By: Francis Robicsek, MD, PhD
President, Heineman Foundation of Charlotte
For decades, Central America has remained well behind in its medical progress compared to what one may see in industrialized countries. Among the six countries in the subcontinent, only Costa Rica had well-organized cardiac care and cardiac surgery. These services, in the rest of Central American countries, were either vastly inferior or non-existing. Even today, one may see only a few occasional cases performed by fledging cardiac surgical programs or by visiting “brigades” of cardiac teams from the United States and Europe. The general public in these countries receives no consistent cardiac surgical care. The rich fly to Mexico City or to the United States.
I have always been very interested in Central American archeology, and in the 1960s and 1970s spent most of my free days roaming the Maya ruins of Guatemala, the site of the once magnificent Maya civilization. On one of my Mayan jaunts in 1971, I was introduced to the country’s President by my friend, Dr. John Keshishian, a thoracic surgeon from Washington, D.C. I met President Carlos Arana Osorio, who was also deeply interested in pre-Columbian cultures.
One evening, sitting at the campfire, the President asked me, “What do you do when you are not in the jungle?”
I replied, “Mainly operating on hearts.”
He suddenly became very interested and asked, “Do we have heart surgery in Guatemala?”
“No,” was my answer.
I did not have to wait too long for the next question: “Could you make it possible?”
“Yes,” I said, “but you have to help me.”
From there on, it was only a matter of time. The fact that the President was personally involved rapidly cut through the usual Central American bureaucratic maze. The Guatemalan Ministry of Health assigned a young Baylor-trained Guatemalan surgeon, Dr. Raul Cruz Molina, as the future head of the cardiac program in Guatemala. Dr. Cruz immediately flew to Charlotte, N.C., where he began an 18-month intensive cardiac surgical fellowship. Simultaneously, his supportive team of cardiologists, anesthesiologist, perfusionists and intensive care nurses traveled to Charlotte to train at Carolinas Medical Center, then known as Charlotte Memorial Hospital. For these training opportunities, we operated on a shoestring budget. The Guatemalans usually stayed with their hosts, so the only costs incurred was the air fare. At the same time, we were able to procure used and refurbished perfusion equipment and vital-sign monitors. In 18 months, the Guatemalan team was ready to initiate the program.
In 1974, supported by a grant from the Heineman Foundation of Charlotte, we returned with our friends to Guatemala and carefully selected some patients with relatively simple anomalies, atrial and ventricular septal defects and pure mitral stenosis as the first surgical candidates. The diagnostic studies were made in Charlotte. The great day arrived. The Guatemalans were backed by a full Charlotte team of eight. The operations went smoothly and the patients came through well. We usually slept after surgery in the Spartan recovery room.
The program proceeded in an orderly fashion. Dr. Cruz gradually accepted more and more complex cases. Soon, however, it became evident that the trafficking of patients between Guatemala and Charlotte for diagnostic studies would exhaust our limited financial resources. So we called on the President, again. After that conversation, a Guatemalan Air Force transport plane regularly landed at the Charlotte Douglass International Airport, carrying between 35 and 40 patients in need of diagnostic studies. Those who required additional testing underwent heart catheterizations around the clock. It was a most welcome event that Dr. Federico Alfaro, now a renowned cardiologist practicing in Guatemala but then a resident in Houston, Texas, arrived to Charlotte at midnight and joined our efforts after hearing of the project. After being diagnosed, the patients were flown back to Guatemala, where those who in need of surgery were operated on by Dr. Cruz and his care team, still actively supported by a cardiac team from Charlotte.
The situation changed gradually. In 1976, with Dr. Cruz steering the ship, the cardiac program was officially established in Guatemala City at the Roosevelt Hospital, the largest health institution in Guatemala. The team at Carolinas Medical Center continued its supportive role but, within a year, the number of visiting Charlottean clinicians gradually decreased from eight to three and, finally, to none. By and large, the Guatemalans were on their own in the Operating Room.
During the next three decades the cardiac program in Guatemala City grew from a service of a half a dozen beds to a modern Department of Cardiac Surgery, which not only performed an important clinical task but also served as the first nucleus of training of Guatemalan cardiac surgeons. The year 1989 was an especially important year: it marked the opening of UNICAR, the Guatemalan Heart Institute, in a dedicated building on the Roosevelt Hospital Campus. The Cardiology-Cardiac Surgery Program gained a most significant momentum as the core of UNICAR, which today serves patients from across Guatemala, as well as from neighboring Honduras, Belize and Nicaragua.
With its Guatemalan-trained staff supplemented with noted, native cardiac surgeons and educators, including Dr. Rafael Espada and Dr. Aldo Castaneda, the scope of services at UNICAR is wide-ranging.
It treats complex adult and neonatal cases and in 1977 led to establishment of its internationally renowned Department of Pediatric Surgery. Already of international fame, UNICAR obtained autonomic status in 2000, and in 2013 the number of open heart operations performed at the Institute exceeded 800. Dr. Cruz and supportive teams from Charlotte were recognized with the highest civilian decoration in the country, The Order of the Quetzal.
One may justly ask: What is the secret of UNICAR’s success? What made UNICAR conquer the difficulties which still plague the cardiac surgical programs of other Central American countries?
The answer is complex. The key ingredient was without question the dedication and hard work of our Guatemalan colleagues, supported by a federal government committed to their success, despite the country’s ongoing financial difficulties. Did our Charlotte teams also play a role? Undoubtedly. We were at the right place, at the right time. I want to emphasize one very strong point: We have supported surgeries in Central America for a long time, but seldom do we actually perform the operation. We assisted the local surgeon and assured that his initial results were good and that he received reliable support from his team. As always, we remained available should there be a need for assistance. Our approach to assist has been different from the “visiting brigade” approach, where training seldom takes place and the procedures are done by the visiting clinicians, who leave after seeing a limited number of patients. Of course, some help is better than none, but the demand for the services remains after the visiting clinicians leave. Sustainability of cardiac care cannot be achieved without training local physicians and clinicians to be the main surgeons, interventionists or caregivers.
Is the approach of shipping patients to the United States any better? Again, you may save a few lives, but it does not respond to the need of a country. And it is costly. By comparison, the total cost to initiate UNICAR was less than the cost of a few heart operations in a hospital in the United States.
With Dr. Cruz still at the helm of UNICAR, our cooperation and friendship continues 35 plus years later. The training of healthcare providers between Guatemala City and Charlotte never ceased. Most recently, Atrium Health engineers assisted in modernizing UNICAR’s record-keeping system, transforming it from a manual system to a digital one. We are also helping UNICAR to establish a unique, nationwide referral network of echocardiographic laboratories, a service previously available only in a few private clinics outside of UNICAR. The tests are performed in echocardiography stations in 12 rural hospitals in Guatemala, Belize and El Salvador, by technicians trained at UNICAR and in Charlotte. The images are transmitted digitally and are read at UNICAR, which in turn relates the results to the patient’s treating physician. Any images may also be transmitted and problems discussed “live” through a special digital communication portal with the cardiologists and surgeons of UNICAR and Atrium Health.
To our friends at UNICAR – 25 years, 21,768 hemodynamic studies, and 13,047 heart operations later – Happy Anniversary!