Five years since defining global cardiac surgery: from afterthought to tipping point

BACKGROUND

Six billion people lack access to safe, timely and affordable cardiac surgical care [1, 2]. In low- and middle-income countries (LMICs), access to cardiac surgery has been poor due to a multitude of factors, including but not limited to an insufficient workforce, a scarcity of cardiac centres and training programs, fragmented supply chains, variable quality of care, minimal financial risk protection and a lack of political will [2]. In high-income countries, access may be impeded due to geographical, financial and systemic barriers [3]. In 2018, global cardiac surgery was first coined as ‘an area for study, research, practice and advocacy that places priority on improving health outcomes and achieving health equity for all people worldwide who are affected by cardiac surgical conditions or have the need for cardiac surgical care’ [4]. Five years later, encouraging progress has been made, although many gaps still persist.

THE WAKE-UP CALL

Historically, cardiac surgery has been considered an afterthought in global health, whereas cardiac surgery approached global health almost solely through fly-in fly-out mission trips, involving short-term visits with minimal follow-up and/or capacity-building. In 2015, the Lancet Commission on Global Surgery’s landmark report Global Surgery 2030 and the World Health Assembly Resolution WHA68.15 ‘Strengthening emergency and essential surgical care and anaesthesia as a component of universal health coverage’ resulted in a shift in thinking in terms of broader access to surgical care. Nevertheless, in the early years since the Commission, cardiac surgery was rarely, if ever, raised, whereas cardiac surgery stakeholders did not meaningfully engage with the broader global surgery movement. In 2018, a recognition of cardiac surgery as part of health systems strengthening arose, emphasizing the cross-cutting nature of the specialty in multidisciplinary collaboration with all levels of the health system [4].

THE TIPPING POINT

The following years proved successful in going from afterthought to a tipping point as a result of online advocacy, increasing research, and collaborative efforts through and beyond societies [5]. Prior to 2021, global cardiac surgery and broader global health discussions at national and international cardiac surgery conferences were few and far between. Since 2021, all major European, North American, Latin American and African societies have hosted successful global cardiac surgery sessions at their annual meetings. Similarly, the Cardiothoracic Surgery Network (CTSNet) established CTSNet Global to provide an easily accessible, open-access and dedicated library to publish, read and view global cardiac surgery content. Furthermore, major societies convened to establish the Cardiac Surgery Intersociety Alliance, committing to support 2 cardiac centres in Rwanda and Mozambique. Moreover, the first textbook on global cardiac surgery was published [6], serving as an important starting point for policymakers, funders, researchers and advocates to understand the nuances of the field through the lenses and experiences of experts and voices from different corners of the world. Lastly, the National Heart, Lung, and Blood Institute hosted expert-informed and public-consulted workshops on defining priorities to tackle rheumatic heart disease, notably including a tertiary care working group. In November 2023, the World Heart Federation’s World Congress on Rheumatic Heart Disease will have dedicated cardiac surgery sessions and talks, further emphasizing the role of cardiac surgery in global health.

THE HOPEFUL FUTURE?

The recent momentum provides hope for a more equitable future in which cardiac surgical care is no longer considered a luxury only for those able to pay. Various opportunities exist to build on this momentum. Social media use has substantially contributed to the acceleration of global surgery and global cardiac surgery by providing low-threshold avenues for disseminating information, creating collaborative network and advocating across time zones, country income groups and career stages [7]. Furthermore, the increasing recognition of historical inequities, such as (neo-)colonial practices and anglocentrism, has resulted in an encouraging shift in approaching global health efforts. This will require greater inclusion and empowerment of local partners, self-reflection of practices as high-income country actors, and an active commitment to anti-racism, decolonization and diversity, equity and inclusion in our specialty. Lastly, challenges pertain with regard to careful patient selection and, more importantly, follow-up after cardiac surgical care. As such, Heart Team approaches will be essential to ensure patients get the appropriate care and have the necessary cardiology and primary care follow-up. Indeed, reducing silos and extending efforts beyond the operating room and the surgeon's voice will be necessary to sustainably improve access to cardiac surgical care. Important efforts may be noted by various groups, including:

• Patient and family voices: patients must be centred in global cardiac surgery efforts. For example, the Global Alliance for Rheumatic and Congenital Heart (Global ARCH) provides a voice for dozens of patient-family organizations worldwide, of which approximately half are based in LMICs.

• Non-governmental organizations: over 80 organizations are active in the field of cardiac surgery, supporting efforts through surgical and non-surgical care, capacity building and providing supplies [8]. Opportunities now exist to streamline their efforts and ensure collaboration rather than redundancy in resources and learnings.

• Financing and policy: the lack of meaningful global health financing and political buy-in for global cardiac surgery requires greater efforts to engage funders and policymakers, as has been the priority of the global surgery community. For example, the Global Surgery Foundation recently launched the SURGhub, a global surgery learning platform, and the SURGfund, the world’s first catalytic fund dedicated to surgical systems strengthening [9].

• Trainees: trainees of today represent the cardiac surgical workforce of tomorrow and, therefore, are an important voice when thinking long-term. For example, the Global Cardiac Surgery Initiative, established in 2018, convenes trainees worldwide to synergize global cardiac surgery research and advocacy efforts. The Initiative’s membership includes and is co-led by a large number of LMIC trainees.

Ultimately, moving the needle in global cardiac surgery will require collaboration beyond the walls of the operating rooms. Surgeons and trainees can serve as advocates to better understand and highlight the effects of social determinants of health and barriers to care on population health [10]. This will include better-recognizing disparities globally, including locally, to ensure all individuals with cardiac surgical conditions or requiring cardiac surgical care are given the opportunity to access the care they need.

ACKNOWLEDGEMENTS

Dominique Vervoort is supported by the Canadian Institutes of Health Research (CIHR) Vanier Canada Graduate Scholarship for work outside this article.

Conflict of interest: Dominique Vervoort is a Founding President of the Global Cardiac Surgery Initiative, a Board Member of the Global Alliance for Rheumatic and Congenital Hearts and an Advisor to the Global Surgery Foundation.

DATA AVAILABILITY

No data were used or generated for this manuscript.

REFERENCES