The Cape Town declaration on access to cardiac surgery in the developing world

Twelve years after cardiologists and cardiac surgeons from all over the world issued the 'Drakensberg Declaration on the Control of Rheumatic Fever and Rheumatic Heart Disease in Africa', calling on the world community to address the prevention and treatment of rheumatic heart disease (RHD) through improving living conditions, to develop pilot programmes at selected sites for control of rheumatic fever and RHD, and to periodically review progress made and challenges that remain [1], RHD still accounts for a major proportion of cardiovascular diseases in children and young adults in low-and middle-income countries, where more than 80% of the world population live. Globally equal in prevalence to human immunodeficiency virus infection, RHD affects 33 million people worldwide [2]. Prevention efforts have been important but have failed to eradicate the disease. At the present time, the only effective treatment for symptomatic RHD is open heart surgery, yet that lifesaving cardiac surgery is woefully absent in many endemic regions. In this declaration, we propose a framework structure to create a coordinated and transparent international alliance to address this inequality. Elimination of RHD and relief from its debilitating consequences can only occur through interdisciplinary effort, as outlined in the Cairo Accord [3]. Previous initiatives have focused on primary and secondary prevention of RHD [4]. Their declarations have been recognized by the Heads of State of African Union countries and by the World Health Organization. This recognition has been important in developing recommendations by the World Health Organization Executive Board to the 2018 World Health Assembly to enlist global commitment to RHD. Progress in prevention of RHD has been slow during the past 15 years [5], and thus, surgery will likely remain an integral part of RHD treatment for several generations. Lack of access to cardiac surgery services and the cost of valve replacement render this disease fatal for millions of patients. In endemic regions of lowincome countries, the need for cardiac surgery is estimated at 300 operations per 1 million population ('Global Unmet Needs in Cardiac Surgery', unpublished work by Zilla et al.), yet, the nearly 1 billion people living in Sub-Saharan Africa between the Maghreb and South Africa have access to only 22 cardiac centres [6]. Although there is 1 cardiac centre per 120 000 people in the United States, there is only 1 centre per 33 million in Africa. Furthermore, RHD is not restricted to Sub-Saharan Africa. India, Pakistan, China and Indonesia together account for 72% of mortality of RHD cases worldwide [2]. We strongly endorse the position that building local capacity is the best solution for this serious public health problem. Many lives have been saved by humanitarian 'fly-in' missions, but these efforts are neither sustainable nor cost-effective. The non-government organizations associated with these programmes are shifting focus towards building long-Term partnerships with host countries to develop autonomous local services with government buy-in [7]. A massive investment in new cardiac centres in these regions is unrealistic; globally, an additional few thousand cardiac centres would be required to address the unmet needs ('Global Unmet Needs in Cardiac Surgery', unpublished work by Zilla et al.). It is not sufficient for governments and non-government organizations to support the training of cardiologists and cardiac surgeons from these regions at high-income country facilities, because they will not be trained in most of the pathologies awaiting them in their own countries and will be unfamiliar with resource-constrained circumstances. There is an urgent need for a concerted effort by all stakeholders to address the plight of the poor in these regions who need cardiac surgery. As signatories and endorsing organizations of the Cape Town Declaration, we propose a comprehensive solution with 2 principal aims.