The Heart Needs More Than Medicine. Sometimes It Needs Someone to Pay the Bill.

Sultan Al-Mansur Qalawun established one of the most remarkable hospitals of the medieval world in Cairo: the Qalawun Bimaristan.

An inscription at its entrance stated that treatment was available for the rich and the poor, the free and the enslaved, men and women alike. Patients remained in the hospital until they had fully recovered, not until they had exhausted their savings.

More remarkably, when patients were discharged, they received financial support to help them return to work without immediately falling back into poverty.

The physicians were not paid by patients. Their salaries came from an endowment (Waqf), a permanent charitable fund established specifically to ensure that healthcare remained available regardless of a person’s financial status.

More than seven centuries later and after a night in the cathlab, I find myself asking a simple question:

Have we really improved this model, or have we simply made healthcare more advanced and more expensive??

Cardiology has never been cheap. As an interventional cardiologist, I witness this reality every day. Saving a patient’s life during an acute myocardial infarction may take less than an hour in the catheterization laboratory. Keeping that patient healthy for the next ten years is another story. Coronary angiography, primary PCI, coronary stents, cardiac surgery, pacemakers, structural heart interventions, medications, cardiac rehabilitation, follow-up imaging, lipid management, and repeated clinic visits all carry high costs.

For many patients, surviving the heart attack is only the beginning. The greater challenge starts when they leave the hospital carrying prescriptions, follow-up appointments, and bills they may not be able to afford.

Medicine has advanced tremendously. Access has not !!!

Financial barriers become medical problems ! This is no longer simply an opinion. Evidence consistently shows that financial hardship directly influences cardiovascular outcomes. A landmark study by Rahimi et al published in JAMA, followed patients after myocardial infarction and demonstrated that patients experiencing financial barriers had more angina, poorer quality of life, and higher rates of rehospitalization compared with those who could afford their care.

The heart attack had been treated. The financial burden had not !!

More recently, research by Alkindi et al published in the Journal of the American College of Cardiology (JACC) showed that patients who benefit from financial assistance programs after myocardial infarction recover better than patients who leave the hospital with medication alone.

These findings should change the way we think about cardiovascular care. Removing financial barriers is not charity after treatment. It is part of the treatment.

The gap is even larger worldwide. Globally, cardiovascular disease remains the leading cause of death. Yet access to advanced cardiac care is far from equal. A review by Velasquez et al in JACC, described enormous disparities in access to coronary interventions between high-income and low-income regions and even between wealthy and disadvantaged communities within the same country. Perhaps the most heartbreaking example involves children born with congenital heart disease. A global survey published in the World Journal for Pediatric and Congenital Heart Surgery reported that nearly 90% of children with congenital heart disease in low- and middle-income countries never receive the cardiac care they need. Not delayed care. No care at all.

Charities have always been part of healthcare. When discussing healthcare financing today, conversations usually focus on governments, insurance companies, and private hospitals. We rarely discuss charitable organizations.

Historically, however, charitable institutions were not a small addition to healthcare. They were the healthcare system. Throughout the Islamic world, Waqf-funded hospitals operated for centuries. They paid physicians, supplied medications, trained healthcare professionals, and cared for patients regardless of their financial circumstances. This was never intended as temporary generosity. It was designed as a sustainable healthcare model.

As governments evolved, they assumed responsibility for public healthcare, expanding services on a national scale. Later, private hospitals and health insurance improved access for many patients through faster services and newer technologies. Each system solved important problems. None solved every problem.

Even today, there remains a group of patients who fall between these systems. These are the patients who are too wealthy to qualify for government assistance but cannot afford expensive cardiac procedures. These are the patients who often delay treatment until it is too late.

Charity still has a unique role. One of the most inspiring modern examples comes from India. A study published in the Indian Journal of Thoracic and Cardiovascular Surgery described the Sri Sathya Sai Sanjeevani hospitals, which provide completely free congenital cardiac surgery through philanthropic funding. Between 2013 and 2024, these hospitals performed almost 20,000 pediatric cardiac operations without charging families. The authors proposed the GIVE model, where Government, Institutions, Values, and Engagement work together instead of replacing one another.

I believe this is exactly the direction healthcare should take . Charities should not replace governments. Governments cannot replace charities. Private healthcare is not the enemy of either. Each has strengths that complement the others. The real success lies in collaboration.

A partnership rather than a donation.

When people hear the word “charity,” they often imagine occasional donations.I think we should think much bigger. Healthcare charities should become strategic partners. Imagine a hospital signing long-term agreements with charitable organizations to fund a defined number of coronary angiograms, PCI procedures, pacemaker implantations, structural heart interventions, or cardiac rehabilitation programs each year.

Patients would receive treatment according to clinical need rather than financial circumstances. Hospitals would be able to plan resources more effectively. Charitable organizations would have measurable outcomes demonstrating exactly how many lives their contributions changed.

Everyone benefits. Why does this matter to me? As physicians, we celebrate successful PCI, perfect angiographic results, and excellent door-to-balloon times. These are important achievements. But every one of us has experienced another kind of success that is never included in quality metrics. The patient who quietly says, “Doctor, I thought I was going to die because I couldn’t afford this treatment.” That sentence reminds us that medicine extends beyond procedures.

Sometimes the greatest obstacle is not the coronary artery. It is the financial barrier standing between the patient and the catheterization laboratory.

Hospitals and charitable organizations should work together through structured agreements that fund essential cardiovascular services for patients who cannot afford them. Rather than relying on occasional donations.

Success should not be measured only by the number of procedures performed. It should also be measured by the number of patients who received life-saving care because financial barriers were removed.

More than 700 years ago, the founders of the Qalawun Bimaristan understood something that modern healthcare systems are still learning. Treating disease is only part of medicine. Removing the obstacles that prevent patients from receiving treatment is also healthcare. Technology has transformed cardiology. Artificial intelligence is transforming diagnosis. New devices continue to improve outcomes. Yet one challenge remains remarkably unchanged. Many patients still do not need better medicine. They simply need access to it.

Perhaps the future of cardiovascular care will not depend solely on the next breakthrough device or medication. It will depend on how effectively hospitals, governments, insurers, and charitable organizations work together to ensure that no patient is denied life-saving treatment because of the cost. The heart has always needed more than medicine.

Sometimes, it simply needs someone willing to open the door to care!!