World-wise: As In-Person Meetings Resume, Global Voices Hope to Be Heard

Nearly 2 years’ worth of studies and surveys make it abundantly clear: COVID-19 has widened preexisting gaps in health and medicine, spanning gender, race, geography, and beyond. Mothers more than fathers have borne the brunt of work-from-home policies, canceled childcare, and shuttered schools; wealthier countries have started rebounding while lower-income nations struggle to even get vaccines; front-line workers, more likely to be ethnic or racial minorities, have faced soaring rates of COVID-19 illness and death while those with white-collar jobs have sheltered-in-place.

Cardiologist Zainab Dakhil, MB ChB (University of Baghdad, Iraq), has heard all the stories and understands the reasons for the growing schisms in many parts of the world. But as the pandemic entered its second year, she herself experienced something different.

“I read about how academics were [adversely] impacted by COVID 19, especially women in academia. But I personally felt this might not be the same for everyone,” she told TCTMD. At the time, Dakhil was the only female interventional cardiologist actively practicing in Iraq. When the world initially went into lockdown, she had only just finished her interventional training and happened to be attending her first international cardiology conference as faculty—the CardioEgypt 2020 meeting, in Cairo. “I thought: maybe for some there will be actually increases, not decreases, regarding the gender balance” as a result of the pandemic, said Dakhil.

She decided to take a look.

Cardiology congresses that transitioned to virtual during the COVID-19 pandemic typically offered registration to online sessions free of charge or at a vastly discounted rate, and they saw their numbers skyrocket. What Dakhil set out to discover is whether virtual and hybrid meetings helped expand the breadth not only of attendees, but also of presenters and nations.

Her hunch was right. In an analysis of the more than 10,000 abstracts submitted to the American College of Cardiology, Heart Failure Society of America, and TCT meetings, she found that researchers from low-and middle-income countries were significantly more likely to have presented studies during the pandemic than in the year prior. She followed this analysis up with another looking specifically at women. Here, again, in an abstract accepted to the TCT 2021 meeting, Dakhil showed that 27.4% of abstracts that were presented at TCT 2020 had women as lead authors, compared with just 7.05% of abstracts in 2019.

“There was a remarkable increase in women’s contributions to TCT during the COVID-19 era compared with the previous year,” Dakhil’s abstract concludes. “This increase could be due to ability of female cardiologists to attend the meeting and showcase their work via the virtual platform, which enabled them to balance their work, household, and community responsibilities.”

Getting Into the Tent

As meeting programmers around the world take tentative steps towards planning medical congresses for 2022 and beyond, insights like Dakhil’s warrant consideration, said Mirvat Alasnag, MD (King Fahad Armed Forces Hospital, Jeddah, Saudi Arabia). The ability to present science virtually has unquestionably been better for early-career cardiologists, especially women but also men with young families. Over the past year, she said, “I heard that a lot.”

I read about how academics were [adversely] impacted by COVID 19, especially women in academia. But I personally felt this might not be the same for everyone. Zainab Dakhil

Family and domestic commitments are only part of the story, Alasnag notes. Long before COVID-19 hit, getting visas to travel to meetings in Europe and the United States had become increasingly cumbersome for physicians in many countries. This was particularly true in the Middle East, Africa, and Asia.

Dakhil experienced this firsthand, having been chosen from hundreds of applicants to attend the 2020 World Heart Federation’s Emerging Leaders Programme in Portugal, only to face nearly insurmountable hurdles obtaining a visa. “I and my colleague were among those who were chosen, but the visa was the barrier,” she said. “Without some help from the Italian embassy that accelerated things for us, we really were about to give up on this opportunity to go to Lisbon for the meeting.”

For many physicians, particularly junior ones, the actual costs of the travel, hotels, expenses, and meeting registration itself make attendance unattainable without institutional or industry support. Even “minor” costs that cardiologists in other countries might not think twice about are factors to consider. Dakhil pointed out that the “processing” fees for abstract submissions to many meetings can be prohibitive to physicians and scientists in low- and middle-income countries. To submit an abstract, she herself pays out of pocket if the meeting requires it.

