Poverty and Human Development
The Global Implications of Cardiovascular Disease
Cardiovascular disease (CVD) is absent from the global development agenda. This absence is striking, because CVD is a major impediment to human development, imposing large health and economic burdens in low- and middle-income countries. These burdens have a reciprocal relationship in that poverty is a potent cause of CVD, whereas CVD contributes to poverty. The present editorial explores and seeks to explain the global neglect of CVD in pursuit of a strategy for its prevention and control worldwide.
Global Health Burden of CVD
Chronic (noncommunicable) disease, principally CVD, cancer, chronic respiratory disease, and diabetes mellitus, caused 35 million deaths (60% of all deaths) in 2005. CVD (mainly heart disease and stroke) is the leading chronic disease, with 17 million deaths. The contribution of diabetes mellitus is underestimated; deaths due to diabetes are usually recorded as being due to heart disease or renal failure.
CVD is also responsible for much disability, often for decades of a person’s life. Nearly half of the global burden of disease is caused by chronic diseases, and CVD is the leading contributor among these.1
Although the CVD burden and trends vary from country to country,2,3 from a human development perspective, 4 aspects of the burden of CVD are critical. First, the number of CVD deaths is similar in men and women, although the average age of onset is older in women than in men, so no gender bias exists in the burden of CVD that might remove it from development agendas.4 Second, the poorest countries are often deeply affected. CVD deaths are spread evenly among the developed and developing world; this is not a disease specific to wealthy nations. Of the world’s population, 80% of people live in developing nations, and 80% of all CVD deaths, occur in countries with a per capita income in 2001 of less than US $9000 per year.
Third, although death due to CVD is more common with increasing age, almost 45% of CVD deaths occur among people under the age of 70 years. Furthermore, CVD death rates in middle-aged people are considerably higher in low- and middle-income countries than in wealthy countries,5 as they were in the United States and other Organisation for Economic Co-operation and Development nations in the 1960s.
Finally, not only is the burden of CVD especially heavy in poor countries, but it falls disproportionately on disadvantaged populations within all countries. In fact, the greatest inequalities in the distribution of CVD are found within low- and middle-income countries. CVD is having a major and largely unrecognized impact on the health of the workforce and the economies of low- and middle-income countries.1,5
CVD, Poverty, and Human Development Goals
The costs of CVD can be variously estimated with economic metrics. Remarkably few estimates have been made of the macroeconomic burden of CVD, but those that have been done provide no comfort. In 2004, Leeder et al5 examined the impact of CVD on 5 countries and estimated that it could have a serious effect on national productivity. The total number of years of productive life lost for the 5 study countries in people aged 35 to 64 years is already high and will increase from 20.6 million in 2000 to 33.7 million in 2030. In 2005, the World Health Organization (WHO) estimated full-income losses due to heart disease, stroke, and diabetes mellitus in 9 countries and found that these conditions were responsible for huge amounts of forgone national income.1
CVD and poverty are interconnected. As a country develops economically and urban development and migration occur, CVD risk factors first increase among the wealthy, but soon, as they learn their lessons and revise their lifestyles, these risks concentrate among the less affluent. The susceptibility of the less affluent because of these factors is amplified by psychological stress, higher levels of environmentally induced risk behaviors, and limited access to good-quality and affordable health care. The connection between poverty and cardiovascular health extends beyond prevention and includes care. In most high-income countries, people with CVD are protected, at least to some extent, by social security systems and considerable financial discretionary power that enables them to buy necessary care.6 However, in low- and middle-income countries, health insurance systems are poorly developed or nonexistent, and the costs of care for CVD are borne individually, often with catastrophic consequences, or treatment is foregone.
The United Nations Millennium Declaration of September 2000 set 8 Millennium Development Goals to focus international development efforts on halving global poverty by 2015. Three of the 8 Millennium Development Goals directly address health issues, but these do not include CVDs or other chronic diseases.7
To assist the global community and national authorities in focusing on the prevention and control of CVD and other chronic diseases, the WHO has proposed a global goal, in addition to the Millennium Development Goals, that aims to reduce chronic disease death rates by 2% per year over current trends.8 The goal was based on coronary heart disease trends in wealthy countries over the past 4 decades and recent changes in middle-income countries such as Poland. The goal is ambitious but is achievable on the basis of current knowledge. The goal, if reached, would avert ≈36 million chronic disease deaths by 2015, of which half would be due to CVD.8 Three fourths of the averted deaths would be in low- and middle-income countries, and approximately half would be in those under the age of 70 years. These averted deaths should result in economic savings, and men and women would benefit equally.
Global Progress on CVD
Despite the epidemiological and economic data suggesting that CVD is a priority health concern, only ≈3% of WHO’s 2006 to 2007 budget is allocated to chronic diseases, and most other large development agencies spend even less. Despite these meager budgets, tobacco consumption is now receiving increased attention both nationally and internationally. The Framework Convention on Tobacco Control, the first multilateral treaty to be negotiated by WHO, is a powerful legal agreement ratified by >140 countries, and several protocols, including ones concerning cross-border smuggling and advertising and promotion, are under negotiation by treaty partners.9
International efforts directed at 2 other major risk factors for CVD, poor nutrition and exercise, are included in the WHO Global Strategy on Diet, Physical Activity, and Health adopted by member states in 2004.10 Although several major multinational food and beverage companies are modifying their products in line with Global Strategy recommendations, more effort and commitment are needed to ensure that positive moves in Europe, North America, and Australasia now follow in low- and middle-income countries. The large number of small and medium-sized companies must be encouraged to follow the lead of the progressive multinationals.
