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Global Expansion of Cardiac Surgery in the New Millennium

Shortly after the submission of this editorial, a massive terrorist attack took place in the United States (US) on September 11, 2001. This tragedy killed over 6,000 people and injured countless more both physically and emotionally. Many of those killed and injured were from other countries as well. Clearly, this has created inter-national outrage and has focused international awareness, fear, and concern for the whole problem of terrorism and what it represents. I think all of us in the cardiothoracic community are united in extending our sympathies and sorrow to the families, relatives, and friends so deeply affected by this immense tragedy. I have been personally moved by emails received from colleagues around the world expressing their condolences and support. Hopefully, it will bring us all closer together to work in a common effort to not only rid the world of terrorism, but to try and understand the conditions that spawned it, and ultimately come to the realization that we are all human beings sharing this fragile planet for such a short time. Perhaps by assisting others and fostering common goals and objectives, as I have tried to cover in this editorial, we are — in fact — helping ourselves as well.

Furthermore, medicine is one of the few spheres of human activity in which the purposes are unambiguously altruistic — in itself, a remarkable achievement.¹

With the advent of humanism during the Renaissance, medicine moved from the stagnant theories of the four bodily humors — blood, phlegm, yellow bile, and black bile — to a more focused understanding of human anatomy and physiology. The explosive expanded growth, however, came over the last two centuries with notable advances in chemistry, cellular biology, genetics, anes-thesia, microbiology, body imaging, and pharmacology.¹

The challenges of the 21st century are numerous. Against the background of environmental, economic, political, cultural, and social problems, the role of medicine and healthcare has become increasingly more important and dominant, especially in terms of cost and access. The world population stands at 6 billion, with a growth to 9 billion by the mid-21st century. There were over 55 million deaths worldwide in 1999 (The World Health Report 2000, http://www.who.int/whr). Surprisingly, over 33 million were secondary to noncommunicable conditions. Of these, approximately half were secondary to cardio-vascular disease. Ischemic heart disease accounted for over 7 million deaths, and rheumatic heart disease almost 400,000 deaths. Epidemiological transition is defined as a shifting of these chronic diseases to those countries and regions where there is improvement of social and economic forces. The emergence from famine, communicable disease, and pandemics to degenerative chronic disease has and will slowly occur.² This will place an increasing burden on the global healthcare system.

With regards to heart disease, many of the transition countries and economies are still faced with the "first wave" of infectious etiology (e.g., rheumatic heart disease and Chagas' disease).³ As an example, the incidence of rheumatic fever remains one case per 1,000 children per year in Bangladesh. With a population of 120 million, the incidence is 20,000 new cases per year.³ In a more recent survey in Yemen, the incidence was 3.6 per 1,000 (USA is 0.6 per 1,000).⁴ At the same time, the incidence of ischemic heart disease is rising in those developing countries where there is a rising lifespan, increased smoking, decreased infant mortality, and the unhealthy eating habits of Western society.³

Faced with this background, the cardiac surgeon of the 21st century must reassess his/her role in this "global village." The phenomenal growth and development of cardiac surgery is clearly a product of the last half of the 20th century. Within a short span of the 21st century, the artificial heart, xenotransplantation, and genetic remodeling and transfer will be realized. This expansion, however, will be experienced primarily in the in-dustrialized developed countries and economies. In recent years, with the dramatic impact of the Internet, com-munication has linked the international cardiac surgery community. More and more cardiac surgeons are aware of "what's going on." The CardioThoracic Surgery Network (CTSNet), pioneered by Drs. Ferguson, Replogle, Greene, and others has made basic and new knowledge readily available.⁵ This transfer of knowledge is immediate, precise, and complete. The challenge of the Internet, however, is not to dehumanize the experience. Just as the doctor/patient relationship must be earned and nurtured, so too the relationship between medical colleagues. There is a tendency to think of "us" (i.e., those with the knowledge, experience, and resources) and "them" (i.e., those without the same). Paul Sergeant described the "Le Colloque Singulier" which stresses the equality between two partners of a relationship.⁶ As this transfer of knowledge reaches an equilibrium, the quantitative disparity will dissipate and the qualitative phase of adjusting standardized databases and evidence-based paradigms will then dominate the Internet.

