Written by Luiza Ghazaryan

Many heart diseases such as arrhythmias, congenital heart defects, coronary artery disease, heart failure, heart valve disease and thoracic aortic aneurysm will require cardiac surgery to prolong the patient’s life. According to the National Heart, Lung, and Blood institute, each year, more than 2 million people around the world have open-heart surgery to treat various heart problems. However, the American College of Cardiology states that in low- and middle-income countries, 93% (around 6 billion) of the population lacks access to safe, timely, and affordable cardiac surgical care as a result of geographic, infrastructure, quality, and financial barriers. These surgeries are highly necessary in the world healthcare as cardiovascular diseases stay the top cause of death worldwide, responsible for 17.5 million deaths every year, of which 80% occur in low and middle-income countries.

Human Resources and Education

A total of 12,180 adult cardiac surgeons (and 3858 pediatric cardiac surgeons) were listed in the CTSNet (Cardiothoracic Surgery Network) registry, which translates to 1 adult cardiac surgeons per 0.61 million people globally, or, conversely, 1.64 adult cardiac surgeons per million people. It is extremely stressful for a surgeon to treat this many people. The cardiac surgeries take hours of preparation and procedure, however, what’s important is all the risks and decisions that the doctor has to deal with all alone in the operating room. Regional distribution ranged from 11.12 adult cardiac surgeons per million population (32.82% of total) in North America to 0.12 adult cardiac surgeons per million (1.05% of total) in sub-Saharan Africa. As we see, besides the significant disparity between the continents, the world is facing a shortage of cardiac surgeons. One reason is due to long years of education (around 7 years after medical school) and in some countries the lack of practice, schooling and funding for these healthcare professionals. For example, surgeons training abroad in South Africa as “supernumerary registrars” are often not paid and require their own or external funding. Without external support, the debt incurred by the end of training forces many to seek jobs in HICs (high income countries) to compensate, further exacerbating that many do not return home. 

The other main cause of shortage of surgeons is the unimaginable stress and effects on a surgeon’s mental health. Before becoming a surgeon, medical students study long hours, take life-determining exams and after medical school, they go through a lengthy residency program. Having this many responsibilities, the professionals end up having no energy and time for simple everyday activities and social life. According to the National Library of Medicine, “Serious manifestations of chronic stress among surgeons include depression, anxiety, divorce or broken relationships, mistakes at work and thoughts about giving up their profession as well as symptoms of burnout, such as emotional exhaustion, depersonalization, and low personal accomplishment.” Dr. Ikonomidis, MD, PhD, University of North Carolina at Chapel Hill has reflected on this challenge among surgeons, “Cardiothoracic surgery—as a ‘frontline’ surgical specialty—is at great risk for burnout and depression because of high stress and long working hours.” Another factor is the empathy that the doctors have for their patients – working so long and seeing many struggling families can be heavy. Healthcare professionals also need psychological support, which many institutions tend to neglect. This results in fewer students choosing the career pathway of a surgeon.

Financing the surgery

The operative costs of open-heart surgery are extraordinarily high in the United States (up to US$100,000 per operation), but costs are found to be as low as US$6,000-11,000 in Nigeria, less than US$10,000 in Brazil, US$2,000-5,000 in Vietnam, and less than US$2,000 in India. However, low- and middle-income countries across the world have equally low domestic health care funding, with most spending less than 5% of total Gross Domestic Product on health, making it still difficult for patients to find funding for their vital surgeries. These surgeries are a necessity for patients to live, however people of developing countries lack basic governmental and financial support to get the treatment. The majority of patients in low- and middle-income countries are able to obtain cardiac surgical care secure funding through out-of-pocket payments, non-governmental organizations or visiting teams, or philanthropic support. It’s important to remember that in these countries, not everyone can afford to make out-of-pocket payments. To find a solution for these cases, the world and their governments can follow the examples of Nepal and India. Nepal, through the Poor Patients Relief program, have established governmental schemes for life-threatening cardiac conditions for the poor, the children, and the elderly, and parts of other countries, such as India through Narayana Health, have leveraged co-financing models whereby wealthier patients cover part of the costs for poorer patients.

Infrastructure and Supplies Accessibility

The National Institutes of Health (NIH) has done research regarding the supplies for cardiac surgical care to help to identify its effects on the availability of cardiac surgeries. They surveyed thirty-seven institutions in seventeen different countries. The results found out that seventeen (46%) respondents at least sometimes resterilize and reuse items normally meant for single use. Items reported to be resterilized and reused included vascular patch materials, vascular conduits as well as cannulation suction tubing. While defibrillators were available in the majority, only 18 (51%) programs reported having rapid-fibrillators available. In 21 (59%) of the programs, intraoperative neurological monitoring is routinely conducted whereby eight (22%) of the institutions used brain symmetry index (BSI) and 13 (35%) programs used near infrared monitoring. Again, thinking of the medical personnel who have to face the emotional difficulties that come with the field, but now they have to work and save lives in hospitals with no equipment. The specialists work closely with the families of the patient to make the best decisions for them and show their compassion; nevertheless, in most cases the hospitals fail to provide the tools for doctors to cure complex diseases. The NIH report concluded that the deficit in infrastructure that requires long term investments, specifically operating room capacity, intensive care capacity and trained staff, demonstrably limit the case volumes, complexity mix and access to care.

Congenital heart disease is the most common major congenital anomaly with a relatively stable incidence worldwide, affecting 1 in every 100 live births. According to the CDC, only in the US one person dies every 34 seconds from cardiovascular disease. These statistics convey how crucial it is to provide the necessary cardiac care globally.

Some ways forward include fostering and strengthening heart teams across countries with considerable socioeconomic returns on investment. Governments and other stakeholders should prioritize these long-range investments to match the expected number of infants born with CHD or living with CHD in specific regions, as a starting point towards achieving equitable CHD care across the globe. 

The results illustrate that in order to enhance the global access to cardiac surgery, the countries need governmental prioritization and inclusive policies. As observed, the inequality regarding cardiac surgeries depends on not only the complexity of the medical procedure but also on crucial factors such as the doctors’ health, the availability of education in the area, and funding of hospitals. Patients deserve to have well-educated and healthy doctors who can work in appropriately-equipped medical institutions.