Building a Healthier World, Free of Cardiovascular Diseases and Stroke
Presidential Address at the American Heart Association 2008 Scientific Sessions
This week, thousands of healthcare providers and scientists from throughout North America and from >70 countries have come to this conference. We are here in New Orleans, a city that was devastated by Hurricane Katrina in 2005. This community is still recovering and rebuilding. By attending this meeting, we are providing support for the people of New Orleans and helping the city flourish again.
We are also here today at an exciting moment of transformation in the United States. Just 5 days ago, we elected a new president, and our nation’s mood is one of hope and expectation. Many believe that this change in our nation’s leadership marks a new era of opportunity. Like New Orleans, the United States was stricken by an almost unfathomable assault and disaster early in this new century. Our nation has struggled to understand that disaster. Some of our responses have been unsettling, both to us and to many of our friends. But we are now looking to the future with new confidence.
In this moment of opportunity and renewed hope, let us remind ourselves that all of us here today, as well as our colleagues in the healthcare professions, are de facto leaders in our communities by virtue of our education and our professional responsibilities for others. In addition to our individual roles in clinical medicine, research, and many related fields, we are also citizen leaders in our societies. “To whom much is given, much is required” certainly applies to us. And this is what I would like to talk to you about today.
I want us to acknowledge our shared mission as citizen leaders and challenge ourselves to consider the implications of this rallying cry, which is just a nuance away from the American Heart Association’s newly defined mission statement: “Building healthier lives, free of cardiovascular diseases and stroke.” I want us to become passionate for prevention.
Two years ago, we heard Association President Ray Gibbons1 speak about an elephant in the room, his metaphor for the impending crisis in the US healthcare delivery system. Last year, Dan Jones2 used his presidential address to focus on the failure of our healthcare system to deliver on its promise to all Americans, in particular to many of the most vulnerable in our society. Both speakers also identified the global aspects of these challenges—the inadequate resources and embedded societal inequities in healthcare systems, especially in developing societies.
The cardiovascular community has seen incredible success over the last several decades. In fact, the American Heart Association just celebrated a spectacular success in the United States in achieving, 2 years early, its 2010 goal of reducing deaths resulting from coronary heart disease and stroke by 25%.3 These recent reductions are in addition to the remarkable 50% decline in US deaths resulting from coronary disease between 1980 and 20004 (Figure).
Coronary heart disease mortality peaked in the United States in the mid to late 1960s, whereas the decline in coronary deaths lagged by about a decade in the United Kingdom and elsewhere in Europe.5,6 Epidemiologists generally attribute about half of the global reduction in coronary heart disease mortality to risk factor reduction, in particular to the reduction in smoking and the treatment of hypertension and elevated cholesterol. Improved acute care and secondary prevention account for the rest of this remarkable decline in death rates.7
My own father suffered his first myocardial infarction at 49 years of age in 1959. Before his death 9 years later at 58 years of age, he was the longest-surviving male member of his family; his 4 brothers had died at younger ages, most as a result of cardiac disease. Before his heart attack, my father had enjoyed an apparently healthy and active life. He was a high school teacher and athletic coach, had been a Navy officer in the Second World War, and was an active and successful athlete throughout his life. He was the “picture of health.” But sadly, at the time of his premature death, he had met only 2 of his 10 grandchildren, and none of them had the opportunity to know him.
As a society and especially as a profession, we have made dramatic improvements in reducing the scourge of coronary heart disease deaths since those awful days of commonplace premature cardiac death. Paul Dudley White, the 12th president of the American Heart Association, has been quoted as having said that a heart attack after 80 years of age is the work of God and a heart attack before 80 years of age is a medical failure. In these past 4 decades, our cardiovascular care community has been remarkably successful in reducing those medical failures. Life expectancy has reached record highs in the United States and throughout the world.8
Despite this progress, serious challenges remain. First and foremost, the complexities of our healthcare system have resulted in inadequate care for many people. This will worsen as the cost of health care increases and outstrips the cost of living. This situation is true in many other countries as well. But the major threat to continued reductions in preventable and premature deaths from cardiovascular disease and stroke is the increase in risk factors: obesity and diabetes, untreated high blood pressure, smoking, and lack of physical activity.9
Let us recall how shocked and saddened we were, just months ago, when 2 highly respected public figures in the United States died suddenly. Tim Russert of NBC News had an acute myocardial infarction at work from which he could not be resuscitated. Congresswoman Stephanie Tubbs Jones of Ohio, a rising leader in the House of Representatives, succumbed to a massive stroke. Both were 58 years of age, the same age as my father, who died prematurely 40 years ago. Both were at the height of their highly productive careers. Their deaths were losses not just to their families and friends but also to our society. And sadly, it is possible that their deaths were preventable.
