Oportunidad Editorial Oportunidad A. Thomas Pezzella Director of Special Projects, World Heart Foundation Director/Founder International Children’s Heart Fund Attending Cardiothoracic Surgeon Shanghai Chest Hospital Shanghai, China Opportunity “There are two kinds of opportunity: one which we chance upon, the other which we create.” (An Asian perspective) Takamori Saigo “No great man ever complains of want of opportunity.” (An American perspective) Ralph Waldo Emerson “Success is being available at the time of opportunity.” (An European perspective) Disraeli Fear, anger, frustration, despair, and despondency are not uncommon moods these days amongst cardiotho- racic (CT) surgeons worldwide. The periods of joy and happiness related to personal and professional satisfac- tion have grown less and less. The expansion of general thoracic surgery reached its peak in the mid fifties and subsequently decreased with the introduction and use of new and more effective antituberculous medications. Next, the growth and expansion of cardiac surgery in the fifties with the introduction of the heart/lung machine, and peak- ing in the last twenty or so years with coronary artery bypass surgery, is slowly but progressively decreasing with better preventive methods, drugs, and emerging sophisticated angioplasty/stent strategies and devices. Hav- ing abandoned general thoracic and vascular surgery during the heyday of coronary artery surgery left many cardiac surgeons devoid of skills/experience and referrals in these areas. A growing somber mood is readily witnessed at medical meetings and in the literature. It is interesting to note that this unrest is felt across the entire cardiotho- racic global community. A few thoughts regarding volun- Cir. Cardiov. 2006;13(3):129-36 A. Thomas Pezzella 17, Shamrock Street Worcester, MA, USA 01605 Phone: 1-508-791-1951 E-mail: tpezzella@hotmail.com (www.ichfund.org) (www.world-heart.org) 9 tary humanitarian efforts may help mollify, or even eradicate some elements of this somber mood. In the developed countries/economies, decreased job opportunities, reimbursement, salaries, and caseloads are contrasted with increased complexity, patient/society ex- pectations, accountability, increased malpractice suits, and an oversupply of CT surgeons. This is in the setting of sophisticated facilities, resources, ready access, and ad- vanced technology. On the other hand, in the developing countries/emerging economies there exists large caseloads, waiting lists, increased need, fewer qualified CT surgeons, less compensation and resources, uneven access, and lim- ited governmental financial or political support. This rep- resents a comedy in the former and a tragedy in the latter scenarios. Previous publications have given an appreciation of the global picture of cardiothoracic surgery. Our global popu- lation of 6.5 billion lives in 268 countries/dependencies/ territories (191 in the United Nations). Over 6000 active cardiothoracic surgeons practice in over 5,000 centers, performing over 2 million cardiac operations and another 3000-4000 non cardiac thoracic procedures. The unbal- ance of access, manpower, and caseloads has been previ- ously reported by Cox and Unger1,2 (Fig. 1). It is clear that the global village appreciates the prob- lems, devastation, and concerns caused by communicable diseases that include tuberculosis, malaria, and HIV/AIDS. The emerging threat of Asian flu has increased this val- id concern and emphasis. However, non-communicable diseases/problems far outnumber communicable diseases in terms of mortality and morbidity (DALYs)*3-7 (Table I). Cardiothoracic surgeons are actively involved in the care of these major diseases worldwide. A huge outpouring of money and resources has been appropriately allocated to address these horrific diseases, yet more will be needed, as these non-communicable diseases increase, especially in the developing countries4,7 (Fig. 2). So, as the government (bilateral), multinational (mul- tilateral e.g. United Nations), non-government organiza- *DALYs: the sum of life years lost due to premature mortality and years lived with disability adjusted for severity7. 