At the national level, progress is also evident. Several low- and middle-income countries are developing and implementing national plans of action for chronic disease prevention and control. India has funded a national plan for the prevention and control of CVD, stroke, and diabetes mellitus11; China is preparing a national plan of action.12 These are brave beginnings that need strong support to flourish more generally in today’s world.
Myths About CVD
Several myths shroud CVD and are used as a screen by international development and aid agencies to ignore its importance.1 Antagonists argue that CVD is a result of unhealthy personal choices, and hence all responsibility for prevention should lie with the individual. This lets government and civil society off the hook. Individual choice is indisputably important with regard to lifestyles that lead to CVD but is limited by the extent to which the individual has the wherewithal—determination, knowledge, commitment, time, and money—to exercise it. Healthy individual choices will be easier if supported by environments such as tobacco-free public and work spaces, ready availability of healthy food, and opportunities for physical activity.
The urgency of the poverty agenda and its strong linkage to infectious diseases, especially in sub-Saharan Africa, is used to justify the relegation of CVD and other chronic disease to the back burner until poverty and its infectious diseases have been banished. Two rebuttals can be made to this argument. First, as stated, CVD is, like infectious disease, a major development issue because of its effect on the health and economic wellbeing of individuals, families, and countries. No moral or ethical justification exists for ignoring it while attending to other problems. Second, the same health development strategies are appropriate for the prevention and management of both communicable and noncommunicable diseases. As strengthened primary healthcare systems are developed to respond to infectious diseases, the same systems should be used for CVD and other chronic diseases, as recognized by some development agencies.13
Another myth is that the causes of CVD are still not fully known, that the classic risk factors explain only a fraction of the causes of CVD. In reality, the classic risk factors explain up to 70% of all CVD and operate in similar ways and to a similar extent in all countries.14 Although genetic variations exist among populations with regard to cardiovascular risk, existing knowledge about major environmental determinants is sufficient to develop and implement efficient programs at an acceptable cost for the prevention and control of CVD in all but the very poorest countries.15
Overcoming the Neglect: Principles for Action
CVD, as a global problem, challenges the health community to harness clinical, health promotion, and advanced public health approaches for its resolution. Three approaches to the prevention of CVD could be applied simultaneously in low- and middle-income areas, with different emphasis on the 3 tactics depending on local need and capability.16 The first of these should be of immediate interest to cardiologists.
First, primary care interventions for those at high risk of CVD and medical treatment for those with disease symptoms would yield rapid dividends. In both groups, smoking cessation would confer immense benefit, halving the risks of heart attack or stroke by 50% in 2 years. Other inexpensive preventive therapies include antihypertensive drugs. WHO is pioneering the development and evaluation of multiple risk factor assessment protocols for use in resource-constrained settings.17 These interventions are located in the clinic.
Second, educational interventions at all levels of society would increase health literacy and understanding of CVD risk, promote a healthy lifestyle (healthy diet, exercise, and smoking reduction), reduce barriers of ignorance to healthy choices, and provide information enabling informed, healthy choices in regard to food, tobacco use, and exercise. Third, interventions at a macroeconomic level, with support from civil society, industry, and governmental portfolios beyond health and professional organizations such as heart foundations, would use tobacco taxation to discourage tobacco smoking, change agricultural subsidies (for example, decrease subsidies for dairy and meat fat industries), and promote sympathetic town planning, with generous space and structural arrangements to encourage walking, cycling, and using stairs.
Putting these principles into action requires a sustained whole-of-society response that is integrated, comprehensive, and introduced in a politically opportunistic sequence. CVD epidemics are caused by a wide range of factors in many sectors of society. A comprehensive approach combines in a balanced manner population-wide measures and actions directed toward high-risk people. Some actions are straightforward and will be widely accepted, for example, a focus on key aspects of tobacco control. Other proposed actions may be more contentious and may, for example, require legislative actions if self-regulation by industry is found to be insufficient or ineffective. For this reason, a stepwise, or phased, approach is indicated with initial attention to relatively straightforward and effective interventions. Later, as the need becomes apparent and the political will strengthens, more contentious actions can be implemented. Clear lines of accountability for the national response are critical, especially because so many stakeholders are involved. Accountability is more easily assessed if the national response is directed toward agreed, quantified, and timed goals and targets for the entire population, as well as high-risk groups.
In all countries, the response to CVD would desirably be integrated not only with the response to other chronic diseases but also with the response to infectious diseases. A prerequisite for effective implementation of a fully integrated approach is a functioning and equitable primary healthcare system.
Several organizing principles are required for an initiative in CVD prevention and control with foreign-assistance funding. First, the control of solutions must be in the hands of the nations with the problem, and programs need to reflect the capacities and cultures of individual nations. Foreign-assistance agencies must work as colleagues and long-term partners. Second, outside-assistance money must match the commitment from within the country (public and private sectors): There should be no donors and no recipients, only coinvestors. Third, solutions are not confined to the health sector but must include employers, investors, social security, education, and the agricultural sector—all those with some influence on risk factors and disease management. Within the health sector, primary care and specialist care providers must work closely together, at both national and global levels, to advocate for appropriate policies, education of the public, early detection and effective control of multiple risk factors, and cost-effective means of acute-care secondary prevention. For this to happen, we need cardiologists to link with diabetes, hypertension, stroke, nephrology, cancer, nutrition, obesity, and internal medicine groups, as well as with broader civil society movements (such as the tobacco control groups), to create the critical mass and momentum for change.
The authors thank Henry Greenberg and Susan Raymond for several of the ideas about preventive strategies, and Masoud Mirzaei for his critical reading of the draft of the paper and for providing information on global variations in CVD deaths and prevalence.
The opinions expressed in this editorial are not necessarily those of the editors or of the American Heart Association.
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