The incidence rates and consequences of cardiovascular disease and stroke are rapidly evolving globally, especially in countries with emerging societies. With improvement in basic health care and the continued decline in infectious diseases and malnutrition, people throughout the world are living longer and becoming more susceptible to cardiovascular diseases. Adoption of the lifestyle and culture of the Western world has resulted in increasing problems with cardiovascular disease and stroke in developing countries.
Tobacco use in these countries, often aggressively promoted by United States–based multinational corporations with major tobacco divisions, is rampant. Population-based health initiatives, including tobacco product regulation, are rare, perhaps understandably so because of other development-related challenges in these societies. Regardless of the reasons, global cardiovascular illness is increasing dramatically, and public health efforts, preventive measures, and promotion of health are being outmatched and outgunned in most societies around the world.
We battle cardiovascular disease and stroke, some of us through work in our research laboratories, some through interactions with our patients, and some in both. But what more can we do, in our role as citizen leaders, to address these diseases? First, each of us can become part of public awareness and public health initiatives.
The American Heart Association’s long-standing efforts to promote healthfulness and increase risk awareness have been enhanced by the 4 Cause Campaigns that were launched sequentially in the past several years. Go Red For Women, Power to End Stroke, the Alliance for a Healthier Generation, and START address specific population health goals. These campaigns are intended to embed health awareness and prevention strategies into our popular culture. Physicians and researchers have been an active part of making these campaigns a reality. Go Red For Women has had a huge impact, not just in bringing the message of heart disease susceptibility to an audience of women, most of whom did not understand their risks, but especially by getting women to focus on their own health. Women function as the head of the household when it comes to the family’s health issues. As women better understand and act on their own risks and health needs, our society will become healthier.
The American Heart Association has been pleased to work with the National Heart, Lung and Blood Institute on this important cause and with the World Heart Federation to make this program available around the world. Likewise, the Alliance for a Healthier Generation, the American Heart Association’s partnership with the Clinton Foundation, is having a positive impact in addressing childhood obesity. Nearly a third of children and teens in the United States are overweight or obese; we are in the midst of a childhood obesity epidemic.10,11 And across the globe, this epidemic continues to spread.
Many young people struggle with lifestyle choices and unhealthy behavior, including smoking. They do not understand the consequences for their future health and do not have role models and an environment that support health. In fact, our young people are captives in the environment in which they find themselves. We adults have created or acquiesced in those unhealthy environments.
The Healthy Schools Program of the Alliance has already generated measurable changes in areas like the percent of healthier beverages consumed in schools. We hope that these positive results are steps toward increasing the numbers of kids who leave school with normal body weights and healthier eating habits. The START campaign is bringing the message of healthy physical activity to the public in partnership with ≈27 000 companies.
All of these campaigns are dramatic demonstrations of the American Heart Association’s effectiveness, using 21st century marketing and messaging, in support of our efforts to build healthier lives in our communities, free of cardiovascular diseases and stroke.