130 Cirugía Cardiovascular, vol. 13, Núm. 3/2006 10 tions (NGOs), medical societies, institutions, and competing specialties continue to argue, debate, and compete for di- rection and control of the best ways to analyze, approach, resolve, and resolve their differences, let us look at some alternate approaches to these problems. This hopefully will result in an array of practical/tactical initiatives that may well serve the global cardiothoracic surgical community, and perhaps alleviate, if not solve, the somber mood and flat affect we are witnessing today amongst our peers. In 2001, Dr. Jim Cox delivered a landmark presiden- tial address at the AATS meeting that reached out for global initiatives to address the global disparity in car- diothoracic surgery resources, care, and access1. This energized the 40-80 worldwide NGOs, and institutions long involved in volunteer/humanitarian efforts. A series of symposia, lectures and conferences have subsequent- ly been held over the past 5 years by the four major cardiothoracic surgical societies American Association for Thoracic Surgery (AATS); Socity of Thoracic Sur- geons (STS); European Association for Cardio-thoracic Surgery (EACTS); Asian Society of Cardiovascular Sur- gery (ASCVS), reporting a number of experiences, ini- tiatives, and proposals, and providing a forum for others to engage and present their own individual experiences and recommendations for future endeavors. The primary mission of the World Heart Foundation founded by Jim Cox is basically to help increase the quan- tity and quality of cardiothoracic surgery worldwide8. The major programs and initiatives to date include co-sponsor- ing and supporting three annual outreach conferences, and hosting three symposia on global cardiothoracic surgery at the last three annual AATS meetings. A humanitarian web- site (www.world-heart.org), readily available directly, or 1222 1,400 1,200 1,000 800 600 400 200 N um be r of c as es p er m il li on 0 No rth A me ric a Au str ali a Eu ro pe M ea n So uth A me ric a Ru ssi a As ia Af ric a 786 569 169 147 37 25 18 Figure 1. Discrepancies by region in access to cardiac surgery1,2. TABLE I. SELECTED DEATHS BY CAUSE IN WHO REGIONS FOR 2002*† Total deaths 57,029,000 – Cardiovascular diseases (CAD/CVD) 16,733,000 • Ischemic heart disease (CAD) 7,208,000 • Rheumatic heart disease 327,000 • Congenital heart abnormalities 281,751 – Tuberculosis 1,566,000 – Trachea/bronchus/lung cancers 1,243,000 – Road traffic accidents 1,192,000 – Esophageal cancer 446,000 *World Health Report 2004 (www.who.int/whr/2004/annex/topic/en/annex_2_en.pdf). †Krug EG. Injury surveillance is key to prevent injuries. Lancet 2004:364:1563-6. CAD: coronary artery disease; CVD: cerebrovascular disease. 30 Western countries Non-Western (devoloping) countries25 M il li on s of d ea th s fr om c ar di ov as cu la r ca us es 20 15 10 5 0 1990 9 2020 19 6 5 Figure 2. Cardiovascular deaths (Deaths from cardiovascular causes, worldwide, in 1990, and estimated for 2020 4,7). 131A. Thomas Pezzella: Oportunidad 11 from the CTSNet website, is evolving into a viable portal relating to information and news on global volunteer/hu- manitarian efforts/opportunities, as well as a vehicle for others to share their views and experiences. Working with a number of NGO affiliates and individuals, strategies for global partnership and support for a variety of projects and initiates are emerging. Examples include cooperation with the NGO Heart to Heart International (www.heart-2-heart. org) to help support new initiatives in Russia. Another re- cent project to help develop a model CT surgery residency in China is a basic attempt to help increase and improve an already existing and viable training system (www.world- heart.org). Now, let us consider some other practical/tactical proposals that hopefully may be of some interest. Let us divide the world into 10 regions, separated into three spheres by 8 h time zones (west/central/east) (Fig. 3). It is readily observed that there is imbalance of cardiotho- racic services in all regions, but the major challenges are concentrated in five regions. It is proposed that the spheres of influence be controlled and administered by the developed and emerging countries within that sphere, with occasional overlap, based on previous projects/pro- grams8. The surgeons and societies will look at and support those programs within their sphere. These pro- grams are of five categories9 (Fig. 4). Upscale are pro- grams where surgeons/teams go to learn sophisticated or modern approaches to cardiothoracic problems. Lateral programs are like sister affiliations with exchange of a variety of clinical/education/training/research/adminis- trative initiatives. The other three programs are unique to emerging or developing countries. Upgrade programs need exposure to advanced training and techniques, and to be supported financially until the local health care economy catches up. Rejuvenate programs involve re- establishing a program that has ceased, whereas de novo is a new program. The donors are those who can