions cannot solve the problem of lack of access to cardiac surgery. Indeed, some criticise these humanitarian efforts, because they are costly and episodic and help relatively few people. Although humanitarian efforts cannot provide a complete solution to the problem of access to cardiac surgery, for the patients whom they do help, they can make all the difference, and provide life-saving surgery. Such efforts can have an impact beyond the relatively small numbers of patients operated, and can improve the overall level of healthcare for the entire country. Eventually, however, in order for sustainability to be achieved, there must be a mechanism identified to provide funding for the care of the poor. Certainly, participation by the government in funding for surgery would be ideal. Unfortunately, however, the reality is that many governments of developing nations lack the capacity to provide such funding.

This paper illustrates the issues that plague developing countries in their efforts to address healthcare. With respect to CHD, it is reasonable to assume that the incidence of CHD in Nigeria is similar to that in all other countries surveyed – 8–10 cases per thousand live births. Owing to an almost total lack of capacity for early diagnosis and appropriate facilities for the treatment of these children, particularly in sub-Saharan Africa,Reference Yankah, Fynn-Thompson and Antunes ⁷ most of them die during the first month or first year of life. Some, however, will survive to adulthood. Surgery and interventional catheter approaches are the mainstay of treatment for these adult patients with CHD who account for between 10% in Ghana and 13.7% in Mozambique of candidates for heart surgery.Reference Edwin, Zühlke and Farouk ⁸ Therefore, unless and until this situation improves, and as is the case with the patients in the current report and in most of the low- and middle-income countries, particularly in Africa, expatriate teams of providers constitute one of the only options for the delivery of care.Reference Binagwaho, Rusingiza and Mucumbitsi ⁹ As depicted in this paper, such teams are characterised by variable degrees of interest and ability in transferring skills and knowledge to local caregivers. The patients they treat, as demonstrated here, generally have satisfactory outcomes, at least in the short term. However, unless there is a commitment by these humanitarian teams for transition to sustainability, they will come and go episodically and leave the country no better than they found it with respect to its ability to ultimately provide this care on a sustainable basis.

At a minimum, humanitarian expatriate teams should have, as part of their mission, a commitment to the transfer of knowledge and skills to the local caregivers. Without question, the main focus must be achievement of the best possible outcomes for the patients who receive care. For a transition to achieve ultimate sustainability, however, it is vitally important that relationships build with the key thought and government leaders in the country begin early in the experience. Only through such relationships the government can communicate its wishes clearly to the visiting team(s), and also gain a comfort level with the team(s) that can translate to collaboration, to overcome the obstacles in the path of achieving sustainability.

There are examples where episodic, humanitarian expatriate efforts in cardiac surgery have functioned in this manner and have led to the establishment of permanent, dedicated facilities for cardiac care. Such examples can be seen in Mozambique with “Chaîne de l’Espoir France”Reference Mirabel, Lachaud and Offredo ¹⁰ and at Tenwek in Kenya with White et al.Reference Kramer, Quinn and Odera ¹¹ In terms of total impact on the entirety of the deficiency of cardiac surgery access in low- and middle-income countries, however, such examples of transition to sustainability remain far too rare.

With a focus on rheumatic heart disease and CHD, the recently published experiences of the humanitarian cardiac surgery programme in Rwanda is emblematic of this approach.Reference Binagwaho, Rusingiza and Mucumbitsi ^{9 ,} Reference Swain, Pugliese and Mucumbitsi ^{12 -} Reference Swain, Sinott and Breakey ¹⁴ From the inception of the program in 2006, among the four visiting teams from three countries, two were providing cardiac surgery and transcatheter interventions for CHD. The other teams focussed primarily on rheumatic heart disease in children and young adults. In addition to a comprehensive approach emphasising public awareness and prevention, major efforts have been directed to knowledge and skill transfer to the Rwandan caregivers. Moreover, a Rwandan surgeon has been sponsored for cardiac surgery training in South Africa, and other specialists are trained in Belgium, with the goal of building up a core local team to play a major role in the transition to sustainability. Even though a cardiac centre is not yet established, these efforts, combined with excellent surgical outcomes in more than 400 patients, over 11 years of humanitarian surgical development trips, and the establishment of a relationship of trust with the government of Rwanda, have created a framework whereby serious deliberations for the creation of a permanent cardiac centre are taking place at the highest levels in both organisations.

Of course, there are very serious challenges. One must begin with the premise that every person deserves the same chance and right to cardiac healthcare, irrespective of their place of birth. With that as a guiding principle, there are various pathways that can achieve this goal. The solution may be very different from one country to another, but not necessarily achievable in all developing countries. Some examples in Africa have also shown that regional cardiac care and training centres of excellence may be an option to explore. This approach requires a strong political commitment from countries and regional organisations and eventually private/public partnerships.Reference Mirabel, Lachaud and Offredo ^{10 ,} Reference Yacoub, ElGuindy and Afifi ^{15 -} Reference Turone ¹⁷

The sine qua non-condition for achievement of sustainability in cardiac care in any given country is dedication to the well-being of the population and a willingness to consider which approach may work best in that particular setting. In Nigeria, even today, the expatriate surgery teams have provided the only available solution for the treatment of adults with CHD. In order for a more sustainable model to be created, many challenges must be overcome. These include, in no particular order, lack of trained providers, lack of suitable facilities, lack of an identified source for funding of care, inadequate resources for diagnosis and for post-intervention follow-up, pervasive poverty, and lack of education among the population. This situation, for better or worse, pertains in many low- and middle-income countries in Africa and elsewhere.

Within medical and governmental sectors of society available worldwide, there is a growing awareness of the enormous impact of the lack of access to cardiac surgery in the developing world.Reference Binagwaho, Rusingiza and Mucumbitsi ^{9 ,} Reference Yacoub ¹⁸ Though primarily focussed on rheumatic heart disease, the recently published Cape Town Declaration constitutes a clarion call to the cardiac surgery, cardiology, medical industry, and government sectors to come together to address the enormous deficiency in access to cardiac surgery, which exists in the developing world.Reference Zilla, Bolman and Yacoub ¹⁹ Such a universal commitment, though overdue, is a vital and encouraging step toward addressing the neglected masses of the world, a small portion of whom are exemplified in the present paper.