Meet Dr. Sable
Dr. Craig Sable has a strong commitment to global health that includes extensive clinical outreach, multiple research publications in rheumatic heart disease (RHD), world wide telemedicine experience, leveraging his long standing role as echocardiography director, educational portfolio mentoring over 75 fellows and other trainees and leadership roles in national and international committees and writing groups. Dr. Craig Sable has collaborated with the medical team at the Uganda Heart Institute (UHI) at Mulago Hospital in Kampala Uganda, the largest public teaching hospital in Uganda, to improve the care of children with heart disease in Uganda. Dr. Sable has personally led over 20 medical/surgical missions to Mulago Hospital since 2003; the last eleven have focused on performing open-heart surgeries at the Uganda Heart Institute. He has also coordinated nine other surgical trips by teams from North America, Europe, India, and Asia. Nearly 1,000 children have received life-saving care, dozens of nurses and physicians have received training, and the foundation for a self-sustainable tertiary cardiac care program in East Africa has been established. This collaboration serves as the foundation for a very productive research partnership as well.
Dr. Sable provides senior mentorship for the most productive team of active RHD investigators in the United States, focusing their research on using echocardiography, task-shifting, highly portable technology and telemedicine to develop novel approaches to secondary prevention of RHD. RHD remains the most common cause of cardiovascular morbidity and mortality in children and young adults in the world today despite being preventable. He currently serves as one of four Center Directors in the American Heart Association Strategically Focused Children’s Research Network; this center is focused on prevention of RHD.
His 100+ peer reviewed publications include 25 publications in RHD, 9 as senior author. Dr. Sable has 7 additional publications in other global health topics including a 2017 manuscript on building a sustainable cardiac surgery and catheterization program in Uganda. He played a key role in the 2015 AHA scientific statement, Revision of the Jones Criteria for the Diagnosis of Acute Rheumatic Fever (ARF) in the Era of Doppler Echocardiography. Dr. Sable’s primary contribution to this paper, developing guidelines that redefined the role of echocardiography in subclinical carditis, was one of the two significant changes from the 1992 Jones Criteria (and is reflected in the title).
Dr. Sable has established a vast telemedicine network for interpretation of echocardiograms from over 100 locations around the world, including Uganda, Morocco, and Brazil. The advanced infrastructure of the telemedicine program and echocardiography laboratory has allowed for seamless interpretation of RHD echocardiograms, ensuring that a large volume of de-identified data can be translated into timely and meaningful scientific presentations and publications. Dr. Sable has significant collaborations in the global RHD community. He served on the World Heart Federation RHD Working Group from 2011 – 2015 that developed critical RHD research priorities. Dr. Sable is the RHD program chair for the 2017 World Congress of Pediatric Cardiology and Cardiac Surgery. His fundraising efforts have contributed to bringing in nearly $3 million of funding for global health activities to CNHS over the last 15 years.
Dr. Sable’s interest in global health and RHD traces back to his very first global health trips to Africa and Latin America, starting in 1991. While his main interest at the time was improving treatment and diagnosis for congenital heart disease (CHD), it became increasingly apparent that for every CHD patient, there was a patient with RHD. Despite this ratio, “there was a huge gap in the ability to diagnose and treat RHD in sub-Saharan Africa and Latin America,” he recalls. Even though it was a very similar disease burden, RHD is frequently ignored, and gets “thousands of times less funding than other global health concerns,” adds Dr. Sable. His interest also has a personal motivation. As a child growing up, Dr. Sable’s grandmother was always very sick. In 1969, she had two heart valves replaced as a result of having had rheumatic fever as a child and later developing RHD. Motivated by the clear international need and his personal history, Dr. Sable has made it his life’s work to expand access to resources for screening and treatment of RHD for children around the world.
In addition to his remarkable work in Uganda, Dr. Sable is also focused on RHD in Brazil. As a middle-income country, Brazil has a better system in place and a greater capacity to handle RHD diagnosis and treatment. Consequently, the project there is focused principally on “school-screening, task-shifting, (and) telemedicine” describes Dr. Sable, similar to his goals for the Uganda initiative. Additionally, they are working on “transitioning from one-off school screenings to systematic screening within the healthcare system,” says Dr. Sable. Essentially, echocardiograms would become part of children’s annual physical appointments. “The local providers do not need us to tell them about care,” he adds, saying, “they need help increasing accessibility and improving routine screenings.”
