In 1999, Professor Felix Unger from Salzburg, Austria published the results of a remarkable worldwide survey that clearly defined the magnitude of the differences that exist in cardiac care in developed versus underdeveloped countries (see Figure 1).
Figure 1. Discrepancies by Region in Cardiac Surgery Cases
The average number of cardiac surgical cases performed in North America, Australia and Europe is 860 cases per million population. This means that in an optimal environment where every patient who needs a heart operation can actually get one, there will be 860 cases performed for every million population. On the other hand, the average number of cardiac cases performed in South America, the Russian Federation, Asia and Africa is 60 cases per million population. This means that of all the people living outside North America, Europe and Australia who actually need an open-heart operation, 93% cannot get that operation. In absolute numbers, this translates to 4.5 billion people in the world having no access to cardiac surgery.
Numerous surgical teams travel to underdeveloped countries to perform surgery each year and to train the local surgeons and ancillary personnel as best they can. However, in most such cases, the surgical teams are present at those remote sites for no more than one week per year, leaving the local populace and surgeons to struggle for themselves for the remainder of the year. The World Heart Foundation proposes that rather than continuing with the current disorganized and inefficient system, the problem should be addressed by multi-diminsional approach directed at both an improvement in surgical services and an enhancement of education and training, taking maximum advantage of contemporary communications technology and educational techniques.
The recruitment of government support and the re-energizing of our surgical leaders and our organizations such as the AATS, the STS and the EACTS, are strategic initiatives and while they represent the infrastructure that is necessary for ultimate success, they will fail without the creation and implementation of a feasible and effective tactical plan. The approach should revolve around efforts to increase local surgeons' accessibility to established experts in the field of cardiac surgery and to improve the training and expertise of those local surgeons and their teams. If successful with this approach, the local teams will ultimately not need our help. In the meantime, we must establish a delivery system that serves the clinical needs within a certain sphere of influence in a more efficient manner.
With a concerted effort of the appropriate companies and organizations, many of our Operative Clinics and Educational Courses can be transmitted into underdeveloped countries. These conferences are much more effective if presented live. In order to broadcast them live and still during reasonable hours, the world can be conveniently divided into 3 broadcast time zones, -- Western, Central and Eastern (see Figure 2).
Figure 2. Broadcast of Live Operative Clinics and Educational Courses
Conferences broadcast from the each zone would be transmitted via satellite to numerous countries and cities within that zone where surgeons are capable of paying a registration fee for the course. These sites are indicated by the yellow lines. The same signal could then be broadcast into those countries in the same zone where surgeons cannot afford the registration fee, as indicated by the red lines in Figure 3.
Figure 3. Strategy for Satellite Broadcast
Fortunately, when broadcasting a course by satellite, the cost is determined primarily by the uplink and is not affected so much by the number of down links. Hardware costs are minimal in the grand scheme of things. Thus, this is a very cost-effective way of delivering live operative clinics and educational courses into developing countries.
A second approach is to provide Weekly Internet Video Conferences to all available sources within each broadcast time zone. These conferences would feature two prominent surgeons each week from each respective zone who would present state-of-the-art information on a given topic followed by questions submitted via the internet from surgeons anywhere within that zone.
Figure 4. Weekly Internet Video Conferences
Each conference would last 2-3 hours and would be held at the same time each week. The two experts would change each week so that no surgeon would be asked to do this more than 2-3 times per year, and hopefully, only once per year. The schedules would be posted well in advance on that particular website as well as in the major cardiothoracic surgery journals of the world.
A third approach is to establish an Elective Consultation Service on the internet to provide expert consultation to any surgeon in the world. The e-mail consult would be sent to a specific web address that is published free of charge in every issue of our major journals. The e-mail will be received at a Triage Center that is equipped with off-the-shelf software that is capable of forwarding 90% of the messages to the appropriate surgical team. Most of these queries can be handled by the surgeon's staff because they frequently relate to perioperative care and non-technical issues rather than to the specific surgical technique itself.
