Cardiology becoming an extinct specialty in SA

Patients with cardiovascular diseases in South Africa could be left with little or no access to care if plans are not implemented to address what has been described as the “profound deficiencies” that exist to train enough cardiologists, cardiothoracic surgeons and paediatric cardiologists in the country. SA HeartÒ estimates that there are currently only 140 to 150 practicing cardiologists in South Africa. Of them, fewer than 20 are working in the state sector with several provinces having to cope without any cardiologists in the face of a growing population, a significant rise in heart disease, limited training opportunities, an increasing case backlog, a severe lack of equipment and infrastructure, and a growing disease burden.

Compared to figures cited in a position paper SA HeartÒ published in 2016 on the lack of training opportunities for cardiac subspecialties, South Africa has lost a number of cardiologists in the past six years of whom many have retired, died or left the country. Meanwhile, a lack of posts for consultants to train future cardiologists and very few posts available for fellows and those who qualify, remain serious obstacles to training more specialists in the field.

“Having only around 140 to 150 cardiologists in a country with a population of more than 60 million and only 20 looking after the health of more than 80 percent of patients is an impossible situation,” says Dr Blanche Cupido, outgoing president of SA HeartÒ and senior clinical and interventional cardiologist practicing at Groote Schuur Hospital and UCT Private Academic Hospital.

The Covid-19 pandemic has contributed further to an already dire situation.

“The bottom-line is, we were drowning before Covid. Now it is far worse because of the added backlog that developed during the pandemic as people were not coming for check-ups or presenting to doctors timeously, leading to situations that could have been dealt with timeously and more efficiently, now having become much more advanced,” she explained.

Emphasising that the low number of cardiologists is not due to a lack of interest in the specialty, Dr Cupido cites a decline in the number of consultant and training posts as the two main reasons for the dire shortage. This is compounded by a training and working environment that is getting less and less attractive and no strategy in place to retain specialists once they have qualified.

“You need an academic core at training hospitals to be able to train cardiologists and that is non-existent in some institutions. So, the pipeline doesn’t get fed, which could eventually lead to South Africa ending up with no cardiologists at all in the public sector and no adequate ability to train,” she warned.

In the past few years, the number of cardiologists qualifying in the country has dwindled to less than 10 a year and is expected to decline further owing to the lack of functional training centres. Included in this number are foreign fellows funded by their governments or themselves to study and work in South Africa. In many ways, they are a saving grace to the state sector as they don’t need paid posts but once qualified, they return to their home countries.

At Groote Schuur there are only four paid posts for fellows training as cardiologists. Another four have their own funding for the time they are being trained and are being utilised to work at the academic hospital for the four years they are specialising.

“We train them like we train our own doctors and for that four years you have doctors in the system that wouldn’t have been there otherwise without government having to pay for their labour,” noted Dr Cupido.

Lack of indemnity cover

Furthermore the lack of indemnity cover provides a major obstacle for private specialists to work in state. Dr Cupido says getting private cardiologists to do sessions in the public sector could offer some relief but that the lack of indemnity available to them when working in the state is a major stumbling block.

“Government covers only public doctors and medical protection providers only offer indemnity to private doctors when they work in the private sector but not when they assist in the state. Cardiology is a very procedure-driven specialty – not to be covered should something goes wrong is a huge risk for both the private specialist and the state facility,” Dr Cupido elaborates.

“If medical protection insurers can provide an option where it can, for example, offer limited cover to private doctors doing pro bono work in the state, many private cardiologists would opt to do this. It is something that needs to be considered in the next couple of years as it would make a huge difference to the services available in the state.”

Heart disease prevalence on the increase

In the past decade, heart disease prevalence has become massive in South Africa with one in five people suffering a stroke, one in three having hypertension and up to 240 myocardial infarctions a day.

However, South Africa’s disease burden with its combination of first- and third world diseases makes it challenging to plan and prioritise.

“The dilemma is you have an overwhelming burden with limited resources that all demand attention. NCDs haven’t raised the same awareness as communicable diseases in the past. If I say to you there is an Ebola outbreak for instance, everyone goes into a panic. When I say to you there is someone who had a heart attack, you go, ‘it doesn’t affect me directly’. So, communicable diseases raise more public health attention because of the potential impact on the whole of the population,” Dr Cupido explains.

“That is why a well-functioning primary healthcare system is key to address the country’s growing burden of non-communicable diseases (NCD)s by keeping risk factors for serious disease in control,” she added.

NHI – emergency services need to be prioritised

Asked about National Health Insurance’s possible role to solve some of the state’s dire problems, Dr Cupido says while it is in principle a potential solution to a system where wealth is a determining factor in access to health services, there are issues that need to be separated out as urgent priorities.

This includes coverage for emergency care for state patients at private facilities. Currently, at times, the down-payment that patients without medical aid must pay before they can be treated in a private emergency unit is not only an impossible requirement for most South Africans but also delays lifesaving medical treatment.

“Because of the bad publicity, and often suboptimal service, around state facilities, the average person with an emergency will prefer to present themselves at a private hospital to find out that they cannot afford care. Without money they are frequently transferred to the state, and often, in the case of myocardial infraction, outside the window to make a meaningful therapeutic difference. A potential advantage of the NHI (if it could be implemented successfully) could potentially aid the emergency care of indigent people presenting into the private sector.”

In the meantime, Dr Cupido says, the creation of more training posts is a vital necessity to start addressing the massive gaps to provide cardiology services.

But says Dr Cupido, there are positive signs that the Department of Health is starting to realise the urgency of the situation leading to what she terms “increased engagement” including a CVD Indaba at the end of last month.

“This is very encouraging, but we must be very careful how we manage these engagements. Going into meetings pointing fingers won’t help. Our aim should be to convince the department to recognise that our concerns are valid and consider our input on how the challenges can be addressed to bolster the production of more cardiologists and create an environment conducive to the delivery of quality care to the thousands of CVD patients who are struggling to access proper and timeous care,” Dr Cupido concluded.