Global Expansion of Cardiac Surgery

The challenges of the 21st century are numerous. Against the background of environmental, economic, political, cultural, and social problems, the role of medicine and healthcare has become increasingly more important and dominant, especially in terms of cost and access. The world population stands at 6 billion, with a growth to 9 billion by the mid-21st century. There were over 55 million deaths worldwide in 1999 (The World Health Report 2000, (http://www.who.int/whr). Surprisingly, over 33 million were secondary to non-communicable conditions. Of these, approximately half were secondary to cardio- vascular disease. Ischemic heart disease accounted for over 7 million deaths, and rheumatic heart disease almost 400,000 deaths. Epidemiological transition is defined as a shifting of these chronic diseases to those countries and regions where there is improvement of social and economic forces. The emergence from famine, communicable disease, and pandemics to degenerative chronic disease has and will slowly occur.(2) This will place an increasing burden on the global healthcare system.

With regards to heart disease, many of the transition countries and economies are still faced with the "first wave" of infectious etiology (e.g., rheumatic heart disease and Chagas' disease).(3) As an example, the incidence of rheumatic fever remains one case per 1,000 children per year in Bangladesh. With a population of 120 million, the incidence is 20,000 new cases per year.(3) In a more recent survey in Yemen, the incidence was 3.6 per 1,000 (USA is 0.6 per 1,000).(4) At the same time, the incidence of Ischemic heart disease is rising in those developing countries where there is a rising lifespan, increased smoking, decreased infant mortality, and the unhealthy eating habits of Western society.(3)

Faced with this background, the cardiac surgeon of the 21st century must reassess his/her role in this "global village." The phenomenal growth and development of cardiac surgery is clearly a product of the last half of the 20th century. Within a short span of the 21st century, the artificial heart, xeno-transplantation, and genetic remodeling and transfer will be realized. This expansion, however, will be experienced primarily in the industrialized developed countries and economies. In recent years, with the dramatic impact of the Internet, communication has linked the international cardiac surgery community. More and more cardiac surgeons are aware of "what's going on." The cardiothoracic Surgery Network (CTSNet), pioneered by Drs. Ferguson, Replogle, Greene, and others has made basic and new knowledge readily available.(5) This transfer of knowledge is immediate, precise, and complete. The challenge of the Internet, however, is not to dehumanize the experience. Just as the doctor/patient relationship must be earned and nurtured, so too the relationship between medical colleagues. There is a tendency to think of "us" (i.e., those with the knowledge, experience, and resources) and "them" (i.e., those without the same). Paul Sergeant described the "Le Colloque Singulier" which stresses the equality between two partners of a relationships As this transfer of knowledge reaches an equilibrium, the quantitative disparity will dissipate and the qualitative phase of adjusting standardized databases and evidence-based paradigms will then dominate the Internet.

The major cardiothoracic societies have broadened their efforts to extend both the body of membership and the annual medical meetings to the international community. Again, Eugene Baudet stresses the need for direct relationships amid the fear that major annual meetings could be replaced by virtual meetings, thus replacing the transfer of knowledge with technology devoid of human interaction.(7) Additionally, the major cardiac surgery databases are now poised and ready to develop and expand an international database.(5),(8)

The American Society for Thoracic Surgery (STS) and the European Association for Cardio-thoracic Surgery (EACTS) should be congratulated in this endeavor. Caution, however, should be applied to expanding databases to the regional and international levels. Again, Sergeant stresses the point that the ultimate goal of database collection is not just an epidemiological survey, but a benchmark to achieve quality control.(6) However, quality control is a gradual process. It should not penalize or hinder the developing, struggling, or emerging programs. This would only hamper or hinder access to care as these new and struggling programs will become hesitant, timid, or in fact paranoid with regard to reporting their data.

