I read about Rene Favalaro’s tragic death as a fleeting news item in the inside pages of the newspaper. The surgeon who pioneered coronary artery bypass graft (CABG) using saphenous vein graft had committed suicide on July 24, 2000, at his home in Buenos Aires, Argentina. He was 77 and was apparently suffering from depression. However, it was only some time later that the shocking details emerged about his suicide. (1, 2)

I did not have the privilege of meeting Dr. Favaloro for when I went to the Cleveland Clinic in 1973, he had already left for his roots. But his legend was warmly felt in the clinic’s cardiac catheterisation laboratories and operation suites. He was remembered as a fine human being and as an outstanding surgeon. He had championed the cause of universal and equitable health care for his people.

I was at the Texas Heart Institute as a visiting surgeon in 1986. It was there that I came across a patient for a re-do coronary artery bypass operation; his coronary arteries were dangerously narrowed with severe blockages but the vein graft to the left anterior descending artery was still patent after 19 years; Rene Favaloro had sutured this graft with 6/ 0 silk at the Cleveland clinic in December 1967.

Denton Cooley in an emotional tribute recalled Rene Favaloro’s pioneering contributions to the coronary artery surgery and referred to him as an incredible inspiration. (3) I feel good that Rene Favaloro was a cardiac surgeon, a compassionate cardiac surgeon. Rene Favaloro’s suicide far away in Argentina has a lesson for us in India and other developing countries that seem to be on a fast track towards globalisation.

Globalisation and health care in India

With the mandatory structural adjustment policies (SAP) in India under the dictates of the World Bank and the International Monetary Fund, the government’s commitment to public health has dropped and currently stands at less than two per cent of its gross domestic product. As a result, facilities in public hospitals have shrunk over the years. Lack of essential drugs and equipment, malfunctioning machines due to lack of maintenance, rampant corruption, frequent strikes and a poor work culture have all contributed to the decay in the public health care system. On the other hand, a profit-making private health care sector has grown at the cost of a deteriorating public sector, even as newer specialties and sub-specialties with rapidly changing, cutting-edge technologies are introduced. Hapless patients rush to these hospitals for services which are ensured but which come at a considerable cost.

It is the poor who are hurt most by user charges or veiled attempts at privatisation being effected at public hospitals. Doctors trained at great expense at public hospitals leave these hospitals to join the private health care sector, thus directly using public funds for private gains. Many of them support the health services in the USA, UK, and Australia after training at a tremendous cost to the public exchequer.

It is in this light that Favaloro’s story is worth telling. Rene Favaloro was born to a poor family in La Plata on July 12, 1923. He and his brother became doctors and served the rural community of La Pampa. Favaloro had a natural bonding with his country and felt deeply and passionately about his people. He spent 12 years in La Pampa educating patients on preventive medicine, training nurses and even starting the first “mobile blood bank”. (3) His interest in thoracic surgery was sustained through this period. He went to the US in 1962, relatively late in his life, but his stay in the Cleveland Clinic from 1962 to 1971 was epoch-making.

Favaloro worked closely and intently with Mason Sones, Donald Effler and others in the problems related to myocardial revascularisation. In May 1967, he and Effler did the first case of direct coronary artery bypass using reversed saphenous vein as the conduit. This single act changed the management of coronary artery disease forever. Favaloro could not have been happy that soon CABG exceeded the number of tonsillectomies and hysterectomies being performed in the US. Cardiological interventions and bypass operations probably hold the same ‘distinction’ in India today.

Favaloro received many international awards and accolades from his peers honouring his imagination and innovations. He was made many lucrative offers but decided to remain at the Cleveland Clinic on a modest salary. (4) Nobody would have blamed him if he had made his home in the USA but his heart was beating for his ‘beloved Argentina’.

Favaloro returned to Argentina in 1971. He continued with cardiac surgery at a private hospital initially but only to gather enough funds for his dream hospital where the best in cardiac treatment could be given to all patients irrespective of their paying capacity. Thus the Favaloro Foundation was born in 1992, incorporating the highest standards of research, academics, training and surgical skills, and where rich and poor shared the same facilities. Workers received the same care as did socialites. Favaloro traveled widely and trained a large number of cardiac specialists in the South Americas. His contributions to cardiac surgery continued, in keeping with his true scientific temper.

