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Paediatric cardiac surgery in less privileged parts of the world

Published online by Cambridge University Press:  21 January 2005

Rodolfo Neirotti
Rodolfo Neirotti
Affiliation:
DeVos Children's Hospital, Grand Rapids, Michigan, USA
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Cardiology in the Young , Volume 14 , Issue 3 , June 2004 , pp. 341 - 346
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© 2004 Cambridge University Press

Every gun that is made, every warship launched, every rocket fired signifies, in the final sense, a theft from those who hunger and are not fed.

Dwight D. Eisenhower

The results of a global survey that clearly defined the differences that exist in cardiac care in developed vs. underdeveloped countries were published in 1999.1 The survey showed that there are approximately 4000 cardiac surgical centres in the world, with a remarkable mal-distribution of access.

In North America, each centre serves around 120,000 people. In Europe and Australia, each cardiac surgery centre serves a population of 1 million people. In Asia, there is one centre for every 16 million people, while in Africa the amount is one to 33 million people. This mal-distribution has a significant impact on the number of operations performed in these countries.

The average number of cases performed in North America, Australia, and Europe per million people, and possibly the ideal number, is 860. The average number of cardiac operations performed for every million of the population in South America, the Russian Federation, Asia, and Africa is approximately 60. Based on these figures, it is possible to calculate that 4.5 billion people, representing more than nine-tenths, of those living outside North America, Australia, and Europe have no access to cardiac surgery (Fig. 1). It does not seem unreasonable, therefore, to consider these areas the “less privileged parts of the World”. This general pattern also applies to Paediatric Cardiac Surgery.

Figure 1. Difference in cardiac care in developed as opposed to underdeveloped countries. NA: North America; EU: European Union; AF: Africa; SA: South America; AU: Australia; CS: cardiac surgery.

The fact that modern cardiac surgery is not available to people in the most impoverished nations of the world is no great surprise. Poor right of entry to cardiac surgery is just one of the harms generated by sheer poverty and inequality in the developing world where, on the whole, cardiac surgery is not a priority, and cannot be performed because of lack of money or infrastructure.2

Bureaucratic indifference and the concept of issues being a world apart are damaging. In the future, it will be important that physicians take an active role in political, economic, and social aspects in order to defend the interests of those suffering around the globe. The time has come when physicians have to decide whether they will continue to be a part of the problem, or whether they will be part of the solution.

Although my essay will focus on the situation in the emergent countries, “the less privileged parts of the world” can be anywhere, and are not necessarily due to economic constraints. Lack of diversity due to social, intellectual, educational, and professional inbreeding, the latter representing cultural stagnation, can easily be responsible for the lack of scientific progress and development.

Paediatric cardiac surgery with limited resources

Paediatric cardiac surgery has been available for many years in several developing countries, thanks to the creativity and hard work of individuals who were able to produce good work in spite of the limited resources. Leadership, patience, perseverance, dedication, and the capacity to adapt, have been the keys to success. Some important contributions, such as the evolution of the Fontan procedure, the arterial switch operation, the better understanding of the anatomy and surgery of Fallot's tetralogy with absent infundibular septum, and early extubation after paediatric cardiac surgery, came from these parts of the world. Because of the escalating cost of cardiac surgery, and the lack of money, most of these centres have simplified the cardiac surgery process, adopting the KISS approach (Keep It Simple and Safe) to help more patients with the available funds, equipment, and manpower.3 Additional considerations are the allocation of the scarce resources to patients who are most likely to benefit from cardiac surgical procedures, and avoiding those with a low expectation for a satisfactory outcome.3

The important features of this approach are as follows:

  • Using anaesthesia, perfusion, and surgical techniques that facilitate early extubation. A previous extensive experience with this technique in Argentina encouraged us to evaluate its impact in a completely different environment. A retrospective review was done of all hospital records for 1000 consecutive patients who underwent surgery for congenital cardiac disease between April 1993 and January 2001 at our institution in the United States of America. Extubation occurred within 6 hours following surgery in four-fifths of the patients, and was achieved for three-quarters in the operating room. It was also possible for complex anomalies, being achieved in over nine-tenths of those undergoing correction of Fallot's tetralogy, and almost nine-tenths of Fontan procedures. There were no deaths related to early extubation. Preoperative intubation was a risk factor for postoperative ventilation. As expected, the patients requiring ventilation after surgery were younger, smaller, and more critically ill than those who met the criterions for early extubation. The benefits include simplified postoperative care and, when combined with clinical practice guidelines, also result in a significant reduction in the cost of cardiac surgery. It is important to emphasize that extubation in the operating room saves on respiratory therapy, and the costs of equipment, by avoiding ventilator-related charges in the intensive care unit.4
  • Minimizing monitoring and the involvement of ancillary services whenever a careful bedside clinical evaluation is able to provide enough information, with the nursing staff taking an active participation to achieve this goal.
  • Economizing in hardware and disposables by using locally produced ventilators, heart-lung machines, oxygenators, devices, cannulas, sutures, patches, and so on. Brazil is an excellent example of a country that, despite its large population, and significant socioeconomic problems, addressed access to cardiac surgery in the early 1960s. It started under the leadership of Professor E. J. Zerbini, who established a centre of excellence in Sâo Paulo that trained a large number of cardiologists and surgeons who subsequently spread all over the country. At present, the Heart Institute of the University of Sâo Paulo Medical School is one of the largest in the world. Currently, cardiac surgery of good quality is available in every major city in Brazil, and more than 50,000 operations are performed per year. Developing a medical industry that will gradually replace imports was a priority from the very beginning. Presently, over four-fifths of the medical equipment is locally made, with a total market of US$2.4 billion.
  • Reducing invasive investigations with the majority of patients undergoing surgery without cardiac catheterisation with echocardiographic diagnosis. Our work with limited resources at the Italian Hospital in Argentina attracted the attention of Dr. John W. Kirklin and Dr. Eugene Blackstone, from the University of Alabama in Birmingham, in the 1980s. They retrospectively reviewed 1250 operations undertaken over the period 1978 through 1985 using multivariate analysis, and the inferences of that study were:
  • Simple methods imposed by limited resources allowed generally good results in patients treated surgically.
  • In the environment of the study, many patients must have died before being presented for surgical treatment. For example, 10 of 15 patients with totally anomalous pulmonary venous connection presented at the age of 6 months or older, but 14 of the 15 survived.
  • Young age at operation was an incremental risk factor.
  • A number of preliminary operations were deemed necessary in infants.
  • More sophisticated methods are required for obtaining excellent results in infants.
  • Simple methods are often sufficient for standard operations for congenital cardiac disease in children.

Movement of cardiac surgery to the very young

In the late 1980s and early 1990s, the movement of surgery for congenital cardiac disease to the very young became a powerful trend. Two individuals were primarily the innovators and the driving force, namely Sir Brian Barratt-Boyes in New Zealand and Aldo Castañeda at the Boston Children's Hospital. The advantages of early repair are well known and multiple.5

Neonates and infants: a word of caution

Neonates and infants have a limited physiologic reserve, have cardiac lesions with a complex pathophysiology that often require technically demanding procedures, and are prone to complications and/or sequels related to cardiopulmonary bypass. Although the accuracy and quality of the surgical procedure are the most important determinants of survival after surgery, neonates and infants, in addition to early diagnosis, capabilities for transportation, and pre-operative resuscitation, require sophisticated support, expertise, manpower, and technology.

In some developing countries, well-trained and skillful surgeons, while being able to generate excellent results in children, have difficulties reproducing the same kind of outcomes with neonates and infants. As expected, increasing costs, the lack of sufficient resources, and the widening technology gap with the rich countries, have an important impact on cardiac surgery. Neonatal cardiac surgery will linger last in developing in most evolving programmes.

International aid and cooperation

Much of the poorer world is in turmoil, caught in a vicious cycle of disease, poverty, and political instability. Financial and scientific help from the rich nations is a vital investment, as are the economic benefits of integrating the Third World into the global economy.6 If social and economic problems are not solved, it is difficult to ensure that certain groups are not excluded from society.

A long-standing disagreement over whether decades of foreign aid have done any good has prompted economists to review their thinking. On average, foreign aid has failed to foster economic growth in recipient nations, except in special cases when governments implemented supportive policies, such as low budget deficits and openness to trade.7 Those countries with visible success, measured by higher rates of growth, and more foreign investment, should be rewarded by donors and used as examples.