The European Society of Cardiology (ESC), TCT, EuroPCR, and Society for Cardiovascular Angiography and Interventions (SCAI) meetings all accept abstract and case submissions free of charge, but others charge a fee. The American Society of Echocardiography, for example, requires a nonrefundable US $20, the Heart Rhythm Society submission fees range from $25 to $75, an American College of Cardiology (ACC) abstract will set you back $49 per abstract and an American Heart Association (AHA) abstract submission can cost as much as $99 for nonmembers, although the meeting has instituted a World Bank Abstract Fee of just $15 for scientists submitting from low- and middle-income countries.

For junior faculty in many parts of the world, these seemingly nominal fees can sometimes mean being very selective about what study or studies to send. “I have to send in only the one that I'm really sure will [get accepted],” Dakhil told TCTMD.

Of note, all meetings typically require that a presenter register for the conference in order for the abstract to be formally included in the program and thereby “published” as an abstract. Here, too, the ability to register as a “virtual” attendee—ideally at a discounted rate—could mean the difference of having an abstract accepted and published, or not.

Unique Opportunities for Women

Aaysha Cader, MD (Ibrahim Cardiac Hospital & Research Institute, Dhaka, Bangladesh), told TCTMD that prior to COVID, she might have attended two or three meetings a year, including regional meetings. During the pandemic, however, “as a result of everything turning virtual, I've been able to attend at least seven or eight meetings,” including the large congresses like ESC, EuroPCR, and TCT as well as smaller subspecialty meetings. At half of these, she said, she’s presented a case or an abstract, and in one instance was invited as faculty, something she typically wouldn’t have expected as an early-career cardiologist. As co-founder of the Global Women in Cardiology - Early Career initiative, she’s also been on the flip side of organizing and inviting participants and has seen firsthand how these can become critical networking events for women.

You can't physically be in more than one place at one time. Mirvat Alasnag

“It would be very challenging to gather in person for a number of women who would ordinarily have domestic responsibilities,” Cader said. “They'd have to find places to keep their kids, to get the time off work and support for the finances of making the trip, but we've actually been able to connect, to a great degree, through virtual meetings. And I now am quite good friends with colleagues regionally in India, as well as the Middle East.”

Alasnag, too, said the pandemic has allowed her opportunities that weren’t possible in the past. As chair of the ACC’s International Working Group, she’s received back-to-back invitations to speak at conferences and grand rounds all over the world.

”You can't physically be in more than one place at one time,” she said. “In one week I might be presenting in a meeting in Pakistan and then the next day I'm presenting in South America and then I'm presenting in Europe and so on.” The ability to do so virtually has made that possible. “Even though I'm not early career, even though my family has now adjusted to all of my travel, it's actually been an opportunity for me to be able to represent international women and really go all the way across the globe doing that.”

Other Geographies Represented

It’s not only early-career and female presenters who will benefit if some aspect of “virtual presentation” continues postpandemic. Claudio Gil Araújo, MD, PhD, is the director of research and education for the CLINIMEX Exercise Medicine Clinic in Rio de Janeiro, Brazil. Now 65 years old, Araújo attended his first international cardiology meeting in 1977 and continued to do so every year for four decades, giving lectures in “20 countries around the world so far,” he said.

But travelling to those meetings, even with direct flights from Rio, typically takes 24 hours door-to-door. While Araújo appreciates the invitations he receives, at this stage of his career he says he has an established network of colleagues and there are plenty of opportunities for excellent online learning—which he described as two of the big reasons to travel to a meeting. These are no longer enough of a draw for him to want to step away from his practice and his family, or spend the considerable time and money required, to give an in-person lecture. 

“Nowadays, my feeling is, I don't think you can return to the old model,” said Araújo. “The 2 days that I had to lose traveling—that’s an old story to tell the kids. It's very expensive, it’s very time-demanding, and it’s exhausting.”