Another initiative aimed toward greater sustainability is facilitating relationships between middle- and low- income countries. Dr. Sable has increasingly been working on fostering such a relationship between Brazil and Uganda. The reason? “The Brazilians are better than us at developing the initial system and improving the healthcare infrastructure,” as they have gone through the process relatively recently, says Dr. Sable. Both places, however, can use help “implementing task-shifting and telemedicine for greater connectivity and improved consultation and care.” Not only does this help local providers manage their patient volumes, it connects these providers to physicians and specialists all over the world, enabling them to gain additional expertise for their patients all the time, not just during a week or two week long mission trip. It’s really a win-win, as patients consistently have access to a higher level of care and foreign providers can have a global impact without leaving the office.
Dr. Sable began his work in Uganda in 2003, focusing on improving providers’ ability to diagnose RHD and take care of their patients. He began with efforts to expand the Ugandan Heart Institute’s surgical capacity to provide the life-saving operations necessary for curing heart valve defects caused by RHD and CHD. Dr. Sable recalls some initial skepticism at the effort, but eventually “our partner in Uganda agreed that the program would lead to an improved infrastructure, more effective implementation, and educational and training improvements.” After four years of consistent visits and development, the team at UHI performed their first open heart surgery in 2007. That year, Dr. Sable met with the president of Uganda, and through a clear demonstration of the team’s accomplishments so far, was able to cement a local commitment to the project and sustained improvements to both UHI and the regional referral network. At the same time, Dr. Sable established support and planning for the development of a cardiac catheterization lab at UHI.
In 2012, the project gained a game-changing addition: Dr. Andrea Beaton. “When (Dr. Beaton) joined with her capacity for research and treatment, it created an additional level of legitimacy not only on the Uganda front, but also on the whole African stage by bringing additional resources critical to building the platform and funding additional research,” says Dr. Sable. Their first regional program, run in 2013 in Gulu, brought in an entirely new group of providers and leaders, mostly from rural areas. This was key to implementing a further expansion of access to care. The interest from these providers enabled the team to develop a telemedicine network, connecting rural tertiary care centers to UHI in Mulago, and Mulago to the rest of the world.
From his close to thirty years of experience working in low and middle income countries, Dr. Sable advises “the most important thing, is to build trust slowly based on strong personal relationships and frequent visits and communication. It is impossible for anyone to believe your impact if you go to a site once.” Not only does consistent financial and physical support impart faith in the project, it also significantly impacts the sustainability of the venture. Additionally, providing education and training partnerships, which become more profound over time, has considerable implications for long-term growth and expansion. Dr. Sable and his closest partner in Uganda, Dr. Lwabi, have been working together since the beginning of the project to spearhead the development of a system of referral, the implementation of local screening, and the cultivation of a robust diagnostic treatment system. These accomplishments, despite the many challenges Dr. Sable and his colleagues have faced, transformed the healthcare system in Uganda, setting an excellent example of sustainable global outreach that can be replicated internationally. In addition, UHI has gained considerable national support and Uganda has been internationally recognized as “the best place to conduct RHD research,” adds Dr. Sable.
As the project moves forward and the most pressing needs are being met, Dr. Sable describes how Dr. Beaton has been working on providing education about RHD and CHD to the general public and establishing support systems for children and young adults affected by the cardiac disease. “(Dr. Beaton and her team) have developed…a support group and structure so kids can continue to get support from providers, have peer groups, and ensure there is available continued education,” says Dr. Sable. This helps “to make up for the impact of the diagnosis,” which can have negative societal implications. As Dr. Beaton and her Ugandan partner Dr. Okello take on greater responsibility and leadership roles, they are heading the project in a more research-oriented direction. This summer, they are beginning the first phase of a three year undertaking, and expect to screen 45,000 children for RHD via portable ultrasound. The project has been funded through a multimillion dollar grant from the American Heart Association, awarded to Dr. Sable, Dr. Beaton, Dr. James Dale, an infectious diseases specialist at the University of Tennessee, and Dr. David Watkins, a hospitalist and data sciences expert at the University of Washington, Seattle.