help, whereas the hosts are those that can also help, or are in need of help. As with most CT surgery programs there are four areas of practice (Fig. 5). Clinical initiatives include paying and non-paying patients coming to a donor coun- try for services, unavailable or unaffordable in the host country. It also includes individuals/teams/groups going to host countries, hopefully on a recurring short term basis to perform operations either independently or with the host team. Education/training initiatives occur in many ways and at many levels. The internet/web, especially the North America Europe China USA Western/Eastern Mongolia Canada Tibet * † * † § * § Central America North Africa India Pacific Rim Mexico Middle East Pakistan Central Caribean * † ‡ § * † ‡ § * † ‡ § * † § South America Africa Australia/New Zealand West/Central East/South * † ‡ § * † § * † Major concerns *Imbalance × 10 – Access to care – Finance – Level of care †Major health challenge × 5 – Disease (e.g. HIV) – Poverty – Violence/war ‡Volunteer programs – Donor × 8 §Volunteer programs – Host × 8 Figure 3. Global scheme – Ten regions. 132 Cirugía Cardiovascular, vol. 13, Núm. 3/2006 12 CTSNet, is the premier source of cardiothoracic related information/knowledge. In countries without library sup- port, journals/texts are hard to find or purchase. Meet- ings continue to be a valuable asset to learn, interact with new/old colleagues, and receive updated informa- tion re-equipment/supplies – product. Visionary efforts of the EACTS like the Bergamo school pioneered by Lucio Parenzan and Ottavio Alfieri (European School for Cardio-Thoracic Surgery) and the Multi Media Man- ual of CT Surgery (http://mmcts.ctsnetjournals.org/) de- veloped by Marko Turina have been invaluable to many CT surgeons, especially in developing countries, as well as short term observational opportunities, and accredited or non-accredited residency/fellowship training in devel- oped programs. Yet, the most valuable and most effec- tive modality remains on site, sustained training of not only surgeons, but the entire staff of the host team. This last effort is the most important and gratifying, since it helps provide increased local support, and satisfaction, decreases despondency and frustration, adds hope and enthusiasm, as well as curtailing emigration and “poach- ing” of qualified health care workers. Donor individual/ program/partner Upscale Lateral Upgrade Rejuvenate De novo Host individual/ program/partner Figure 4. Categories of cardiac surgery centers/programs/units9. Research – Ethical prospective clinical studies – Basic/bench initiatives at host programs where the pathology is prevalent Cardiac surgery program/Project Clinical Basic Clinical initiatives – Patients (paying/non – paying) to developed countries – Individual team support in developing host countries Education/Teaching – In support of clinical initiatives – Broad based telecommunication efforts – CTS Net A/P/L (Administrative/Political/Logistical) – Financing – Marketing examples of successful programs/ projects – Equipment/supplies – Product Figure 5. Cardiothoracic program structure. 133A. Thomas Pezzella: Oportunidad 13 Research, be it bench, bush, or bedside, is an impor- tant part of the overall effort. Helping with clinical case reports, technical advances, retrospective reviews, pro- spective studies, and basic reviews should be fostered and encouraged by the major journals, with a sustained effort to assist/help with English as a second language challenge. Again, present and future research opportuni- ties may be more practical and cost-effective in those countries where the relevant pathology is more wide- spread. Sir Magdi Yacoub delivered a provocative over- view of research in developing countries at The Global Thoracic Surgery Symposium at the 83rd annual AATS meeting in Boston, MA in 2003 (www.aats/o/index.html). He outlined valid reasons for research/development (R/D) in developing countries. This included developing local expertise, especially with talented individuals already in place and providing them an opportunity. Local R/D gives emphasis to recognizing local problems. It generates an- swers locally for specific problems, enhances dignity, and allows participation and contributions to global knowl- edge. He stressed the issue of funding, and offered some practical solutions, including targeting neglected, but im- portant diseases, cooperation between NGOs and multilat- eral/bilateral organizations/countries, as well as “twinning” programs between institutions. An example is the endo- myocardial fibrosis research joint project conducted in