Okechukwu Ogah, MBBS, PhD (University of Ibadan, Nigeria), raised similar concerns about travel costs, visas, and time away from his practice. In countries like Nigeria, he said, there is little in the way of academic funding or industry grants to make meeting travel feasible. A silver lining of the pandemic, however, was presenting several abstracts, virtually, at the Pan-African Society of Cardiology meeting held in Mombasa, Kenya.

He believes meetings, too, get something out of having a more international footprint, even if that means attendees and presenters are participating virtually. Not only would they be able to vastly expand the number of attendees tuning in online, but having contingency plans in place for someone to participate remotely would be helpful even for presenters from higher-income countries, who for a range of reasons might need to cancel at the last minute.

COVID opened a vista on doing things in other ways that we never thought was possible, and I think it has come to stay. Okechukwu Ogah

“There are advantages and disadvantages” to in-person meetings, Ogah acknowledged. “The advantage is that when you go there physically, you have the opportunity of meeting other people, you have the opportunity of collaborating, you have the opportunity of seeing some of the people you’ve only read about in books, or in journals, and you get to see them there physically. But I do think that the hybrid form should be the way forward. COVID opened a vista on doing things in other ways that we never thought was possible, and I think it has come to stay. And I think organizations that want high attendance should leave the door open for both physical and virtual attendees.”

Dakhil, too, spoke of her own moment of wonder, seeing in a live case the kinds of devices and procedures she had hitherto only read about in books, noting that even physicians in lower-income countries appreciate and benefit from learning about cutting-edge technologies.

“Great things are now being done,” she said. “I think if we make it [to these meetings], even virtually, we can communicate, network, collaborate with others, and see these technologies. And if we want to do something, we can introduce something here. It is possible.”

Meeting the New Reality

It remains unknown just how meetings will juggle the lessons learned during the pandemic, the new financial models, and the wider reach but shorter attention spans. Course directors contacted by TCTMD all hinted that it’s a delicate balance: they want physicians to attend in person—something sponsors and exhibitors also are eager to see—though they recognize the value of digital for its global reach.

Nata Nambatingué, MBA, congress and event director for the ESC, crunched the numbers. In the 3 years prior to the pandemic, just 9.6% of registrants were from a low- or middle-income country, he noted. That number jumped to 16% in 2020, when all ESC events were free online, then dipped again to 12% in 2021, reflecting the fact that a fee was reintroduced but at less than half the rate charged to physicians in higher-income countries. The same discounted rate will be in place for next year’s ESC Congress, which is being planned as an in-person event with a hybrid component. As it stands today, the standard registration fee to participate online will be €230, but just €75 for online attendees in low- and middle-income countries. Nambatingué confirmed that the plan for 2022 includes virtual presenters.

The ESC is also looking to renew an initiative launched in 2019 that supported 198 delegates from lower-income nations, all of whom received free registration and financial support to cover their travel.

These researchers are providing points of view and science from areas around the world we don’t often have the opportunity to hear from, and our meetings are better when these researchers are a part of them. Joyce Donnellan

“We are always looking for ways to expand our research and access to our meetings, especially to underserved areas,” TCT Course Director Juan F. Granada, MD (Cardiovascular Research Foundation, New York, NY), told TCTMD, adding that TCT planners have as their objective an in-person meeting, but “are also aware of the importance of adding flexibility to people that cannot attend by using virtual technologies.”

One of the biggest considerations, however, is the “limited bandwidth” of the viewer, Granada said. “There are so many digital offerings available that we’ve started to see a stabilization in the number of people available to consume digital content. Then, in order to be successful, meetings will have to carefully balance the quality and relevance of their content.”

Having virtual presenters enhances “does add operational costs and the risk of degrading the quality of the in-person sessions if the right technologies are not used,” Granada said, a point echoed by TCT Course Director Martin Leon, MD (NewYork-Presbyterian/Columbia University Irving Medical Center, NY), who noted that “inconsistent or poor-quality online connections from certain geographies” can’t be easily standardized, making them hard to integrate into live sessions.

