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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 30, No 2, March/April 2019
74
AFRICA
The Cape Town Declaration on Access to Cardiac Surgery in the Developing World:
Is it a true reflection of the needs of sub-Saharan Africa?
Dear Sir
We read with interest the article by Zilla
et al
., titled the
Cape Town Declaration on Access to Cardiac Surgery in the
Developing World.
1
The declaration does not mention the burden of congenital
heart disease in Africa. Rather, corrective ‘lifesaving surgery’
for rheumatic heart disease (largely valve replacement) is
emphasised. Is this an oversight?
Expensive valve-replacement surgery in Africa is a disaster
and should not be advocated. Anticoagulation in low- and
middle-income countries is hopelessly inadequate; penicillin
prophylaxis is variable. By contrast, mitral valve repair is
rarely performed
2
because of fly-in missions and lack of skills.
Even the results of mitral valve repair for rheumatic valvular
disease is sub-optimal and is inferior to the results of repair for
degenerative mitral valve disease.
3
Zilla
et al
. estimate that 300 operations per million of the
population is required in the developing world. Is this for
rheumatic heart disease only, or a combination of rheumatic and
congenital heart disease?
Three hundred thousand children are born annually with
congenital heart disease on the African continent. Most of these
will require surgical correction, which is extremely efficacious.
Many will require further operations, for example, pulmonary valve
replacement post tetralogy of Fallot. Some patients survive to their
teens or even young adulthood without surgery but subsequently
need an operation. So the number escalates year on year.
Sub-SaharanAfrica(SSA)isfacedwithenormousdemographic
and economic challenges. The incidence of cardiac disease in
children approximates that of human immunodeficiency virus
infection,
4
but non-communicable disease particularly is simply
not a government priority. Sadly, therefore, only 2% of the
paediatric patients in SSA have access to surgical treatment.
2,5
In our view, the initial solution would be the establishment of
regional cardiac hubs, which, through economics of scale, would
reduce costs. Importantly, there should be global standards of
training, education and certification with continued competence.
Because of the lack of political priority, some form of private–
public integration is mandatory.
Lenmed Ethekwini Hospital, Durban, South Africa
Robin H Kinsley, Darshan Reddy
German Heart Centre, Berlin, Germany
Charles Yankah
References
1.
Zilla P, Bolman RM, Yacoub MH, Beyersdorf F, Sliwa K, Zühlke L,
et al
. The Cape Town Declaration on Access to Cardiac Surgery in the
Developing World.
Cardiovasc J Afr
2018;
29
(4): 256–259.
2.
Yankah C, Fynn-Thompson F, Antunes M,
et al
. Cardiac surgery capac-
ity in sub-Saharan Africa. Quo vadis?
Thorac Cardiovasc Surg
2014;
62
(5): 393–401.
3.
Duran CM, Gometza B, Saad E. Valve repair in rheumatic mitral
disease: an unsolved problem.
J Card Surg
1994;
2
(Suppl): 282–285.
4.
Zilla P, Yacoub M, Zühlke L,
et al
. Global unmet needs in cardiac
surgery.
Glob Heart
2018;
13
: 293–303.
5.
Metras D, Ouezzin-Coulibaly A, Ouattara K, Chauvet J, Longechaud
A, Millet P. Open-heart surgery in tropical Africa. Results and peculiar
problems of the 1st 300 cases of extracorporeal circulation performed in
Abidjan [in French].
Presse Med
1983;
12
(10): 621–624.
Letter to the Editor
Reply
The authors fully support the main aim of the Cape Town
Declaration, namely to create local hubs that will make low-income
countries independent of fly-in missions. Based on this congruence
of goals, it is difficult to decipher the issues the authors have.
One concern they express is the perceived neglect of cardiac
surgery for congenital heart disease. Although contradicting their
own goal, they also seem to advocate the
de novo
establishment
of cardiac units that perform valve repair and congenital cardiac
surgery rather than replacement, as ‘valve replacement in Africa
is a disaster’.
To comment on the last point first, it is rather unlikely
that low-income countries will ever be in the position of
privileged, private, first-world institutions to employ fully trained
staff, particularly at a level that provides mainly valve repair
and congenital cardiac surgery. Therefore the criticism can
be interpreted in one of two ways: either, as the concluding
sentence indicates, promoting the roll-out of centres, which
operate on a specialisation level that would be rare even in
high-income countries, primarily catering for those who can pay
(‘private–public’ partnership), or alternatively, to continue to
offer expatriate ‘missions’ or generously offer to fly a few patients
to higher-income countries to operate on a handful of children
at a time. These measures are but a drop in the ocean,
1
when the
overall global unmet need is 600 000 per year.
2
The Cape Town Declaration
3
spawned the creation of an
umbrella body that comprises all major cardiac surgical societies.
This Cardiac Surgery Intersociety Alliance (CSIA) is the best
guarantor to date that a unified and concerted academic effort,
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