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Cardiac Surgery in Haiti: High Need, Low Support

journal contribution
posted on 2023-02-22, 20:48 authored by Louvenser Minthor, Jean Wilguens Lartigue, Dominique Vervoort, Owen Robinson, A. Thomas Pezzella

Haiti is home to over 11 million people and is facing a growing burden of cardiovascular disease (CVD). Currently, about 29 percent of all deaths in Haiti are from CVD, which can often be treated with surgical intervention (10). Despite this, there is no local cardiac surgical capacity to manage patients in need of cardiac surgical care.

Globally, more than 100 countries and territories do not have a single cardiac surgeon, and six billion people lack access to safe, timely, and affordable cardiac surgical care when needed. The situation in Haiti is particularly challenging because the nation has the lowest health index among countries in the Western Hemisphere.

A better understanding of access to care and the need for cardiac surgical care is crucial to enabling more streamlined advocacy and encouraging policymakers in Haiti, as well as national and international non-governmental organizations (NGOs), to accelerate efforts to build capacity for local cardiac surgical care delivery.

What follows is an historical overview of cardiac surgery in Haiti through visiting teams and partnerships and a look ahead at opportunities for Haiti to introduce local cardiovascular services in the near future.

Disparities in Cardiovascular Health 

Cardiovascular diseases (CVD) are the leading cause of death worldwide (1–3). They are responsible for about 17.5 million deaths every year (1), of which 80 percent happen in low- and middle-income countries (LMICs) (4). Nevertheless, 93 percent of people in LMICs lack access to cardiac surgical care (1,5), driven in part by regional cardiac surgery workforce disparities. LMICs possess about 0.04 adult cardiac surgeons per million population, compared to 7.15 adult cardiac surgeons per million population in high-income countries (HIC); the same trend exists for pediatric cardiac surgeons (1). 

With the epidemiologic transition away from communicable and toward noncommunicable disease, global cardiovascular mortality is currently more than five times higher than the mortality of HIV/AIDS, malaria, and tuberculosis combined (6). Furthermore, congenital heart defects (CHDs) are the most common major birth defect and present with some of the highest associated mortality rates (7). The world prevalence and incidence of CHD are 1.8 per 100 live births and 19 to 75 per 1,000 lives, respectively (7,8). Approximately 260,000 people die per year from CHD, of whom two-thirds are children younger than one year old (7–9). Despite these facts, in LMICs, 90 percent of patients with CHD do not receive the care they need (9).

In Haiti, CVD now constitutes the leading cause of death and loss of disability-adjusted life-years among adults in the country (10), and the burden continues to grow (11). The Global Burden of Disease study estimated that CVD was responsible for about one-third of deaths across all ages in Haiti in 2016, and the prevalence of RHD is as high as 5 percent in rural settings (10, 15). Moreover, thousands of Haitian children die from heart disease, and about 2,000 are born with some CHD each year, of whom approximately 50 percent will eventually require surgery or interventional care (16). Thus, because of a lack of pediatric cardiac care, hundreds of Haitian children die of curable heart conditions each year.

It is worth noting, like many LMICs, the true incidence of CVD in Haiti remains unknown largely because of a lack of screening, reporting, and data systems. And though cardiac surgery is, for the most part, a life-saving intervention, very few Haitian institutions or organizations are involved in supporting local access to cardiac surgery. This is largely because the infrastructure, workforce, and financial coverage that are required are currently unavailable there (11). 

Brief Overview of Haiti

Haiti is a Caribbean country of 10,641 square miles and a population of about 11.6 million people (12). It is the poorest country in the Western Hemisphere, with a 2020 gross domestic product (GDP) per capita of $2,925 USD, which is also the lowest in the Latin American and the Caribbean (LAC) region and less than a fifth of the LAC average of $15,092 (11,13). 

Haiti also has the lowest health index (13). The life expectancy of women at birth is 67.2 years and that of men is 62.8 years (12). In comparison, the United States has a life expectancy for women of 79.1 years and 73.2 for men. The infant and maternal mortality in Haiti remain at high levels, and the coverage of prevention measures is currently stagnating or declining (11–13). For example, in 2020, the infant and under-five mortality rate were 48.0 per 1,000 live births and 71.6 per 1,000 live births, respectively (12).

Because of limited public resources and local health infrastructure, more than 70 percent of the health care delivery in the country is provided by NGOs (11). 

In addition, sociopolitical instability and insecurity remain present. In the past two years, more than twenty health care workers, especially physicians, have been kidnapped or killed in Haiti (14). Moreover, the country is extremely vulnerable to natural disasters, to which 90 percent of the population are exposed (13).

Governance, Financing, and Information Management

In Haiti, there are no national or government sponsored cardiac surgery programs. All the progress in this area so far been made through NGOs (11). The few cardiac interventions that have been held in Haiti were fully funded by the NGOs and supported by private and institutional philanthropic funding (16,22). According to Dr. Samantha Lacossade, lead clinical coordinator at the Haiti Cardiac Alliance, each intervention within the country costs about $2,800 USD. Although this number is among the lowest reported in the world—with cardiac surgery costs ten to one hundred times more expensive in European countries and the United States—the far lower per capita income makes this amount inaccessible for nearly the entire population.

To date, there is no evidence of a governmental, national cardiac surgery database, although some institutions and organizations manage their own databases. A database may make it possible to better understand the impact of CVD in the country and is necessary to clearly identify gaps and needs, and to better advocate for Haitians requiring cardiac surgical care. This issue is the result of the lack of information management infrastructures, qualified workforce to enter and manage the data, budget shortages, and a lack of validation mechanisms (5). As a result, only the hospital or the organization in charge has the patient's medical file. Similarly, research remains very scarce in this field.

History of Cardiac Surgery in Haiti

Throughout the years, cardiothoracic surgery programs in Haiti have always been chaperoned by international organizations to address the country’s challenges with CVD.

In November 1996, the Open Hearts Haiti program was initiated at Hopital Sacre Coeur by Dr. A. Thomas Pezzella and Dr. Ted Dubuque (11, 17). By the second half of 1997, visiting teams equipped the hospital with an operating room and an intensive care unit that was fit for standard open-heart surgery (11). In November 1997, the first two successful open-heart surgery procedures in Haiti were performed—a ventricular septal defect repair in a seven-year-old girl and a mitral valve repair on an eighteen-year-old boy—by a team of six specialists from the University of Massachusetts Medical Center and St. Vincent Hospital. Afterward, the teams made several one-to-two-week trips, through which many patients were screened; some were sent to the Mayo Clinic to have their operations, while about thirty-one received cardiac surgery in Haiti (11). Unfortunately, because of security concerns and political instability, the program was suspended in 2006 and only briefly restarted in 2011, during which only one trip was performed (11).

From 2011 to 2013, Chen Lespwa Ayiti—in partnership with Chaine de l’Espoir (France), Gift of Life International, and Rotary International—performed eleven cardiac surgery visits. During these trips, teams of ten to fifteen people each from France, the United States, and local Haitian health workers came to the Lambert Clinic in Pétion Ville, where they performed about 130 heart surgery interventions over two years (18)...

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