“Although the desire to develop innovative ways to engage faculty in a more-virtual format is important, there are multiple strategic, financial, and operational barriers that must be considered before completely adopting this approach,” Granada said.

EuroPCR 2022 will also be “encouraging the return to on-site participation, with an enhanced program and on-site experience,” Sally Collingridge, the PCR marketing and communication manager, told TCTMD in an email. “But we will not be neglecting those who are unable to come to Paris. We will offer a digital-only attendance option and make it possible for presentations to be delivered virtually.”

The “PCR hubs,” pioneered in 2021, will continue to allow for remote in-person meetings at eight different locations around the globe, while the “PCR pods” will continue to be used selected live-streamed sessions from EuroPCR at different locations worldwide to create local programs with a local audience. Sponsored educational grants as well as free registration for nurses and fellows will also be offered, she noted.

The meeting’s objective—“to gather the interventional cardiovascular community together”—remains “unchanged,” Collingridge said. This includes trying to “facilitate learning, teaching, and participation in any way that reaches the biggest worldwide audience.” PCR currently has no plans to offer discounted in-person registration to participants from lower-income countries.

Manesh Patel, MD (Duke University, Durham, NC), the current AHA Scientific Sessions program committee chair, told TCTMD that the organization is committed to keeping sessions open and accessible. “Equitable access for students, residents, early-career researchers, scientists, healthcare professionals at hospitals with limited resources, and including hundreds of experts and researchers from around the world—regardless of travel restrictions, budget constraints, or economic status—is included in our planning,” he said in an email. The decision to offer the discounted abstract submission fee to lower-income countries actually went into place before the pandemic, he noted, in 2019.

Moreover, said Patel, “virtual participation for presenters, experts, and attendees will continue for the foreseeable future.”

A Two-Way Street

Reaching a large global audience is one thing, but another is learning from other parts of the globe.

Alasnag pointed out that there is always something to be learned from other regions outside of your country of practice. US operators have long been curious about devices approved in Europe or Asia before they were cleared by the US Food and Drug Administration, for example. Yet as COVID-19 has made abundantly clear, illness and disease do not respect national borders, and there are always insights that countries with different economies can share, she noted. She gave the example of infective endocarditis, which has surged globally in recent years, prompting wealthy nations to look for insights from colleagues abroad. Three decades ago, when people were first scrambling to understand HIV/AIDS, “suddenly everyone was talking about tuberculosis, and learning from third world countries about tuberculosis. There's always a lot to learn both ways,” she said.

Joyce Donnellan, RN, MSN, division vice president of education for the ACC, agreed.

“The switch to virtual conferences opened our eyes to the large numbers of people wanting to participate in educational conferences who had not had the opportunity before, including many who, because of the virtual setting, were afforded the opportunity to present for the first time,” she said. “These researchers are providing points of view and science from areas around the world we don’t often have the opportunity to hear from and our meetings are better when these researchers are a part of them. Moving forward, ACC plans to combine the irreplaceable components of in-person meetings, such as networking and real-time debate and conversation, with the broad reach and equity that virtual engagement has allowed as much as possible.”

For Dakhil, hybrid in any form will be better than on-site only, and she believes this will be particularly important for female cardiologists like her working in relative isolation in many parts of the world. For her, having the chance to attend sessions and connect with other women, then using the knowledge and experience gained to offer webinars at the local and national level, has already paid off.

“When women attend these and see that there are other women in cardiology, I think so many things can change not only for them, but even nationally, which is what has occurred here in Iraq,” she said. In the space of 2 years, three more female Iraqi physicians have chosen to specialize in cardiology.

“After decades of a total absence of women in cardiology in Iraq, I think this is a [major] achievement,” Dakhil said.

Note: The TCT meeting is produced by the Cardiovascular Research Foundation, which also publishes TCTMD.