Asian Cardiovasc Thorac Ann 2006;14:355-356
© 2006 Asia Publishing EXchange Ltd
OPEN HEART SURGERY IN A DEVELOPING COUNTRY
A. Thomas Pezzella, MD
Director, Special Projects, World Heart Foundation, 17 Shamrock Street, Worcester, MA 01605, USA, Tel: 1 508 791 1951, Email: tpezzella{at}hotmail.com
I read with interest the recent editorial by Probal Ghosh, FRCS, Setting Up an Open Heart Surgical Program in a Developing Country.1 This represents an update by Dr Ghosh of a previous masterful overview of the establishment of adequate care in emerging economies like India.2 To quote Rudyard Kipling: "I keep six honest serving-men (They taught me all I knew); Their names are What and Why and When and How and Where and Who". At the tactical or managerial level the editorial gives specific details on Where, What, How, and Who. However, further elaboration on Why and When would be useful and informative. The Why may seem obvious. It is clear that the growth of cardiac surgery favors the emerging economies. The backlog of patients with rheumatic and congenital heart disease is immense. Added to this is the epidemic rise of atherosclerotic coronary artery disease, due primarily to the notable risk factors (hypertension, hyperlipidemia, Westernized diet, smoking, inactivity, and lifestyle changes). In China alone, it is estimated that over 8 million people are in need of cardiac surgery.3 When to start a new program is also difficult. Further discussion of this is warranted.
For example, a valid argument can be made for the utility or futility of allocation of limited financial resources for a high priced curative effort available to only a limited portion of the population in need. Also, what is the motivation for this entire effort? Is it purely idealistic, i.e. a desire to help alleviate this heavy chronic disease burden, or is it also fueled by economic considerations to make money for eager venture capitalists. Perhaps it is a combination of both idealistic and realistic factors. In emerging economies there is ready access for those who have financial support, and limited access for those without financial support, be it government, private, or self pay.
A compelling argument can be made for a paradigm shift in our thinking on curative cardiac care. The development of a product line or disease focused effort may be a useful methodology. This means that the varied programs or projects proposed to provide access to this population with disease or at risk include a plan or process that includes prevention, promotion, diagnosis, treatment, and rehabilitation. This holistic approach would elicit the help and support of the entire health care sector, including preventive medicine and public health. They would be working in partnership with their curative medicine partners to develop strategies that cover a wider population with established disease or at risk. Dr. Ghosh and his team should be congratulated for their efforts in a very demanding, challenging, and yet rewarding area. Fifty-seven million people die per year on the planet with over 17 million from cardiovascular disease.4 Non-communicable diseases are clearly a greater cause of death than communicable diseases and will continue to rise. The major causes of these deaths are noted in figure (1).5 The World Heart Forum has published a definitive overview of cardiovascular disease, with strategies for prevention and amelioration of risk factors.6 We, the cardiothoracic surgeons at the high tech, high cost end of this horizontal paradigm shift need to work along with them to develop both strategic and tactical plans/programs that balance cost, access, and improved technology. This is a tremendous challenge, especially in the emerging economies.
REFERENCE
- Ghosh P. Editorial: Setting Up an Open Heart Surgical Program in a Developing Country. Asian Cardiovasc Thorac Ann 2005;13:299–301.[Free Full Text]
- Ghosh PK, Magotra RA. In my opinion: Adequate Care? Conundrum for Nonaffluent Countries http://www.ctsnet.org/doc/9227
- Zhu X, Zhang B. Current Status and Trends of Cardiac Surgery in China-abstract. World Society of Cardiothoracic Surgeons, 14th World Congress, Beijing, China Oct 14–17, 2004.
- Pezzella AT. International Cardiac Surgery; A Global Perspective. Seminars in Thoracic and CV Surg 2002;14:298–320.
- Fuster V, Voute J. Comment: MDGs: Chronic diseases are not on the agenda. Lancet 2005;366:1512–1514.[Medline]
- Smith SC, Jackson R, Pearson TA et al. Reviews: Current Perspectives-Principles for National and Regional Guidelines on Cardiovascular Disease Prevention. Circulation 2004;109:3112–3121.[Free Full Text]
