- Email: [email protected]
The hidden epidemic of cardiovascular disease
EDITORIAL
THE LANCET Volume 352, Number 9143
The hidden epidemic of cardiovascular disease Ask any doctor what the leading cause of death is in developing countries and the answer will be predictable and correct—infection, specifically of the lower respiratory tract. The surprise comes when you report the second commonest cause of death: ischaemic heart disease. Of the 50 million people who died in 1990, 6·3 million succumbed to coronary disease, 57% of whom lived in developing nations. Why? The reason is the health transition that is sweeping the developing world. Demographic changes are driving up numbers of older people in the population. According to the latest UN figures, the number of older people (aged 60 years or more) in less developed countries will increase from 171 million in 1998 to 1594 million by 2050. There are also changes in underlying health determinants— eg, increases in smoking, cholesterol, and blood pressure. And improvements in medical care have tended to focus on treatment rather than prevention, thereby failing to tackle the epidemic of heart disease at its root cause. Can anything be done to make a difference? Inevitably, leadership from WHO is crucial to any global effort. Gro Harlem Brundtland, WHO’s new Director-General, has already made a striking early impact in Geneva. Her two high-profile cabinet projects are the Roll-Back Malaria campaign and the Tobacco Free Initiative (TFI). TFI is a key component of any strategy to tackle heart disease. But by itself, TFI is not enough. The cardiovascular diseases programme at WHO began in 1959, but it was only in 1973 that a fully integrated community-based plan was introduced to include the developing world. The need for reliable epidemiological data was the priority but research and training in cardiovascular disease prevention were additional goals. Despite these early efforts, which have continued at a low level for more than 20 years, the widely accepted view is that they have not been sufficient. With WHO only at the margins of this debate, the US Institute of Medicine’s initiative on “Control of Cardiovascular Diseases in Developing Countries”, published earlier this year, was especially welcome. The report concluded that cardiovascular risk factor prevention and low-cost management were feasible. But calculation of the precise magnitude of the THE LANCET • Vol 352 • December 5, 1998
cardiovascular epidemic remains an essential prerequisite before population-wide strategies for prevention can be considered. A limitation to the bold programme set out by the Institute of Medicine is the lack of national capacities for research and development. WHO, together with non-governmental organisations, must help to develop local research cultures. One organisation is singled out for special praise by the Institute of Medicine. “The International Clinical Epidemiology Network (INCLEN) has a training program for clinical researchers, social scientists, statisticians, and health economists from selected academic institutions in developing countries. Although it is not specifically directed to [cardiovascular]-related research, this program has augmented the capacity for health research in developing countries through multidisciplinary and international collaboration.” For instance, more than 450 INCLEN-trained fellows have conducted research in 24 developing countries, including multicountry investigations of heart disease. INCLEN was founded in 1980 and has depended on the commitment of the Rockefeller Foundation for much of its funding ever since. In recent years, INCLEN has raised US$10 million from other sources for research and training. However, INCLEN’s future is now threatened as Rockefeller rethinks its spending strategy under new leadership. No organisation should expect continued support without proving its value. But INCLEN has repeatedly shown that its concerns with individual and population perspectives, cost-effectiveness, and the social determinants of health and disease make it an important part of the Institute of Medicine’s vision. We hope that the Rockefeller Foundation will soon reaffirm its financial support for INCLEN at a vital moment in the history of health care in the developing world. Finally, WHO must reclaim the lead by making cardiovascular disease its third cabinet-level project. By doing so, Brundtland would signal a shift in her long-term agenda to meet the needs of developing countries, not only now but also well into the next century.
The Lancet 1795
THE LANCET Volume 352, Number 9143
The hidden epidemic of cardiovascular disease Ask any doctor what the leading cause of death is in developing countries and the answer will be predictable and correct—infection, specifically of the lower respiratory tract. The surprise comes when you report the second commonest cause of death: ischaemic heart disease. Of the 50 million people who died in 1990, 6·3 million succumbed to coronary disease, 57% of whom lived in developing nations. Why? The reason is the health transition that is sweeping the developing world. Demographic changes are driving up numbers of older people in the population. According to the latest UN figures, the number of older people (aged 60 years or more) in less developed countries will increase from 171 million in 1998 to 1594 million by 2050. There are also changes in underlying health determinants— eg, increases in smoking, cholesterol, and blood pressure. And improvements in medical care have tended to focus on treatment rather than prevention, thereby failing to tackle the epidemic of heart disease at its root cause. Can anything be done to make a difference? Inevitably, leadership from WHO is crucial to any global effort. Gro Harlem Brundtland, WHO’s new Director-General, has already made a striking early impact in Geneva. Her two high-profile cabinet projects are the Roll-Back Malaria campaign and the Tobacco Free Initiative (TFI). TFI is a key component of any strategy to tackle heart disease. But by itself, TFI is not enough. The cardiovascular diseases programme at WHO began in 1959, but it was only in 1973 that a fully integrated community-based plan was introduced to include the developing world. The need for reliable epidemiological data was the priority but research and training in cardiovascular disease prevention were additional goals. Despite these early efforts, which have continued at a low level for more than 20 years, the widely accepted view is that they have not been sufficient. With WHO only at the margins of this debate, the US Institute of Medicine’s initiative on “Control of Cardiovascular Diseases in Developing Countries”, published earlier this year, was especially welcome. The report concluded that cardiovascular risk factor prevention and low-cost management were feasible. But calculation of the precise magnitude of the THE LANCET • Vol 352 • December 5, 1998
cardiovascular epidemic remains an essential prerequisite before population-wide strategies for prevention can be considered. A limitation to the bold programme set out by the Institute of Medicine is the lack of national capacities for research and development. WHO, together with non-governmental organisations, must help to develop local research cultures. One organisation is singled out for special praise by the Institute of Medicine. “The International Clinical Epidemiology Network (INCLEN) has a training program for clinical researchers, social scientists, statisticians, and health economists from selected academic institutions in developing countries. Although it is not specifically directed to [cardiovascular]-related research, this program has augmented the capacity for health research in developing countries through multidisciplinary and international collaboration.” For instance, more than 450 INCLEN-trained fellows have conducted research in 24 developing countries, including multicountry investigations of heart disease. INCLEN was founded in 1980 and has depended on the commitment of the Rockefeller Foundation for much of its funding ever since. In recent years, INCLEN has raised US$10 million from other sources for research and training. However, INCLEN’s future is now threatened as Rockefeller rethinks its spending strategy under new leadership. No organisation should expect continued support without proving its value. But INCLEN has repeatedly shown that its concerns with individual and population perspectives, cost-effectiveness, and the social determinants of health and disease make it an important part of the Institute of Medicine’s vision. We hope that the Rockefeller Foundation will soon reaffirm its financial support for INCLEN at a vital moment in the history of health care in the developing world. Finally, WHO must reclaim the lead by making cardiovascular disease its third cabinet-level project. By doing so, Brundtland would signal a shift in her long-term agenda to meet the needs of developing countries, not only now but also well into the next century.
The Lancet 1795