The American Stroke Association, a division of the American Heart Association, was created in 1997 and launched its Power to End Stroke campaign in 2006. This campaign is targeted to blacks, who are particularly vulnerable to stroke. The campaign has generated tremendous community interest and support. The Stroke Ambassadors program is a model of how leaders like us can connect in a highly effective manner with communities in support of disease prevention and the promotion of healthfulness. Initial results of these campaigns are encouraging. In 1997, prior to the Go Red For Women campaign, only 30% of women were aware that heart disease is their number 1 killer. By 2005, 55% were aware.12
On the childhood obesity front, the initiative brokered by the Alliance for a Healthier Generation with the beverage companies has resulted in 58% fewer beverage calories being shipped to schools. All of us can help drive these initiatives forward by lending our science and clinical expertise to the effort. As citizen leaders, we must also take a prominent public stance in support of policies that promote health in our communities.
Lewis Atterbury Conner, the first and founding president of the American Heart Association, was known for his personal passion for the prevention of cardiovascular diseases, which stemmed from his experiences with chronic rheumatic patients and others with debilitating heart failure. In 1911, Conner and a few colleagues founded the first Cardiac Clinic at Bellevue Hospital in New York City. Several years later, Conner and his associates established the Society for the Prevention and Relief of Heart Disease, which was the forerunner of the American Heart Association. In 1924 to 1925, he served as president of the newly formed American Heart Association, which included heart societies outside New York. Dr Conner’s work is an example of how we, as citizen leaders, can do something that will have a significant and lasting impact on public health.
As citizen leaders, we can also help raise funds and provide resources for organizations that are driving prevention and the health promotion agenda. In its 85-year existence, the American Heart Association has evolved from that small, regional group of physicians working to improve the care of people with chronic cardiac diseases to a huge health advocacy organization with a recent annual revenue of nearly $800 million.
Most of these funds are raised from >20 million unique donors, literally an army of Americans from all walks of life and from communities in every US state and region. Our donors range from schoolchildren, like my 2 granddaughters in suburban Baltimore, who Jump Rope For Heart at their school each year, to the throngs of enthusiastic heart walkers, like those in Dallas who raised nearly $2.5 million at the annual Dallas Heart Walk in early September 2008. The American Heart Association is the leader, and the icon, of nonprofit organizations devoted to the public good.
The antismoking movement of the past several decades provides encouraging lessons on how we can achieve our healthier world goals and the role that we, as citizen leaders, can play. Let’s look back at the public’s former and current attitudes toward tobacco products and smoking. When I first arrived at Johns Hopkins Hospital as an intern in the Halsted Surgery Program many years ago, there were ashtrays on the backs of the seats in Hurd Hall, the site of Surgery and Medicine Grand Rounds. Most of the doctors in the audience smoked pipes and cigarettes during those medical conferences. There were lots of photos of Dr Alfred Blalock, the famous blue baby surgeon, holding a cigarette in his hand, just like in the picture that appears in the 2-volume collection of his papers. Several years later, after a 2-year tour of duty in the Army Medical Corps in Thailand, I returned to Hopkins, and the ashtrays in Hurd Hall were gone. Someone had even airbrushed the cigarette and smoke out of Dr Blalock’s famous blue baby photo. Those changes at Hopkins marked the beginning of an important public health movement that was led by physicians and other healthcare providers.
The overwhelming majority of doctors in North America stopped smoking during the 1970s. Since then, our community of healthcare professionals has energized the steady groundswell against our society’s acceptance of unregulated tobacco use. We championed this movement in our role of citizen leaders through our advocacy efforts—advocacy within our own practices and hospitals, within our own families and communities, and with our governments.
Throughout the world, we can lend our voices to the work of creating healthier laws, systems, and communities. The American Heart Association has contributed to the antitobacco battle, along with the American Lung Association, the American Cancer Society, and the Campaign for Tobacco Free Kids. We have moved the public’s prior acceptance of smoking as an individual right to a societal awareness and acceptance of the dangers that tobacco use confers on our communities. In recent years, we have had major victories in creating smoke-free environments in cities and states across the nation. A major goal of the American Heart Association’s federal advocacy efforts continues to be the passage of legislation by the US Senate that will empower the Food and Drug Administration to regulate the tobacco industry. Individually and collectively, we have accomplished much in protecting our society from tobacco-associated illness.
