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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 29, No 4, July/August 2018
204
AFRICA
The African context of the Cape Town Declaration
Peter Zilla, Liesl Zühlke, Karen Sliwa, Patrick Commerford
This issue of the
Cardiovascular Journal of Africa
publishes the
Cape Town Declaration (page 256) simultaneously with eight
other journals worldwide.
1
It is a call to arms within the cardiac
surgical community.
A decade after the late Professor Bongani Mayosi led the
Pan-African Cardiology of Africa (PASCAR) call and alerted
the world to the huge public health crisis of rheumatic heart
disease (RHD) in the Drakensberg Declaration,
2
the cardiac
surgery community has also recognised the magnitude of the
problem, aggravated by the lack of cardiac surgery in the most
affected regions of the world. When representatives of all major
cardiothoracic societies, industry, civic organisations as well as
surgeons from all over the world convened to celebrate the 50th
anniversary of the first heart transplant in Cape Town, an entire
day was dedicated to a south–north dialogue, focusing on the
unmet needs of cardiac surgery in low-income countries.
Nowhere is this unmet need more glaring than on the
African continent. In most countries, as far as children are
concerned, this lack of life-saving therapy in the absence of
a curative alternative has been only sporadically relieved by
fly-in missions from high-income countries, bringing teams of
specialists and consumables to remote places to operate on a
handful of children, before departing. For RHD, however, it
is adolescents and young adults who represent the majority of
patients in need of cardiac surgery among the more than six
billion people living outside high-income countries. Although
their numbers approximate those of patients with HIV
3
(World
Health Organisation Global Health Observatory data 2017), to
date, this startling comparison has been largely ignored globally.
There has been little RHD activism similar to the one that drove
the worldwide HIV campaigns, until recently.
Of all the efforts to create awareness for the neglected millions
of patients with RHD, the tireless work of Bongani Mayosi stands
out.
1-4,6-9
His focus on cardiovascular diseases of the poor in Africa
led to South Africa becoming an epicentre of research on RHD,
with other internationally renowned scientists following in his
footsteps.
1,3-5,7-9
Therefore, it seems fitting that all the international
cardiac surgical societies came to Cape Town to not only celebrate
a medical event that happened here 50 years ago and that was
unparalleled in its impact, but to finally unite the cardiac surgical
community behind the plight of those living with and affected by
RHD. Furthermore, in May 2018, the World Health Assembly
resolution against RHD was finally adopted, following the
African Union communique spearheaded by Mayosi in 2016.
7
We
stand at a powerful new juncture in the fight against rheumatic
heart disease, led by those living in RHD-endemic countries.
As a first concrete result of this gathering of leaders from
all over the world, which led to the Cape Town Declaration, an
analysis of the cardiac surgical capacity of 16 different countries
will soon be published.
8
More importantly, this analysis for
the first time provides a needs assessment in affected regions.
Although echocardiographic screening studies had provided
better insight into the burden of asymptomatic RHD, hardly
any data existed on the proportion of patients actually needing
cardiac surgery. Furthermore, cohort studies from tertiary
institutions had already started to highlight one inconvenient
truth for health politicians: although the incidence of rheumatic
fever has significantly dropped, the drastic cuts to financing
cardiac surgery in the public domain of countries such as South
Africa are not justified, since both the incidence of RHD among
adults and the need for surgery remain high.
9
Yet, while the
indigent population of South Africa and the Maghreb has at
least some limited access to heart valve surgery, the majority of
Africans south of the Sahara has none.
What makes the plight of Africa so particularly sobering
in this regard is that the cardiac surgery dilemma is not only a
reflection of economic prowess. In our comparison of 16 different
countries being home to four billion people, there was only a
weak correlation between the per capita GDP and the provision
of cardiac surgery. With a near-identical per capita GDP, Iran
and South Africa spend nearly identical per capita amounts on
health, yet Iran performs 525 cardiac operations per million, as
opposed to 142 in South Africa. Likewise, Nigeria’s per capita
GDP is almost a third higher than that of India, but India delivers
154 cardiac operations per million, as opposed to 0.5 in Nigeria.
8
Similarly, theGini index, as an expression of societal inequality,
does not always correlate with access to cardiac surgery: Algeria,
with a Gini index of 28 and South Africa with 63, provide
similar levels of cardiac surgery (127/million versus 142/million
operations). Yet, an access ratio between affluent private patients
and indigent patients of 12 in South Africa but only 1.2 in Algeria
does correlate with the extremely divergent Gini indices between
these two countries.
8
In that regard, South Africa is at the extreme
end: those 17% of the population who have access to private
medical care receive 595 cardiac operations per million, while the
83% of the population who depend on public medical care receive
only 50 operations per million per year.
Alternatively expressed, one private hospital cares for 300 000
cardiac surgical patients who have medical insurance (with 7.1
cardiac surgeons/million), as opposed to 6.1 million patients per
centre who depend on the public sector (with 0.7 cardiac surgeons/
Chris Barnard Division of Cardiothoracic Surgery, Groote
Schuur and Red Cross Children’s Hospital, University of
Cape Town, Cape Town, South Africa
Peter Zilla, MD, PhD, FCS,
peter.zilla@uct.ac.zaDivision of Paediatric Cardiology, Department of Paediatrics,
Red Cross Children’s Hospital; Division of Cardiology,
Department of Medicine, Groote Schuur Hospital, University
of Cape Town, Cape Town, South Africa
Liesl Zühlke, MB ChB, FCPaeds, Cert Card, MPH, PhD
Hatter Institute for Cardiovascular Research in Africa,
Department of Cardiology and Internal Medicine,
University of Cape Town
Karen Sliwa, MD, PhD
Division of Cardiology, Department of Medicine, University
of Cape Town and Groote Schuur Hospital, Cape Town,
South Africa; Editor-in-Chief (CVJA)
Patrick Commerford, MB ChB, FCP (SA)