Maputo, Mozambique between Chain of Hope and the Harefield Research Foundation, and Imperial College. Administrative areas need but to look at existing models and projects as examples on where and how to get started. Alain Carpentier’s effort in Ho Chi Minh City is a model to study, as well as Aldo Castaneda’s program in Guatemala City, Guatemala, Sir Magdi Ya- coub’s work with Chain of Hope (www.chainofhope. org) and Richard Jonas’s monumental effort with Project Hope at Shanghai Children’s Medical Center in Shang- hai, China. Within each of the three major time zones sphere are long standing host programs to look at: e.g. Children’s Heart Link (www.childrensheartlink.org), In- ternational Children’s Heart Foundation in the USA; Dr. Kalangos’s “Hearts for All” association in Geneva, Swit- zerland10 (www.cptg.ch/en/start.htm); Dr. K.M. Cheri- an’s group in Chennai, India; and Hans Borst’s work in Russia11. At the society level the EACTS has taken a bold step in the establishment of an international com- mittee to explore further opportunities and projects par- ticularly in Eastern Europe and the former African colonies (www.eacts.org/committee/eacts/800). An important area that needs further development is an international data- base that initially collates the global number of centers, surgeons, and caseloads. Subsequent voluntary results and outcomes will follow12. This has been seen recently in a voluntary report of outcomes in Brazil13. Finally, at what levels should one get involved? CT surgery residents should get involved. Exposure to prob- lems like TB, rheumatic fever, and congenital heart dis- ease exist in emerging economies. Going and performing operations in a controlled, mentored fashion is both practical and beneficial to all involved. A recent example is in Uganda14. An international exchange of USA surgi- cal residents from the Department of Surgery of the University of California at San Francisco (UCSF) have a six week elective offering at Makerere University in Kampala, Uganda. This model should be studied close- ly as a future model for CT surgery programs in other countries. Practicing CT surgeons are divided into three groups (Fig. 6). Getting involved in volunteer/human- itarian work is dependent on the individuals own needs/ wants/values/expectations. Yet, it may well be that 10-20% of future paying job opportunities may be in the emerging economies. There is precedent for this. Not so long ago, CT surgeons ventured to several of the Middle East countries for short term lucrative employ- ment. In the future, with medical tourism going global, Figure 6. Surgical career. Premedical Idealistic/Learning stage Medical school Residency – Formative/Learning/Doing stage Practice Stage one – Adjustment phase Stage two – Productive phase Focused/Living stage Stage three – Downsizing phase Semiretirement Legacy stage Retirement TABLE II. QUESTIONS/REQUESTS* – Cardiothoracic surgeons seeking jobs or voluntary opportunities both at home/abroad – Cardiothoracic residents/trainees (both home/abroad) seeking further education/training opportunities be they: • meeting, observation sites, or • accredited non-accredited fellowships – Patient/family/friend/acquaintance/group/NGO seeking help for care/ surgery – NGOs seeking information, team recruitment, or free-donated pro- duct – Individuals/groups/corporate with available product/services to dona- te – Host (foreign) surgeons, teams, centers, countries seeking help/support for their programs *Most frequent E-mail questions/request over a two year period (2004-2006) to the author. 134 Cirugía Cardiovascular, vol. 13, Núm. 3/2006 there may well be future jobs in foreign countries for the adventurous type. The role of semi-retired/retired CT surgeons is a topic for expanded discussion. There are a variety of opportunities to consider: voluntary/humanitarian work, doing surgery, assisting surgery, or observing and giving valuable advice/recommendations. Mentoring is proba- bly the biggest and most effective role for this valuable and effective group of individuals. Floyd Loop has dis- cussed this extremely well15. In summary, there are questions (Table II), and there are opportunities. Gardner16 presented a blunt, yet hope- ful overview of the situation in the USA, with regards to training and job opportunities. He emphasized, as have others that bold and courageous decisions must be made at the training level. In the meantime, those who are in the midst of their practice, be it beginning, mid, or final phases, are looking for some hope and energiz- ing forces. It is somewhat tragic that cardiothoracic sur- gery has