At the academic and training levels, bold new initiatives are taking place. The concept of regional centers of excellence provides a logical and cost-saving mechanism to achieve standardization and parity in educations and training. Clearly, the major training centers in Europe and North America cannot accommodate the increasing number of trainees at the doctor of medicine (MD) or allied health level. Richard Jonas has highlighted the recent political constraints in the US.(9) New regulations in 1999 have limited the Educational Council for Foreign Medical Graduates (ECFMG) sponsorship for foreign medical graduates. Now rigid criteria and time restraints will be placed on non-accredited programs to obtain J1 visa (a training visa usually granted to physicians entering the US as residents or fellows) status for its fellows.

In contrast, David Cheung has outlined a bold training program in China which can well serve as a model for other Asian countries.(10) Additionally, there has been active growth in establishing regional centers of excellence in India. This has been sparked by a bold cooperation between industry and established cardiac centers. This is clearly an attractive strategy for large populations like China and India.

Two recent addresses generated an increased awareness and interest in this global expansion. Hans Borst nicely and succinctly presented an organized approach of Western European centers to help their Eastern European and Russian colleagues.(11) James Cox, in his presidential address at the recent STS meeting, presented a bold and challenging strategy to broaden and expand cardiac surgery globally. His recommendation of the utilization of regional Internet consultations and regional referral centers are certainly innovative and worth exploring. Financing these endeavors will require corporate and government support. This address will certainly spark off increased interest and initiatives, as well as debate and controversy.

Evolving Global Approaches to Cardiothoracic Surgery

A. Thomas Pezzella, MD
(Posted 12/31/06)

Abstract

The incidence and prevalence of cardiovascular disease continues to increase globally, especially in emerging economies and developing countries. Cardiothoracic surgery also is growing, despite decreased access availability of surgical centers, and cost issues. The increase in incidence and prevalence of atherosclerotic coronary artery disease, rheumatic heart disease, congenital heart disease, trauma, and thoracic malignancies is a more urgent problem or challenge than realized in these emerging economies and developing countries. A determined focus and cooperation between the preventive and curative elements of core is warranted. This represents a paradigm shift of shorts to develop a consensus that brings together a team approach that includes prevention, promotion, diagnosis, treatment, and rehabilitation.

I keep six honest serving-men
(They taught me all I knew);
Their names are
What and Why and When and How and Where and Who
Rudyard Kipling

Introduction

The world population stands at 6.5 billion people with an annual death rate of 57 million. Cardiovascular disease (CVD) remains the number one annual cause of mortality with more than 17 million deaths per year. These and other diseases of major concern to cardiothoracic surgeons are summarized in figure (1) 1, 2.

The traditional individual approaches of preventive and curative strategies, though productive in the developed economies, have not had a major impact on reversing the overall trend. In fact, the incidence of cardiovascular disease continues to rise, in emerging economies. Clearly a new strategy or paradigm shift is warranted. This mandates increased cooperation between the preventive public health sector and the curative patient oriented sector. The product line or the cardiovascular disease specific approach encompasses prevention, promotion, diagnosis, treatment and rehabilitation. Strategic or organizational elements combine with tactical or managerial elements to build a consensus that is collaborative and not competitive or adversarial. The horizontal concept is nothing more than turning the flow of prevention or care from the pyramidal or vertical flow to a more practical mode where all aspects of health care are handled at the same time. All five elements are approached concomitantly, rather than the World War concept of attacking the beaches in waves. This horizontal flow of care is practical and cost effective. (Figure 2) Future models and trials will be necessary to test this hypothesis or paradigm shift i.e. a reorientation of thinking about this devastating problem or challenge. The traditional vertical or hierarchical pyramid model is no longer practical or cost effective. (Figure 3) 3 The more for less must compromise with the less for more concepts. Sub Saharan Africa (SSA) will be highlighted, since it represents the least served region of the world with regards to health care, especially cardiovascular disease. Background