In the meanwhile, Argentina had got trapped in the fever of globalisation, and large-scale lay-offs had started to claim workers and their unions. Large numbers of workers and their families were stripped of their insurance cover. Rene Favaloro was perhaps amongst the earliest to recognise the downside of such economic policies on the social sector, and the consequent widening gap between the rich and the poor. He refused to give in to the whims of market forces, and the poor and uninsured continued to receive the same treatment as always at his foundation. This put the foundation under heavy debts and liabilities. Favaloro fought the government and the corruption that the system had brought in. It is said that his institution was under a $70 million debt. (2) Favaloro, who had returned to his native Argentina to champion the cause of universal health care, was disillusioned with the reforms as only the affluent were enjoying what he once called “the right to live.” He blamed globalisation and the free-market revolution of the 1990s for “a growing callousness” toward health care for the poor. (1) Financial difficulties and governmental pressures broke the will of this colossal figure but could not reduce his love and compassion for his people.

This is beautifully illustrated by his message to his staff, only days before he decided to put the bullet through his heart. “I have always practiced medicine with a profound social pledge. For me, all patients are equal. This foundation is for everyone. Every patient, paying or not, will continue receiving the same attention.” (2) Favaloro made a strong social statement through his suicide and we need to hear that statement loud and clear. His love for his people, especially the poor, and his distress when he could not help them, should be a wake-up call for the smug and uncaring.

Rene Favaloro’s death touches the poor and the marginalised not only in the poor countries but even in the US. (4) His story must shake not only cardiologists and cardiac surgeons but the entire medical community. It must also be told repeatedly to governments, sociologists, economists and industrialists. It may not be prudent to undo the reforms but their direction can be controlled so that the poor do not lose out.

Technological advances in medicine and science have presented tremendous opportunities for human development, and it will be indeed foolish not to use these for the betterment of our people. But science also teaches us to be rational and not to accept things blindly. Unfortunately the noble pursuit of science has been hijacked by business interests, and that too in the name of health care. The free market economy and globalisation have only aggravated the gap between poor and rich countries, as also amongst people in the same country. One fifth of the world’s richest have an income more than the combined incomes of four-fifth of humanity in the least developed countries. (5) Further, 50 to 60 billion US dollars are spent in the research and development of diseases that interest the developed world. Only one-tenth of research funds is spent on diseases affecting developing countries. This 10/90 disproportion has attracted the attention at last of concerned individuals and organisations. (5) Even the World Bank talks of reforms with a human face.

Doctors may not think it necessary to get embroiled in economic issues but it is time that they step out of their ivory towers and recognise the important link between poverty and disease. Unfortunately, the connection between poverty and the disease is never taught in medical schools. There, training is limited to exotic diseases and complex strategies in their treatment. In due time the training becomes an “attitude” and traditional knowledge as well as simple and economical treatments are relegated to the status of fringe remedies; history taking and physical examinations are discarded in favour of costly investigations and even marginalised as orthodox. In the process, the poor have no options, and since they are at their most vulnerable, they are victims of artificially created demands of vested interests.

Technology comes at a tremendous cost; unfortunately it is very heady and addictive. The twentieth century saw technology mushroom and medical care costs escalate twenty fold. Most recent technology in medical science is an off-shoot of defense technology, and its emergence in developing countries with the end of the cold war cannot be co-incidental. Gullible doctors, dazzled by technology and mega-bucks, unwittingly became partners to the free mixing of medicine and business. This is perhaps most grotesquely conspicuous in my own specialty of cardiology and cardiac surgery. Industry, media and doctors have become silent partners in the greed perpetuated by an increasing consumerism. As doctors we need to remember that twothirds of our people live in villages and support the lifestyles of the urban rich while they themselves live in abject poverty.

It will do a real honour to Rene Favaloro’s memory if the medical community can continue the crusade started by him to ensure an equal and universal health care for all. Rene Favaloro, a hero when alive, will continue to shine like a bright star even after his death.