to suffer the perils of supply/demand, financial restructuring, outsourcing, and imbalance (Fig. 3). Cer- tainly, in the volunteer/humanitarian area the rewards are both valuable and invaluable to both the surgeon and those they serve9. Aristotle once said philosophy does not thrive on an empty stomach, and an old Italian prov- erb that without money the saints do not perform miracles. So while we are deliberating how to reach our personal and professional career goals, consider the world of volunteer/humanitarian work. It may help generate the fuel and energy needed to meet the challenges of op- portunity. Yet we realize that today’s needs and wants are real, and warrant attention, especially job and fam- ily satisfaction and security. A Chinese proverb that talks about the distant lake not satisfying the immediate thirst still has relevance today. “Wherever there is danger, there lurks opportunity; whenever there is opportunity, there lurks danger. The two are inseparable. They go together.” (A global perspective) Earl Nightingale El miedo, enfado, frustración y desesperación son fre- cuentes en la comunidad de cirujanos cardiotorácicos y vasculares y la alegría y satisfacción personal y profesio- nal han disminuido. La expansión inicial de la cirugía torácica y cardíaca ha disminuido tras el advenimiento de los antituberculosos por una parte, y por otra, por la acción de métodos de prevención, fármacos, sofisticados sistemas de dilatación y otros aparatos. Muchos ciruja- nos que abandonaron la cirugía torácica y la cirugía vascular durante la explosión de la cirugía coronaria han quedado sin experiencia en muchas áreas de conocimien- to. Es interesante observar el sentimiento de inquietud en la comunidad cardiotorácica. Algunas consideraciones acerca de esfuerzos voluntarios humanitarios podrían ayu- dar a suavizar o eliminar algunos elementos de este som- brío panorama. En las economías desarrolladas existe un contraste entre la disminución de ofertas de trabajo, salarios y cargas de trabajo en relación con el aumento de la com- plejidad, demandas del paciente o sociales, auditorías, mala práctica y exceso de cirujanos. Esto en el contexto de instalaciones sofisticadas y tecnología avanzada. Por otra parte, en los países en vías de desarrollo hay impor- tantes cargas de trabajo, listas de espera, aumento de necesidades, menor número de profesionales, menos compensaciones y recursos y apoyo gubernamental y financiero limitado. Comedia en unos y tragedia en otros escenarios. La población del mundo, de 6.500 millones, vive en 268 países y territorios (191 en la ONU). Hay unos 6.000 cirujanos cardiotorácicos en unos 5.000 centros, que rea- lizan unos 2 millones de intervenciones anuales y otros 3-4 millones de procedimientos no cardíacos intratoráci- cos. Las desigualdades en infraestructura y acceso han sido publicadas por Cox y Unger1,2 (Fig. 1). Parece evidente que existe preocupación acerca de los problemas y la devastación causados por enfermedades transmisibles como la malaria, SIDA, tuberculosis, siendo un ejemplo reciente muy claro el de la fiebre aviar. Sin embargo, las enfermedades no transmisibles son muy su- periores a las transmisibles en cuanto a morbimortalidad (DALY)3-7 (Tabla I). Los cirujanos cardiotorácicos están involucrados en el cuidado de estas enfermedades. A pe- sar de importantes presupuestos dedicados a estos temas, se necesitarán cantidades muy superiores, en especial en países en vías de desarrollo4,7 (Fig. 2). Mientras continúa el debate entre organizaciones gu- bernamentales, multinacionales (ONU) y no gubernamen- tales, sociedades médicas, instituciones y especialidades en competencia acerca de la dirección y control de las mejores formas de analizar y resolver esas diferencias, analizaremos abordajes alternativos. Éstos pueden servir a la comunidad cardiotorácica para aliviar estas perspec- tivas sombrías de las que hablamos. En 2001, el Dr. Jim Cox dedicó su conferencia pre- sidencial de la AATS a las iniciativas globales para li- mitar la disparidad global en los recursos, acceso y cuidado en la cirugía cardiotorácica1, potenciando a un total de 40-80 ONG de todo el mundo involucradas en esfuerzos humanitarios. Se han realizado encuentros y conferencias en estos años organizados por las cuatro 14 135A. Thomas Pezzella: Oportunidad sociedades principales (AATS, STS, EACTS, ASCVS), comunicando unas experiencias, iniciativas y propues- tas, proporcionando un foro de expresión para indivi- duos y organizaciones a la búsqueda de recomendaciones para el futuro. La misión principal de la World Heart Foundation (WHF) fundada por James Cox