This world population of 6.5 billion people lives on 29.2% of the earth's surface, the remaining surface being covered with water. This population occupies 193 countries, 61 dependent areas, and 6 disputed territories. In contrast to the annual world mortality rate of over 57 million, there is an annual overall population growth rate of 1.14% or 80 million more people per year increase in overall world population. The global birth rate of 20-24 births/1000 population, and the death rate of 8.86 deaths/1000 population is almost double in SSA. The global life expectancy is 64.05 years compared with less than 51 years in SSA. 4, 5, 6 Further insight into SSA reveals that eight of the top ten countries with the highest infant mortality rate are in Africa. The human development index (HDI ) 7, which is an indicator of quality of life, again reveals that 27 of the top 30 countries in the world with the lowest HDI are also in Africa. HIV/AIDS infects 34-46 million people worldwide with 25.0-28.2 million cases in SSA. 2.2-2.4 million of the annual 3 million deaths secondary to HIV/AIDS are in SSA. The global prevalence rate of 0.9-1.3% is 7.5-8.5% in SSA. This background perspective is necessary as we develop the case for increased concern for non-communicable diseases, and try to strike a balance in priorities.

* HDI – In 1990-1991 the United Nations established the Human Development Index that includes GDP or GDP per head, adult literacy, average years of schooling, and life expectancy Scaled 0-100, with >80 as high, 50-79 as medium, and <50 as low.

The reasons for this disparity in SSA can be attributed to many causes. Simply stated the social, political, economic, environmental (geographic), and demographic factors (SPEED) are the basic elements. Unfortunately, government financing of education and health care are not high priority in most countries, but especially developing countries or emerging economies. (Figure 4) The debate between the Neo Malthusians who believe the growing world population is unsustainable and the Technocentrists who believe that emerging technologies can and will support a rising world population, continue to evoke a sustained emotional response. In summary, ego or the human factor, and money or economics play dominant roles in the overall approach to the challenge of improved, and equitable health care access, evaluation, and treatment.

Given this broad background of the global and the African example, let us focus further on the health statistics. Of the 57 million worldwide deaths in 2002, over 18 million were from communicable diseases, more than 33 million from non-communicable diseases, and over 5 million from injuries.8 A projection for 2005 is summarized in Figure 5 6. Of interest to Cardiothoracic/vascular (CTV) surgeons are the deaths attributable to cardiovascular disease (CVD), thoracic malignancies, and trauma. (Figure 1) Despite on overall decreased prevalence in SSA, the incidence of death from CVD rose from 8.15% in 1990 to 9.20% in 2000. This incidence continues to rise. Surprisingly violent trauma is less prevalent than blunt trauma. Road accident mortality in SSA is > 25/100,000 in contrast to 15/100,000 in the Americas. 8 Smoking, hypertension, stress, diet, and lifestyle changes will continue to impact on regions like SSA with a resultant increase in non-communicable diseases, especially ischemic heart disease, lung cancer, and trauma. It is estimated that over 80% of all CVD, cancer, and other chronic disease deaths in 2005 will occur in emerging economies6.

What are the resources now present worldwide to deal with this present situation. Unger9, Cox10, 11, and Pezzella12 have summarized nicely the present situation, as well as proposing plausible strategies and recommendations. Briefly, there are over 1.5 million open-heart operations done each year worldwide by over 6,000 surgeons, in over 3,000 centers or units. Unfortunately only 2 billion of the world 6.5 billion population has access to these operations. There are 1222 open-heart operations per million population in North America, compared to 18 per million in Africa. This translates into 1 center per 120,000 people in the USA to 1 center per 33 million people in Africa.

Strategic Initiatives
The challenge to increase and improve Cardiothoracic/Vascular surgery must recognize and understand the SPEED constraints. There must be a consensus that the project/program will succeed and be sustained. If the feasibility study for any given country or program is possible then a planned strategic/tactical approach can and should be undertaken.