The major cardiothoracic societies have broadened their efforts to extend both the body of membership and the annual medical meetings to the international community. Again, Eugene Baudet stresses the need for direct relationships amid the fear that major annual meetings could be replaced by virtual meetings, thus replacing the transfer of knowledge with technology devoid of human interaction.⁷ Additionally, the major cardiac surgery databases are now poised and ready to develop and expand an international database.^5,8 The American Society for Thoracic Surgery (STS) and the European Association for Cardio-thoracic Surgery (EACTS) should be con-gratulated in this endeavor. Caution, however, should be applied to expanding databases to the regional and international levels. Again, Sergeant stresses the point that the ultimate goal of database collection is not just an epidemiological survey, but a benchmark to achieve quality control.⁶ However, quality control is a gradual process. It should not penalize or hinder the developing, struggling, or emerging programs. This would only hamper or hinder access to care as these new and struggling programs will become hesitant, timid, or in fact paranoid with regard to reporting their data.

At the academic and training levels, bold new initiatives are taking place. The concept of regional centers of excellence provides a logical and cost-saving mechanism to achieve standardization and parity in educations and training. Clearly, the major training centers in Europe and North America cannot accommodate the increasing number of trainees at the doctor of medicine (MD) or allied health level. Richard Jonas has highlighted the recent political constraints in the US.⁹ New regulations in 1999 have limited the Educational Council for Foreign Medical Graduates (ECFMG) sponsorship for foreign medical graduates. Now rigid criteria and time restraints will be placed on non-accredited programs to obtain J1 visa (a training visa usually granted to physicians entering the US as residents or fellows) status for its fellows.

In contrast, David Cheung has outlined a bold training program in China which can well serve as a model for other Asian countries.¹⁰ Additionally, there has been active growth in establishing regional centers of excellence in India. This has been sparked off by a bold cooperation between industry and established cardiac centers. This is clearly an attractive strategy for large populations like China and India.

Two recent addresses generated an increased awareness and interest in this global expansion. Hans Borst nicely and succinctly presented an organized approach of Western European centers to help their Eastern European and Russian colleagues.¹¹ James Cox, in his presidential address at the recent STS meeting, presented a bold and challenging strategy to broaden and expand cardiac surgery globally. His recommendation of the utilization of regional Internet consultations and regional referral centers are certainly innovative and worth exploring. Financing these endeavors will require corporate and government support. This address will certainly spark off increased interest and initiatives, as well as debate and controversy.

As we await the logical progression of the aforementioned areas, individual preparation is warranted. Just as cardiac surgeons prepare themselves for new procedures and operations, so too background knowledge and preparation is necessary and required to enter the "global village." For those individuals or groups attempting to get involved internationally, a few recommendations are humbly suggested as critical to any immediate, short-term, or long-term strategy, whether it is done at a local, personal level, or as part of a broad-based international initiative.

1. Any individual, group, society, corporate entity, quasi-government, nongovernment organization/private voluntary organization, or governmental body must have a global perspective of geography, en-vironmental issues, and political, economic, social, and cultural considerations of the nation or region of the world being considered. This information is readily available. Background information from the United Nations (UN), World Health Organization (WHO), International Monetary Fund (IMF), and World Bank is readily available on the Internet. The US State Department, as well as Brigham Young University (BYU), offer background notes on most countries. (189 countries — member nations of the UN.)
   
2. Knowledge of the past and present experiences of individuals and groups involved in international activity should be sought and studied. As an example, Children's Heart Link (www.childrensheartlink.org) is a Minneapolis-based nongovernment organization with a wealth of information on global programs and activities. At the present time, approximately 30 US-based groups are involved in active, ongoing programs in developing countries. An additional number of Western European, Indian, European, and Australian groups are also involved. The late Amram Cohen's recent international experience highlights what can be done with a balanced relationship between donor and host groups.¹² Alain Carpentier's dramatic experience in advancing cardiac surgery in Ho Chi Minh City, Vietnam, is a model for future efforts. Corporate data is available in the context of the number of global programs and annual case loads. Detailed information, however, is lacking since most countries in Africa, South America, Asia, and Eastern Europe are serviced by distributors rather than individual corporate representatives.
   