es ayudar a aumentar la calidad y cantidad de cirugía cardiotorácica en todo el mundo8. Los principales programas hasta el momento incluyen el patrocinio y apoyo de tres conferencias anua- les y la organización de tres simposios sobre la cirugía cardiotorácica global en las tres últimas reuniones de la AATS. Una página de internet humanitaria (www.world- heart.org) a la que se puede acceder directamente o a través de CTSNet ha evolucionado hacia un portal viable de información y noticias en relación con esfuerzos hu- manitarios y como vehículo para compartir experiencias. El trabajo de afiliados y miembros de ONG hace que aumenten las estrategias de cooperación globales. Algu- nos ejemplos incluyen la cooperación con la ONG Heart to Heart International (www.heart-2-heart.org) para inicia- tivas en Rusia. Otro proyecto reciente es la ayuda al desa- rrollo de un modelo de residencia en China, con vistas a mejorar un sistema existente (www.world-heart.org). Consideremos ahora otras propuestas que podrían ser de interés. Dividamos el mundo en 10 regiones, separadas en tres esferas por ocho husos horarios (oeste/central/este) (Fig. 3). Se aprecia un desequilibrio entre regiones, pero los retos principales se concentran en cinco regiones. Se propone que las esferas de influencia puedan llegar a controlarse y administrarse por los países desarrollados y en emergencia de esas esferas con solapamiento oca- sional en función de proyectos previos8. Los cirujanos y sociedades de esas esferas apoyarían esos programas, que serían de cinco categorías9 (Fig. 4). Los programas de desarrollo serían aquellos en los que los cirujanos o equipos aprenderían técnicas o abordajes sofisticados. Los programas laterales serían los de intercambio de iniciativas clínicas/educación/investigación/administra- tivas. Los otros tres programas serían únicos para los países en vías de desarrollo. Los programas de mejora necesitan entrenamiento avanzado y apoyo económico hasta que los sistemas de salud locales los incorporen. Los programas de rejuvenecimiento incluyen el restable- cimiento de programas que hayan cesado. Los donantes son los que podrían ayudar y los huéspedes los que podrían ayudar de forma parcial o están necesitados de ayuda. Como en todos los programas cardiotorácicos hay cuatro áreas de práctica (Fig. 5). Las iniciativas clínicas incluyen pacientes que acuden a países donantes para servicios no disponibles en el de origen. También inclu- yen individuos o grupos que se desplazan a países re- ceptores para realizar intervenciones de forma aislada o con los equipos locales. Las iniciativas de educación pueden desarrollarse de varias maneras. Internet, y en especial CTSNet, es la fuente principal de información. En países en desarrollo, las revistas y textos son difí- ciles de adquirir. Los congresos continúan siendo una forma de interacción. Esfuerzos visionarios como la escuela de Bérgamo de EACTS, organizada por Lucio Parenzan y Ottavio Alfieri, y el Manual Multimedia de Cirugía Cardiotorácica, desarrollado por Marko Turina (www.mmcts.ctsnetjournals.org), han sido de gran valor para muchos cirujanos, en especial en países en desarro- llo, así como para muy diversos programas de entrena- miento. La modalidad más valiosa sigue estando en el lugar de destino, el entrenamiento no sólo de cirujanos sino del equipo local completo, siendo el más gratifican- te ya que proporciona más apoyo a los locales, más satisfacción y disminuye la dependencia y frustración, añade esperanza y entusiasmo y limita la posible emi- gración de profesionales cualificados. La investigación es una parte importante. La ayuda con casos clínicos, avances técnicos, revisiones retros- pectivas, estudios prospectivos debería ser apoyada por las revistas principales, ayudando en el lenguaje inglés escrito. Las oportunidades de investigación presente y futura serán más prácticas en los países en los que hay enfermedad relevante. Sir Magdi Yacoub presentó una revisión provocativa acerca de la investigación en paí- ses en desarrollo en el Global Thoracic Surgery Sym- posium en la reunión 83 de la AATS en Boston en 2003 (www.aats/o/index.html), delineando las líneas de inves- tigación en esos países. Estas razones incluían el desa- rrollo de conocimiento local con individuos talentosos, proporcionándoles una oportunidad. El desarrollo local hace hincapié en el reconocimiento de los problemas locales. Genera respuestas para problemas específicos, aumenta la dignidad y permite la participación y contri- buciones al conocimiento general. Yacoub hizo hincapié en la financiación y ofreció algunas soluciones, inclu- yendo el ataque