The strategy for the development of cardiac surgery should consider this integrated horizontal product line concept. What this means is the collaboration of the public health and curative health sectors to foster the prevention, promotion, diagnostic, therapeutic, and rehabilitation elements of cardiac disease. This represents a major paradigm shift. Prevention examples include programs for rheumatic fever, maternal health and nutrition. Promotion encompasses the appropriate teaching of both health care workers and the general public on all aspects of preventative medicine with again specific programs for rheumatic fever, rheumatic heart disease, maternal health and congenital heart disease, the risks of the western diet, smoking, hypertension, and road safety. Diagnostic capability requires increased recognition and documentation of those with cardiothoracic diseases/problems. As another example, low cost portable ECHO machines (eg Acuson Cyprus) provide ready diagnostic capability in outreach scenarios. Strategies to train physicians and technicians to teach and foster these promotion programs, as well as perform basic diagnostic tests remain a major challenge. The therapeutic and curative element is broad based to include invasive, interventional, and surgical modalities. Collaboration and cooperation vs. competition and confrontation for effective, sustained, and cost effective therapeutic modalities should be advocated and promoted. Finally, follow-up care and rehabilitation gets people back to a sustained functional and productive lifestyle. A major modality to assess long term effects of disease, be it communicable or non-communicable is the DALY. Developed by Murray et al 13 this measurable technique highlights the importance of a holistic approach to health care.

+ Paradigm Shift - A term coined by Thomas Kuhn in 1962 in his book “The Structure of Scientific Revolution” (2nd edition, 1970, U. of Chicago Press, Chicago). “Scientific advancement is not evolutionary, but rather is a series of peaceful interludes punctuated by intellectually violent revolutions, and in those revolutions, one conceptual world view is replaced by another.” (www.taketheleap.com/define.html)

Tactical Initiatives

Against this background let us examine a tactical example approach to advancing Cardiothoracic surgery in SSA. With the exception of sustained programs in Sudan, Ghana, and South Africa, most of the existing or soon to start programs in SSA face enormous political and economic challenges. Without short-term (3-5 yrs) foreign or international support, these programs will have difficulty and many will fail. Financial support and political willingness are necessary for long-term success. This will require an organized political lobby to present to the particular local governments and funding agencies a cohesive and organized plan to start, support, and supplement cardiothoracic surgery units/programs in any one given country. Partnerships within the private sector are a practical alternative in some countries like India. Insured or paying patients can support a cardiac program, and be profitable for the investors as well. Built into these programs are financial funding for a percentage of free or discounted core for indigent patients. Future scenarios include a combination of government and private cooperative endeavors. This is being seen in a few centers in China. All this will require dedicated leadership with both vision and attention to practical managerial challenges. Again, it must be stressed to the funding agencies that non-communicable diseases and trauma are rising with a significant impact on the health care sector. Let us consider the four aspects of a cardiothoracic/vascular program, center, or unit: clinical; educational/ training; research/development; and financial/administrative/political/logistical elements.

Clinical

Most agree that the incidence/prevalence of cardiothoracic diseases is increasing. Paying or non-paying patients going abroad is of limited practical value, considering the cost and the logistical difficulties - visa, housing, rehabilitation, and uncoordinated, insufficient, or non-existent follow-up at home. Yet paying patients will continue to go abroad for high cost, sophisticated care, until such times that the local center(s) offers comparable quality care and services. Not surprisingly, sophisticated cardiac surgeons and programs in some countries like India are attracting paying patients to come to India for lower cost and state of the art care. Outsourcing is a growing business in overall health care.
Regional referral centers offer a better solution as a temporary or, even long-term situation. As an example, there are several centers in South Africa that offer a model to study and consider (Walter Sisulu Pediatric Cardiac Centre for Africa in Johannesburg and the Christian Barnard Memorial Hospital in Cape Town). This may be a practical solution for neighboring countries. It is recognized that most countries eventually want their own program. Additionally, training for future programs is within their scope of interest and influence. Also, it is easier to start an adult program in places that are new or being upgraded. Pediatric procedures are phased in progressively according to age, weight complexity, and experience/development of the medical staff.