Each of you can follow the lead of the American Heart Association into a new period of activism at this auspicious moment in our country’s political life. Research must remain a critical priority. The American Heart Association is fundamentally committed to support biomedical research as an essential component in building a healthier world, free of cardiovascular disease and stroke. In the United States, we cannot allow our national investment in the National Institutes of Health to decline, especially not for research into the No. 1 and No. 3 causes of death in this country.
We must also assist the American Heart Association in achieving its billion-dollar annual revenue goal so that we can continue to support our researchers, especially those new young investigators who are the future of science discovery. I know that those of you from other countries face similar challenges. You, too, can make a significant difference in the fight for sustained support for research.
Finally, each of us can play an extended role in improving the healthcare system. Efforts are underway in most countries to improve systems of care—some by the government, some by organizations like the American Heart Association. One example in the United States is Mission: Lifeline, the American Heart Association’s recently launched program to enhance the care received by all ST-elevation myocardial infarction heart attack victims. The program will ensure a nationwide system of care, built on evidence and carefully developed practice guidelines. Like the American College of Cardiology/American Heart Association practice guidelines, the program will be refined continuously on the basis of new science discovery and careful attention to outcomes.
This type of initiative can change the way health care is delivered, and as a citizen leader, you can help make this happen within your hospital, your community, or your country. Each of us has our own unique and very important role to play in the work of building a healthier world, be that as a nurse, a researcher, a clinician, an allied health worker, a health system administrator, or an advocate against cardiovascular disease and stroke. But in addition to our specific role, each of us is a citizen in our community and society. Let the accomplishments to date of the antismoking movement inspire us to do more to ensure that risk factor reduction and the promotion of healthfulness are embedded in our culture and in our public policy.
Societal problems such as obesity (especially childhood obesity), physical inactivity, smoking, unrecognized high blood pressure, and diabetes need our continued attention as engaged citizen leaders. However we approach the healthcare challenges facing society, in whatever community or country we live, the promotion of wellness and the active practice of preventive medicine will best ensure a healthier world, free of cardiovascular disease and stroke. I call it having a passion for prevention. Let us collectively reaffirm our commitment to these goals.
Presented at the 2008 Scientific Sessions of the American Heart Association, November 8–12, New Orleans, La.
Gibbons RJ. Leading the elephant out of the corner: the future of health care: presidential address at the American Heart Association 2006 Scientific Sessions. Circulation. 2007; 115: 2221–2230.
Jones DW. Delivering the promise: progress, challenges, opportunities: American Heart Association 2007 Presidential Address. Hypertension. 2008; 51: 1399–1402.
Lloyd-Jones D, Adams R, Carnethon M, De Simone G, Ferguson TB, Flegal K, Ford E, Furie K, Go A, Greenlund K, Haase N, Hailpern S, Ho M, Howard V, Kissela B, Kittner S, Lackland D, Lisabeth L, Marelli A, McDermott M, Meigs J, Mozaffarian D, Nichol G, O'Donnell C, Roger V, Rosamond W, Sacco R, Sorlie P, Stafford R, Steinberger J, Thom T, Wasserthiel-Smoller S, Wong N, Wylie-Rosett J, Hong Y, for the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Heart disease and stroke statistics—2009 update: a report from the American Heart Association Statistics Committee and Stroke Statistics Subcommittee. Circulation. 2009; 119: e21–e181.
Unal B, Critchley JA, Capewell S. Modelling the decline in coronary heart disease deaths in England and Wales, 1981–2000: comparing contributions from primary prevention and secondary prevention. BMJ. 2005; 331: 614–620.
Luepker RV. Decline in incident coronary heart disease: why are the rates falling? Circulation. 2008; 117: 592–593.Editorial.
US Department of Health and Human Services, Centers for Disease Control and Prevention, National Center for Health Statistics. Health, United States, 2007 with Chartbook on Trends in the Health of Americans. Available at: http://www.cds.gov/nchs/data/hus/hus07.pdf. Accessed October 26, 2008.
Mosca L, Mochari H, Christian A, Berra K, Taubert K, Mills T, Burdick KA, Simpson SL. National study of women’s awareness, preventive action, and barriers to cardiovascular health. Circulation. 2006; 113: 525–534.