a enfermedades olvidadas pero impor- tantes, la colaboración entre ONG y organizaciones y países de forma bilateral o multilateral y la asociación de programas entre instituciones. Un ejemplo es el pro- yecto conjunto de investigación en fibrosis endomiocár- dica que se lleva a cabo en Maputo (Mozambique), entre la Chain of Hope, la Harefield Research Founda- tion y el Imperial College. Se necesitan áreas administrativas, pero estudiando modelos existentes. El proyecto de Alain Carpentier en Ho Chi Minh es un modelo a estudiar, así como los de Aldo Castaneda en Guatemala, el trabajo de Sir Magdi Yacoub con la Chain of Hope (www.chainofhope.org) o el esfuerzo monumental de Richard Jonas con el Project 15 136 Cirugía Cardiovascular, vol. 13, Núm. 3/2006 Hope en el Shanghai Children’s Medical Center en Shanghai. En las tres zonas principales que hemos men- cionado hay programas de larga evolución de los que hay que aprender, p. ej. Children’s Heart Link (www. childrensheartlink.org), International Children’s Heart Foundation en EE.UU., la asociación de Afksendiyos Kalangos en Ginebra Hearts for All10 (www.cptg.ch/en/ start.htm), el grupo del Dr. K.M. Cherian en Chennai (India) y el trabajo iniciado por Hans Borst en Rusia11. A nivel societario, EACTS ha dado un muy importante paso adelante mediante el establecimiento del Interna- tional Cooperation Committee para explorar oportunida- des futuras, y particularmente en Europa oriental y las antiguas colonias africanas (www.eacts.org/committee/ eacts/800). Un área importante que necesita desarrollo futuro es una base de datos internacional que recoja números generales de centros, cirujanos y casos. Datos sobre resultados llegarán de forma voluntaria en el fu- turo12. Esto puede comprobarse en un informe voluntario de actividades en Brasil13. Finalmente, en qué niveles debe centrarse uno. Los residentes deberían involucrarse. La tuberculosis, fiebre reumática y cardiopatías congénitas existen. La realiza- ción de intervenciones con supervisión es práctica y beneficiosa. Un ejemplo reciente está en Uganda14. Un intercambio de residentes de EE.UU. del Departamento de Cirugía de la Universidad de California, en San Fran- cisco (UCSF), ofrece una estancia de 6 semanas electivas en la Universidad Makerere, en Kampala. Este modelo podría estudiarse con cuidado como modelo futuro para programas en otros países. Los cirujanos practicantes se dividirían en tres grupos (Fig. 6). La participación en proyectos humanitarios depende de los propios valores y expectativas de los individuos. Podría ocurrir que el 10-20% de oportunidades de trabajo asalariado se pre- sentasen en las economías en fase de emergencia, y ya hay precedentes. Tiempo atrás grupos de cirujanos se desplazaron a Oriente Medio para empleos lucrativos de corta duración. En el futuro, con la transformación del turismo médico en un fenómeno global, podrían presen- tarse oportunidades de trabajo de este tipo. El papel de cirujanos retirados o semirretirados es un tema de discusión. Hay ciertas oportunidades para consi- derar: trabajo humanitario, realización de intervenciones, asistencia en cirugía o como consultor. La enseñanza es quizás el papel más importante y eficaz de este grupo tan importante de individuos. Floyd Loop lo ha discutido en detalle15. En resumen, hay preguntas (Tabla II) y oportunidades. Timothy Gardner16 presentó una revisión de la situación en EE.UU. relativa a los empleos y oportunidades. Las decisiones importantes deberían tomarse durante el en- trenamiento. Los que están a mitad o al final de sus carreras buscan nuevas energías. Es trágico que la ciru- gía cardiotorácica deba sufrir los peligros de la oferta y la demanda, de la reestructuración financiera, de la ex- ternalización y de los desequilibrios (Fig. 3). En la era de los esfuerzos humanitarios, las recompensas son va- liosas para los cirujanos y para los que se sirve9. Aris- tóteles dijo que la filosofía no sirve a un estómago vacío, y un viejo proverbio italiano dice que sin dinero los santos no hacen milagros. Así pues, mientras delibera- mos acerca de nuestros objetivos profesionales y perso- nales, consideremos el mundo del trabajo humanitario. Las necesidades del momento son reales y requieren atención. Un proverbio chino dice que hablar acerca del lago distante no satisface la sed inmediata, y ello todavía tiene relevancia hoy. BIBLIOGRAFÍA 1. Cox JL. Presidential address: changing boundaries. J Thorac Cardiovasc Surg 2001;122:413-8. 2. Unger F. Worldwide survey on cardiac interventions 1995. Cor Europaeum 1999;7:128-46. 3. Krug EG. 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