Education/Training

The internet, especially the www.ctsnet.org offers a wealth of information, skills, knowledge, and technology for the Cardiothoracic/vascular surgeon. At the humanitarian level the World Health Foundation www.world-heart.org has organized a website that will improve communication between individuals and NGO's (non-government organizations). This will facilitate sharing information with regards to needed programs or projects, resources, and thus matching these efforts in a collaborative way. In SSA developing a relationship with a foreign program, especially Europe is of practical value, as well as in neighboring countries with successful programs e.g. South Africa, Ghana, and Sudan. Outside of South Africa, there are no organized, standardized Cardiothoracic/vascular residency programs in SSA. A Pan-African initiative, like the Pan-African Society of Cardiology (PASC), may be a practical approach. Utilizing the knowledge of other African surgical societies like the West African College of Surgeons, and the Society of Cardiothoracic Surgery of South Africa can strengthen this unity and collaboration. The initiation of a dedicated journal, like the African Annals of Thoracic and Cardiovascular Surgery is another major step forward in stimulating clinical reporting of results and disseminating information amongst the African Cardiothoracic/vascular surgical community.

Research/Development

Certainly not a priority, but ultimately of major benefit and importance is the initiation of bench research, followed by clinical research. Foreign programs are showing an increased interest in research of diseases where there is a high prevalence e.g. HIV/ AIDS, malaria, rheumatic fever and tuberculosis.14 Establishing research centers in the area where the pathology is prevalent is both cost effective and practical. A word of caution is to establish strict guidelines according to internationally accepted standards, in recruiting clinical subjects.15 The Chain of Hope initiative at the Maputo Heart Institute in Mozambique is a notable example of this type of effort. (www.chainofhope.org)

Financial/Administrative/Political/Logistical

Multilateral agencies (United Nations; World Health Organization) are eager to develop collaborative strategies. Bilateral Agencies like the United States Agency for International Development (USAID) are working more with private voluntary agencies, as opposed to direct financial help to governments. Debt relief for emerging economies will provide needed short term relief, but health care is a low financial priority for most struggling economies. Non-government organizations (NGOs), also called Private Voluntary Organizations (PVOs) have been a major source of support. Yet this support is short term, usually 3-5 years. The private sector has enjoyed a healthy growth in some emerging economies eg. India. This is due, in large part, to a growing middle income group that can acquire private insurance, or self-pay. Overall bilateral foreign aid to emerging economies will not substantially increase over the insuring years. (Figure 6) A negligible share of that aid goes to health care initiatives. The United Nations in 2000 established the Millennium Project and issued the Millennium Development goals (Figure 7) 16. Unfortunately direct aid or goals for non-communicable diseases is not addressed. This project remains bogged down in strategy development, with a subsequent loss of time and money. This is highlighted by poor goal results at the 5 year assessment stage. As with many projects and initiatives more is accomplished with less financing by local, smaller groups and organizations. Targeting focused financial aid to these effects would pay much greater dividends.

A major problem in developing or emerging programs is the exodus of trained health care workers to developed programs. This "brain drain" is understandable on a personal level, but certainly not on a national or regional level. As an example, one-fourth of all physicians in the USA are international medical graduates.17 Nurse poaching is a severe problem, especially for Africa. This is especially true in South Africa.18 Training and retaining health care workers, especially doctors and nurses is crucial for overall health care planning, let alone cardiothoracic programs.

The host program(s) must have administrative and political support. This includes an organizational structure that minimizes bureaucracy, fraud, corruption and ego agendas. Foreign financial support, at best, is short term. Innovative, cost effective strategies with prudent management and attention to a disease oriented horizontal model may yield more effective long-term results.

The issue of product, i.e. equipment and supplies, be it disposable or non-disposable is another major problem. Donations are short term. Old donated equipment, or even newer equipment has problems insofar as preventive biomedical maintenance is concerned. Parts are a problem and equipment is frequently cannibalized to get needed parts. Logistical problems with customs and distributors also pose challenges. Inventory and organization is sorely needed in many programs. Ultimately the financial burden of obtaining the needed items for surgery falls on the patient and family since governmental or private insurance is unavailable or unattainable. Unfortunately, corruption at all levels not only drains financial sources, but has a major negative impact on all initiatives.