Programmes designed to relieve debt, as advocated by the makers of policy, some economists, activists, and the public to improve health care, education, employment, and development in highly indebted poor countries have produced mixed results.8

Trade is far more important than aid for long-term development. Poor countries need to sell their labour-intensive manufactured goods, such as textiles and farm products, to rich countries. The problem is complex, and it cannot be solved without fundamental changes in the international financial architecture.9 It is important to remember the developing countries vary tremendously in their socio-cultural, political and economical characteristics.

Because the world faces many formidable problems, we cannot expect to solve the mal-distribution and poor access to cardiac surgery through the regular channels for international aid. Currently, there are numerous groups around the world involved with structured international projects, but without coordination among them. In humanitarian medicine, there is room for cooperation rather than competition, because the people in need outnumber those able to provide assistance.10–12 Unfortunately, there are no humanitarian solutions for humanitarian problems. More comprehensive answers are needed, in which humanitarianism would play only a part.

At our institution, in a combined effort with the Michigan and Ohio Chapters for “Healing the Children”, 150 children from 17 countries around the world underwent cardiac surgery. Physicians from many specialties, dentists, and nurses donate their services. The hospital, social workers, laboratories, X-ray facilities, pharmacies, physical therapists, teachers, translators and others similarly donate their professional services. Airline personnel donate their time, and use their travel passes to escort the children from their home countries and then back.

There are a limited number of programmes involved in bringing patients to affluent countries for free cardiac surgery. More typically, the majority of donor programmes focus on developing an on-going relationship with a host programme. This relationship involves teaching, training, collaborative research, and donation of equipment. Basically, this “twinning process” results in a transfer of knowledge, ideas, and skills to other people. It is important to identify places, “fertile sites”, with receptive individuals where good work is being done, to avoid squandering energy and resources.

This approach will be most effective when local governments, doctors and hospitals have a genuine learning interest. Eventually the host programme becomes autonomous, with the donor programme assuming a consultant role.13

Another approach to the problem is building a new regional centre, but this is not always feasible. Nevertheless, there are some examples that deserve mentioning:

  • The Vien Tim-Heart Institute was erected in Ho Chi Minh by the Alain Carpentier Foundation. More than 11,000 operations have been performed by local and visiting surgeons since its opening in 1990, most of them for congenital and valvar disease.
  • Le Centre Cardiovasculaire de Phnom Penh in Cambodia was built by Chaine de l'Espoir. Surgery has been completed for 600 patients with congenital and valvar disease over the last two years.
  • The Paediatric Cardiac Unit in Guatemala City is a joint venture of the Aldo Castañeda Foundation, the government of Guatemala, and donations from abroad.
  • The aim of the Unit is to:
  • Provide optimal care for the Guatemalan children with congenital heart disease.
  • Train additional members of the local team. Initially Castañeda was the only surgeon. Since then, two young surgeons were trained, and they are currently operating independently, doing about three-quarters of all cases.
  • Create a referral centre for complex cases from Central America. After retiring from the Boston Children's Hospital, Dr. Castañeda has managed, despite many limitations, to lead a local team that has performed surgery on more than 1000 patients, including neonates with complex lesions.14
  • The Shanghai Children's Medical Centre is the result of a productive joint venture that started back in 1983, involving Project Hope, the Children's Hospital of Boston, the Children's Hospital of Philadelphia, and the Chinese government. The Cardiac programme espoused the basic philosophy of Project Hope, which is “train the trainer”. The teams that travelled to Shanghai every 6 months over the past 17 years were sent to target subspecialty areas within the children's hospital where particular instruction was required. The American team educated their Chinese peers, and these individuals subsequently become the instructors for the local staff. In addition to intramural training of staff performed by Project Hope teams, an exchange fellowship programme has enabled numerous physicians and nurses to spend time particularly at Children's Hospital of Boston. The Shanghai Children's Medical Centre is an example of what can be accomplished through collaborative educational efforts. It is one of the largest congenital heart programmes in the world, where 1500 open-heart procedures were performed in 2002.