3. Cardiac surgery programs in developing countries or emerging countries can be categorized as follows:
   1. Nonexistent, but wanting to start.
      
   2. Previously existent, but failed.
      
   3. Small or even larger existing programs now limited by financial and political considerations.
      
   4. Ready to start, but need financial and political support.
      
   5. Already functional, but needing academic support.
      
   6. Various combinations of all the other examples.
      
   
   
4. Appreciation of the need to build and develop relationships. Just as in building any practice, it is important to have mutual trust and respect along with a sense of working in partnership. The traditional US approach of depositing money and material on the "port" without any involvement will not get the job done. Any relationship should be focused with attainable goals.
   
5. What is the role of the industrialized developed donor programs?
   1. Provide and identify leadership in the host program and work together in this partnership.
      
   2. Develop the concept of mentoring rather than dictating. Mutual collaboration is crucial. Many times, the developing program is the teacher with a wealth of information and experience (e.g., technical aspects of closed mitral com-missurotomy).
      
   3. Implement a managerial base that makes the strategies work.
      
   4. Provide specific technical assistance, especially in the infrastructure and biomedical areas.
      
   5. Develop a strategy over time (usually 3 to 5 years) with specifics that realize completion of the project.
      
   
   
6. What is the role of the developing host programs?
   1. Provide the host program with basic infor-mation, i.e., infrastructure, background history, politics, and economics.
      
   2. Develop a plan or strategy, i.e., what is to be accomplished, being realistic regarding success or failure.
      
   3. Facilitate arrival, departure, accommodation, and social program for host group. Building a lasting friendship and future bridge of co-operation.
      
   4. Recognize that free or donated equipment and supplies are short-term (usually 2 to 5 years). Thereafter, negotiations with government, industry, and the private sector must occur to sustain the program.
      
   
   
7. Understanding the corporate role.
   1. Their willingness to help in the short term with financial support, donated goods, and services.
      
   2. Recognize that they have financial constraints.
      
   3. Being realistic regarding expectations from corporate sources.
      
   
   
8. An appreciation of language. English is the dominant medical language. Yet in the majority of the world population, it is at best a second language. John Benfield has beautifully and boldly outlined the importance of language and the need to communicate in English.¹³ For the nonnative speaking, an attempt must be made to acquire a working scientific knowledge of English. Native speaking individuals must show patience and understanding. At the local, up close, and personal level, any attempt to learn the native language — even a few phrases — will enhance and strengthen relationships.
   
9. An appreciation and sensitivity of the ethics of medicine, particularly as it relates to clinical research. Research involving human subjects in developing countries is a major concern. A knowledge of the principles of the Declaration of Helsinki is essential. A sound research design and following basic ethical principles will yield research that is free from any debatable results.¹⁴
   
10. The concept of regional referral programs is sound, practical, and cost-effective. Yet, one must appreciate national pride and the hesitancy to refer patients to a neighboring country. Regional training centers are more feasible.
    
11. Sending or referring patients to the developed programs has been very effective, but of short-term benefit. Approximately 50 US programs have accepted indigent, non-paying, or nonaccess patients over the years. It certainly has benefited those selected individuals and has added hope to the rest. It also gives the host program an up close and personal insight into the problem. Yet, it is not cost-effective. Some organizations like Variety International and the Gift of Life program in metropolitan New York provide some financial support. Historically, paying patients from foreign countries have and continue to come to the large centers in the industrialized countries.
    
12. An appreciation of the other major healthcare concerns of the host country. Usually, the minister of health is faced with a small budget (less than 5% of the Gross Domestic Product) to provide for all the healthcare needs. The sophisticated and expensive curative side of medicine must be balanced with the less expensive, preventive side of medicine. A longitudinal approach to a disease like rheumatic heart disease, by emphasizing preventive strategies to control rheumatic fever as well as identifying and treating the problem, should be considered. Working with family planning and prenatal care programs also helps with trying to decrease the incidence of congenital heart disease. It may also be worthwhile to focus on low-risk congenital heart operations initially. A tremendous burden is placed on local healthcare personnel in triaging the enormous number of children with congenital heart defects.
    