In summary, the challenge for the initiation and sustainment of Cardiothoracic/vascular surgical programs is a difficult, but attainable goal. Cooperation and collaboration should take priority over conflict and competition. It is easier to compete and develop incentives later when basic services are established. It is imperative that concerned physicians and health care workers consider the horizontal model. Gaining widespread attention to the problem of cardiovascular disease in emerging countries is crucial to gain public support, and access to the financial sources to start and sustain this effort. Teamwork remains the key ingredient to the success of this approach. Integration of a paradigm shift begins with the appreciation and realization that the present system can be improved and accelerated to meet this growing problem or challenge. Ultimately, a consensus can be achi8eved that approaches 4 problems or challenges (Figure 8):

(1) Equitable access to quality care, both preventive and curative.

(2) Affordability and cost-effective, recognizing that the major sources for financing are government, private insurance, or personal/family income.

(3) Sustainability i.e. strategies to continue financial and medical support to meet the increasing demand posed by aging populations, and increased non-communicable/chronic diseases, especially CVD.

(4) Accountability - Quality assurance, risk assessment, and database systems to insure transparency of the system for all to study, evaluate, criticize, improve, or reject.

The seemingly illusive goal to improve the quality and quantity of care for the patients we serve can be achieved

"You can accomplish anything in life, provided that you
do not mind who gets the credit."
Harry S. Truman

References

World Heart Report 2004. World Health Organization Statistical Annex p121-125.
Comment: Injury Surveillance is key to preventing injuries. Lancet 364:1564, 2004.
Hyder, AA, Morrow, RH. Chapter 1 - Disease Burden Measurement and Trends. In: Black, RE, Mills, AJ, ed. International Public Health, Gaithersburg, Maryland, Aspen Publishers. Merson, MN, 2001, p4.
Time Almanac 2005. Pearson Education, Inc. p. 553-554, p. 706-112.
World Fact Book - Central Intelligence Agency
http://www.cia.gov/cia publications/factbook/geos/xx.htm.
Fuster, V, Voute, J. MDGs: Chronic diseases are not on the agenda. Lancet 2005; 366:1512-1514.
The Economist - Pocket World in Figures, London, UK. Profile Books Ltd, 2006.
Mock C., Quansah, R., Krishnan, R., Arreula-Risa, C., Rivera, F.Strengthening the Prevention and Care of Injuries Worldwide. Lancet 2004; 363:2172-2179.
Unger, F. Worldwide Survey on Cardiac Interventions, 1995. Cor Europaeum (1999) 7:128-146.
Cox, JL Changing Boundaries. J. Thorac Cardiovasc Surg 2001; 122:413-418.
World Heart Foundation: Our Approach to Improving Cardiac Surgical Services in Developing Countries
http:// www.world-heart.org/doc/8862
Pezzella A.T. International Cardiac Surgery: A Global Perspective Seminars in Thoracic and Cardiovasc Surgery 2002; 14:298-320.
Murray, C JL, Lopez, AD. Regional Patterns of Disability - free life expectancy and disability-adjusted life expectancy: Global Burden of Disease study. Lancet 1997; 349:1436-1442.
Yacoub, M. The Importance of Research at the Local Level in Developing Countries. American Association of Thoracic Surgery (AATS) 83rd Annual Meeting, Boston, MA, May 7, 2003.
Shapiro, H.T., Meslin, E.M. Ethical Issues in the Design and Conduct of Clinical Trials in Developing Countries. N. EngI J Med. 2001;345:139-141.
Sachs, JD, Mc Arthur, JW. The Millennium Project: a plan for meeting the Millennium Development Goals. Lancet 2005; 365:347-353.
McMahon, G.T. Coming to America - International Medical Graduates in the United States. N EngI J Med. 2004; 350:2435-2437.
Nelson, R. The Nurse Poachers. Lancet 2004; 364:1743-1744.

