Cardiac Surgery in Variable-Resource Contexts: Overly Ambitious or Long Overdue?

An estimated 6 billion people lack access to safe, timely, and affordable cardiac surgical care when needed.1 Cardiovascular diseases are the leading causes of morbidity and mortality worldwide, and approximately one-third of patients with cardiovascular diseases will require surgical or interventional care at least once in their lifetime.2 Despite increasing recognition of the cardiovascular surgical disease burden,2 the global capacity gaps,1 and the cost-effectiveness,3 and the socioeconomic impact of investing in cardiac surgical care expansion,4 there remain a disproportionate emphasis and considerable financial and policy focus on other areas in global health. Whereas all noncommunicable diseases, which include cardiovascular diseases, receive less than 2% of global health funding and surgical health care receives approximately 1% of funding, HIV/AIDS, malaria, and tuberculosis receive more than one-half of all global health funding.5,6 Similarly, cardiovascular diseases, including the surgical management thereof, remain disproportionally absent from national and international health policy documents.7,8 This may be a result of skewed global health financing patterns, driven by large donors of development assistance for health, which draw attention away from other areas of global health and health care.9 This issue is particularly noteworthy when comparing the proportion of global health funds with the existing disease burden: cardiovascular diseases (18 million deaths per year) and surgical conditions (17 million deaths per year) are responsible for more than 5 times as many deaths as HIV/AIDS, malaria, and tuberculosis combined.10-12 This implicit power imbalance between funders (high-income country actors), who allocate such generally earmarked funding, and recipients (low-and middle-income country actors) conflicts with the ethos of global health, which seeks to achieve health equity worldwide in a sustainable, contextual, and locally driven manner, thus posing an ethical dilemma for contemporary resource allocation in global health.13 Here we explore the ethical arguments for resource allocation for cardiac surgical care delivery in variable- resource contexts (VRCs) and argue that cardiac surgi- cal care capacity can be established and strengthened in VRCs, without necessarily competing for resources with other areas of global health and international development.