Central to these recommendations is an appreciation of the concept of transfer. It is simply the geographic transfer of three basic entities from the industrialized nations and regions to the less developed or emerging nations and regions:

1. Ideas, knowledge, technology, logistics, planning, and strategy.
   
2. People or personnel.
   
3. Things, i.e., equipment and supplies — be they disposable or nondisposable.
   

What facilitates or hinders this transfer is money and ego. Clearly, financial issues are key to the process. Yet not only the amount, but the most beneficial use of sparse funds, is crucial. The quantity of money is not as important as spending it well. According to the WHO, the US spends $3,724 per person on healthcare each year. Yet it ranks 37th in the world in terms of quality of care. Ego refers to the personalities, biases, and misunderstandings, befuddled with bureaucracy, that makes the process difficult and frustrating. A spirit of understanding and cooperation, tempered by patience and an open mind, will clearly facilitate the process.

It is my hope that more letters, editorials, and scientific articles are generated to debate, challenge, or support these concepts through the pages of the Asian Cardiovascular & Thoracic Annals. Finally, it must be stressed that the international growth of cardiac surgery still favors the developing world, and in today's troubled times the obstacles we all face in trying to assist colleagues have grown even more daunting. Challenges certainly worth undertaking for the good of all Mankind.

REFERENCES

1. Editors, Editorial. Looking back on the millennium in medicine. N Engl J Med 2000;342:42–9.[Free Full Text]

2. Gaziano JM. Global burden of cardiovascular disease. In: Braunwald E, Zipes DP, Libby P, editors. Heart disease. A textbook of cardiovascular medicine. 6th ed. Philadelphia: WB Saunders, 2001:1–18.

3. de Luna AB. International cooperation in world cardiology: the role of the World Heart Federation. J Am Coll Cardiol 1999;33:1427–30.[Free Full Text]

4. Al-Munibari AN, Nasher TM, Ismail SA, Mukhtar EA. Prevalence of rheumatic fever and rheumatic heart disease in Yemen. Asian Cardiovasc Thorac Ann 2001;9:41–4.[Abstract/Free Full Text]

5. Replogle RL. Globalization. Asian Cardiovasc Thorac Ann 1997;5:191–2.

6. Sergeant PT. Think globally. [CTSNet In My Opinion Website]. Available at: http://www.ctsnet.org/inmyopinion. Accessed October 4, 2001.

7. Baudet E. Cardiac surgery in the 21st century: the future is now? Eur J Cardio-thorac Surg 1998;14:545–53.

8. Wyse RKH, Taylor KM. Developing a cardiothoracic surgical registry in Asia. Asian Cardiovasc Thorac Ann 1999;7:255–8.[Free Full Text]

9. Jonas RA. New visa limits for foreign medical graduates: crisis in subspecialty care in USA. Asian Cardiovasc Thorac Ann 2001;9:250–1.[Free Full Text]

10. Cheung DLC. Postgraduate training in cardiothoracic surgery: the Asian setting. Asian Cardiovasc Thorac Ann 1997;5:129.

11. Borst HG. The hammer, the sickle, and the scalpel: a cardiac surgeon's view of Eastern Europe. Ann Thorac Surg 2000;69:1655–62.[Free Full Text]

12. Cohen AJ, Tamir A, Houri S, Abegaz B, Gilad E, Omohkdion S, et al. Save a child's heart: we can and we should. Ann Thorac Surg 2001;71:462–8.[Abstract/Free Full Text]

13. Benfield JR, Howard KM. The language of science. Eur J Cardio-thorac Surg 2000;18:642–8.[Free Full Text]

14. Koski G, Nightingale SL. Research involving human subjects in developing countries. N Engl J Med 2001; 345:136–8.[Free Full Text]

Department of Cardiac Surgery Good Samaritan Hospital Mt. Vernon, Illinois, USA

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