Figure 1

Selected Deaths by cause in WHO regions for 2002 ⁽¹⁾

Total Deaths
1) Cardiovascular diseases
     a) Ischemic Heart disease
     b) Rheumatic Heart disease
     c) Congenital heart abnormalities
2) Tuberculosis
3) Trachea/bronchus/lung cancers
4) Road traffic accidents
5) Esophageal cancer

57,029,000
16,733,000
7,208,000
327,000
281,751
1,566,000
1,243,000
1,192,000 ⁽²⁾
446,000

(1) World Health Report 2004 (www.who.int/whr/2004/annex/topic/en/annex2en.pdf)

(2) Comment: Injury Surveillance is Key to preventing injuries Lancet 364:1564, 2004

Figure 2

Horizontal Approach

Prevention/Promotion/Diagnosis/Treatment/Rehabilitation

Streaming Concept within a single institution, or multiple institutions within one geographic area

* Braithwaite, J. Goulston. Turning the health system 90°down under. Lancet 2004; 364:397-399.

Figure 3 ⁽³⁾

Public Health/Preventive Focus Curative Care Focus

(3) Adapted from Hyder AA, Morrow, RH. Chapter 1 - Disease Burden Measurement and Trends. In: International Public Health, Gaithersburg , Maryland, Aspen Publishers Merson MH, Black, RE, Mills, AH, ed. 2001, p4

Figure 4

Health Indicators in E-9 Nations
Country	Health Expenditures Per Person, 1990-98	Population, 2000	Gross National Product, 1998	% of GNP for Health Care *
	(dollars of purchasing power)	(million)	(billion dollars)
United States	4,121	276	7,903	12.9
Germany	2,364	----	----	10.5
European Union	----	375	8,312	----
Japan	1,757	127	4,089	7.2
South Africa	571	43	137	7.2
Brazil	503	170	768	6.5
Russia	404	145	332	4.6
China	142	1,265	924	5.1
India	73	1,002	427	5.4
Indonesia	38	212	131	1.6

SOURCE: World Bank, World Development Indicators 2000 (Washington, DC: 2000), 90-92, 102-04, 106-08.

SOURCE: World Bank, World Development Indicators 2000 (Washington, DC: 2000), 10-12; Population Reference Bureau, “2000 World Population Data Sheet,” wall chart (Washington, DC: June 2000).

* The Economist – Pocket World in Figures. London, UK. Profile Books Ltd. 2003.

Figure 5

Projected global deaths by major causes, all ages, 2005 (6)

Figure 6

Development Assistance Contributions, Top 15 Countries and Total and 2000
	2000
Country	Total	As Share of GNP
	(million 2000 dollars)	(percent)
Denmark	1,664	1.06
Netherlands	3,135	0.84
Sweden	1,799	0.80
Norway	1,264	0.80
Belgium	820	0.36
Switzerland	890	0.34
France	4,105	0.32
United Kingdom	4,501	0.32
Japan	13,508	0.28
Germany	5,030	0.27
Australia	987	0.27
Canada	1,744	0.25
Spain	1,195	0.22
Italy	1,376	0.13
United Stated	9,955	0.10
All Countries	53,737	0.22

Source: Organization for Economic Co-operation and Development (OECD), “ODA Steady in 2000; Other Flows Decline,” 12 December 2001; OECD, Development Assistance Committee, Development Assistance Committee Online, updated 30 January 2002; OECD, Development Assistance Committee, Development Co-operation 1993 (Paris: 1994), pp. 168-69.

Figure 7

Millennium Development Goals ¹⁵

1 Reduce extreme poverty and hunger by half relative to 1990

2 Achieve universal primary education

3 Promote gender equality and empowerment of women

4 Reduce child mortality by two-thirds relative to 1990

5 Improve maternal health, including reducing maternal mortality by three-quarters relative to 1990

6 Prevent the spread of HIV/AIDS, malaria, and other diseases

7 Ensure environmental sustainability

8 Develop a global partnership for development

Figure 8

Increase in overall quantity and quality of services

Global Aspects of Cardiothoracic Surgery, 2010
(400k PDF File)

	International Children's Heart Fund
	Overview