Letter by Soliman Regarding Article, “Improvement in Congenital Heart Surgery in a Developing Country: The Guatemalan Experience”
To the Editor:
There is no doubt that the Guatemalan experience described in the article by Larrazabal et al1 has set a good example for developing countries that need to start pediatric cardiovascular services. The emergence of cardiovascular disease as a major health problem in developing countries needs a “wake-up call,” as mentioned in Dr Yacoub’s editorial in the same issue of the Circulation.2 From my past experience as a medical advisor to a few African countries, however, often the question facing policy makers is not simply whether to establish pediatric cardiovascular services including congenital heart surgery or not but how much of a service is worth implementing? The unfinished agenda of communicable disease control that must be simultaneously dealt with using limited resources and fragile health systems makes implementing a costly intervention such as congenital heart surgery far from being a priority, even though it is needed. Measured in terms of population-attributable risk, which represents the proportion of the deaths in the whole population that may be preventable if a cause of death were totally eliminated, congenital heart disease still is not one of the major contributors to overall death in many developing countries. In countries like Sierra Leone, Liberia, and Malawi, the death rates of children under 5 years of age are 278.1, 222.2, and 154.3 deaths per 1000 live births, respectively,3 and most of these deaths are related to infectious, diarrheal, and nutritional diseases, a situation in which congenital heart surgery would not be a priority. On the other hand, in countries like Guatemala, Egypt, and Brazil, where the death rates of children under 5 years of age are 48.5, 42.0 and 34.0 deaths per 1000 live births, respectively,3 such a service may be worth implementing. I am not here advocating an all-or-nothing approach of either fully establishing or not starting at all a pediatric cardiovascular service in developing countries. What is applicable in one developing country is not necessarily applicable or even needed in other developing countries. Pediatric cardiovascular services that are less costly, such as programs to prevent rheumatic heart disease, would be more cost-effective in some countries and would serve as a base for future full pediatric heart services that include congenital heart surgery. In this context, the role of individuals as well as nongovernmental organizations is pivotal if actions are to be made against the emerging cardiovascular epidemic in developing countries. However, such role would be more effective in terms of providing overall health if aligned with governments’ efforts in a holistic view that takes into account all competing health needs.
Larrazabal LA, Jenkins KJ, Gauvreau K, Vida VL, Benavidez O, Gaitán GA, Garcia F, Castañeda AR. Improvement in congenital heart surgery in a developing country: the Guatemalan experience. Circulation. 2007; 116: 1882–1887.
Yacoub MH. Establishing pediatric cardiovascular services in the developing world: a wake-up call. Circulation. 2007; 116: 1876–1878.
United Nations, Department of Economic and Social Affairs, Population Division. World Population Prospects: The 2006 Revision, Highlights, Working Paper No. ESA/P/WP.202. Available at: http://www.un.org/esa/population/publications/wpp2006/WPP2006_Highlights_rev.pdf. Accessed November 17, 2007.