A fourth effort is to organize the available surgical teams into a more efficient and effective delivery system for cardiac surgery. The basic premise is that rather than having a surgical team in every country for one or two weeks a year, we will establish regional surgical hubs and move the patients within that region to the surgical hubs. By consolidating the surgical services to one site, the multiple surgical teams can operate at a single site where adequate equipment and personnel can be maintained throughout the year (see Figure 5).
Figure 5. Regional Surgical Hubs
Obviously, an important part of this effort is the selection of an appropriate site for the regional surgical hub. There are basically four groups of countries in terms of the organization of our efforts: Some countries such as those in North America, Western Europe and Australia do not need our services. In other countries, it is simply not feasible for us to attempt these efforts either for political reasons or because of active military conflicts. However, despite these exemptions, we are still left with over 150 countries where our efforts could have a tremendous impact.
It is of paramount importance that we adapt our specific approach in each region to the unique needs specific to that region. For example, in the case of Guatemala, where one of the world's greatest pediatric cardiac surgeons practices, we obviously do not need a host of pediatric cardiac surgeons rotating through his clinic. Rather, there is an urgent need there to train the ancillary personnel better and to secure funding for many of them who now work on a part-time basis. In other regions of the world, the major need is to have multiple surgeons perform as many cases as possible. In others, the major need is education and training.
Where do we get the necessary surgical teams for the direct delivery of surgical care and for the training of local surgeons and their ancillary personnel? In the Fall of 2001, at the request of the World Heart Foundation, the American Association for Thoracic Surgery (AATS) mailed a questionnaire that we had prepared for its membership. This questionnaire was designed to gauge the level of interest among the membership of the AATS in providing their surgical services to underdeveloped countries. Of approximately 1,000 questionnaires mailed, we received over 200 responses, 182 of which were positive. A databank was established at the AATS offices in Manchester, MA for our exclusive use in arranging future "operating schedules" in underdeveloped regions. The leadership of the AATS has recently agreed to request the leadership of both the Society of Thoracic Surgeons (STS) and the European Association of Thoracic Surgeons (EACTS) to mail the same questionnaire to their respective memberships. The STS has a membership of over 4,500 surgeons and the EACTS's membership is over 3,000. Since the AATS membership is only 550 and the combined membership of the STS and EACTS is over 7,000, we anticipate a dramatic increase in the number of volunteer teams as a result of these questionnaires.
While this plan is more efficient and cost-effective than the disorganized system that currently exists, traveling surgical teams alone will not solve the problem. The ultimate solution lies in using these surgical hubs as training sites for surgeons in the surrounding countries. Surgeons from poor countries who cannot afford to spend a year in the USA or Europe (where they probably would not be allowed to scrub anyhow) could participate in operations with experienced cardiac surgeons as often as they wished to do so at a regional surgical hub. In addition, their surgical teams could learn anesthesiology techniques, the principles of perfusion and postoperative nursing care from experienced volunteer teams interested in teaching them.
A part of this training program will include several International Training Sites where surgeons on the Board of Directors and on the International Advisory Board of the World Heart Foundation have already agreed to cooperate in this venture. Ultimately, developing technologies will be used to link each of the regional and international training sites with sophisticated methods for assisting surgeons remotely by means of robotics. Most of the efforts using robotic systems today are directed at making surgery less invasive. However, the greatest promise of robotic systems in not in minimally-invasive surgery but rather is in the possibility of having experienced cardiac surgeons assist inexperienced cardiac surgeons from remote sites (see Figure 6).
Figure 6. Remote Surgical Assistance
The Operative Clinics, the Video Conferences, and the Training Programs all contribute to our first tactical goal of improving the education and surgical expertise of local cardiac surgeons (see Figure 7). The Consultation Services, Surgical Hubs, and Remote Robotic Surgery of the future all contribute to our second tactical goal of increasing the accessibility of local surgeons to leading international cardiac surgeons. We believe that the attainment of these two tactical goals will lead to the strategic goal of improving cardiothoracic surgical services in developing countries.
Figure 7. Multifaceted Approach to Improving Cardiothoracic Surgical Services in Developing Countries