Professional organizations, such as the American Association for Thoracic Surgery, the Society of Thoracic Surgery, and the European Association for Cardio-Thoracic Surgery, can be extremely helpful. They could help by coordinating the efforts, and taking maximum advantage of contemporary technology in communications and educational techniques for fostering the transfer of knowledge, skills, and ideas of its members for the benefit of patients in less developed countries. The Eastern European Committee of the European Association for Cardio-Thoracic Surgery, initiated in 1995, has helped to alleviate educational needs in that part of the world, and continues to flourish. During these years, the Committee has granted 106 fellowships, 12 in paediatric cardiac surgery, sponsored 49 team excursions, disbursed 32 professorial grants, and facilitated the attendance of 76 young surgeons to special courses and symposia. The International Heart School, currently within the umbrella of the Association, located in Bergamo, Italy, and under the leadership of Professor Lucio Parenzan, has provided important support to the fellowship programme.15 The awareness of the cardiothoracic surgeons of the needs and opportunities in this field can be enhanced through more discussions of this problem in the professional journals.

Domestic philanthropic endeavours

Not everybody is poor in the emerging countries. There are often people with enough education and resources to organize and participate in local philanthropic efforts, to help their own “have-nots”. The philanthropic leadership will come once the elites have the opportunity to cross the physical and psychological barriers that make it difficult to get to know the poor, recognizing them as fellow citizens. Philanthropy can also add to the total sum of efforts necessary to rescue the education systems.

The Great Orchestra of Christmas Charity Foundation, a Polish non-governmental and non-profit organization, focused in children, is a good example of how the population can contribute to improve the quality of the health care. Since its establishment in 1993, the foundation has supported 13 major projects, and provided US$44 million in financial assistance to equip different paediatric subspecialties in public hospitals in the country.16

The importance of education and research in developing countries

Education should be part of basic human rights. Overall, the system of education is inadequate, and is crying out for reorganization. The best long-term way to improve the lot of the poorest is better primary schooling, particularly in girls, with an emphasis on improving quality rather than quantity. Higher education should focus on producing well-trained individuals equipped to be a factor of change. Although education does contribute to the human capital of each individual, additional spending on education produces few benefits when it is not accompanied by major socioeconomic reforms. More education does not necessarily mean more growth, as presumed by most politicians and economists.17

Compared to their counterparts in the developed world, young people in the developing countries are 100 times less likely to enter a scientific career. Nevertheless, science and technology can be the answer to their countries' problems. Despite the obvious limitations imposed by the lack of knowledge and scarcity of resources, the importance of research in those areas must not be underestimated. The potential advantages of research under these circumstances18 are to:

  • Develop local expertise
  • Provide opportunities for talented people
  • Determine the size of the problem in cooperation with all concerned locally
  • Generate specific answers for local problems (neglected diseases)
  • Implement a strategy of science leading to technology, and thence to health and wealth
  • Enhance dignity
  • Participate and contribute to global knowledge

Examples of this approach are the joint research projects on endomyocardial fibrosis in Mozambique, and on Chaga's cardiomyopathy in Honduras, in which the Chain of Hope, the Harefield Research Foundation, and Imperial College, London, are involved.

Conclusion

“The less privileged parts of the world” can exist anywhere, and are not necessarily due to economic constraints. Cultural stagnation can easily be responsible for the lack of scientific progress and development.

  • Listing the problems may be easy. Finding solutions is not.
  • The dilemma is complex, and it cannot be solved without fundamental changes in the world's economy. It is unlikely to see these changes materialize in the near future.
  • There are no humanitarian solutions for humanitarian problems. Palliation is possible with a multidimensional approach involving donors and professionals.
  • It is important to identify places, “fertile sites”, where people are doing good work, and help them through the concept of a twinning programme. Success should be rewarded by donors and used as an example.
  • National and international professional organizations can help by coordinating the efforts, and taking maximum advantage of contemporary technology for communications and educational techniques.
  • Developing countries should do as we do, and not necessarily as we say.
  • The intellectual, cultural, and moral benefits of education for individuals and society are undeniable. Thoughtlessly unlimited expansion does not necessarily result in economic growth.

Acknowledgments

I am indebted to Professor Gilbert Davis, Rodolfo Neirotti, Jr., and Gwen Fosse RN, MSA for their helpful advice and comments, and to Michelle Oostveen for technical assistance.

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