The challenge of cardiovascular disease in developing ... · The challenge of cardiovascular disease in developing economies ... The challenge of cardiovascular disease in developing

The challenge of cardiovasculardisease in developing economies

2ND EDITION DECEMBER 2014

2nd EditionDecember 2014

The challenge of cardiovascular disease in developing economies

A RACE

AGAINSTTIME

SIVADASANPILLAI HARIKRISHNAN MD, DM, FRCP Additional Professor in Cardiology at Sree Chitra Tirunal Institute for

Medical Sciences and Technology, Trivandrum, India.

STEPHEN LEEDER MD, PhD, FRACP Professor of Public Health and Founding Director of the Menzies Centre

for Health Policy at the University of Sydney, Australia, and Editor-in-Chief of the Medical Journal of Australia.

MARK HUFFMAN MD, MPH Assistant Professor of Preventive Medicine and Medicine-Cardiology

at the Northwestern University Feinberg School of Medicine and Cardiologist at the Bluhm Cardiovascular Institute and

Northwestern Memorial Hospital, Chicago, USA.

JEEMON PANNIYAMMAKAL MPH, PhD Head of Clinical Research Unit,

Centre for Chronic Disease Control, New Delhi, India.

DORAIRAJ PRABHAKARAN MD, DM, MSc, FRCP, FNASc Executive Director, Centre for Chronic Disease Control (CCDC)

and Professor, Chronic Disease Epidemiology, Public Health Foundation of India.

ISBN : 978- 81-930819-0-7

HOW TO CITE THIS PUBLICATION: Sivadasanpillai Harikrishnan, Stephen Leeder, Mark Huffman,

Panniyammakal Jeemon, Dorairaj Prabhakaran. A race against time:

The Challenge of Cardiovascular Diseases in Developing Economies. Centre for Chronic Disease Control, New Delhi, India - 2014

Preface 1 Henry Greenberg, Susan U. Raymond, Stephen R. Leeder

Foreword 6 K. Srinath Reddy

A. Introduction 8 A1. Origins and rationale of the report

B. The problem and the global data 15 B1. What are the global data? B2. Potential reasons for the epidemic B3. The decline of cardiovascular disease in the developed world and the lessons learned B4. The need and means for control of cardiovascular disease

C. CVD status and projections in five developing countries 29 C1. Methods and demographic profiles C2. Overall CVD experience in the five study and two comparator countries C3. Labour force implications D. The macro- and microeconomic consequences of CVD 55 D1. Potentially productive years of life lost due to cardiovascular disease D2. Macroeconomic consequence of disability-adjusted life-years lost due to cardiovascular disease D3. The toll of disability associated with cardiovascular disease D4. Direct and indirect health care costs for cardiovascular disease D5. Household viability and dependency due to CVD

CONTENTS

E. Intervention strategies to reduce the impact of CVD 74 E1. Levels of prevention of CVD E2. Practicalities of cardiovascular disease prevention

F. From analysis to action 102 F1. The sociopolitical context: Instituting change in civil societies F2. CVD as a macroeconomic challenge

G. Rays of hope 111 G1. International initiatives G2. Group and regional initiatives G3. Country-specific initiatives G4. Combating NCDs: where are we?

H. Conclusions 136 H1. Putting CVD in the developing world on the international health and development agenda H2. Deeper documentation of the prevalence and costs of CVD H3. Developing partnerships at the macroeconomic level with national governments in key developing countries H4. Train the trainer initiatives in health education H5. Undertaking trial treatment and prevention interventions H6. Longer-term research and interventions

DR. COLIN MATHERS

Coordinator, Mortality and Burden of Disease,

World Health Organization

For providing data for the projections in the book

DR. BONGANI MAYOSI

University of Cape Town, South Africa

For reviewing the section on

South Africa in the chapter “Rays of hope”

PROF. NANA POGOSOVA

MD, Professor, and Head, Federal Health Center and Department of Internal

Diseases Prevention,

National Research Center, Preventive Medicine, Moscow,

For contributing the section on Russia in the chapter “Rays of hope”

MS. RIVQA RAFAEL AND MS. MEGHA SHARMA

For proof-reading

MR. SURESH BABU, MR. VINEETH CP AND MR. MANAS CHACKO

Project Fellows, SCTIMST, Trivandrum, India

For data entry

MR. MOHAMMED TAYYAB

Research Associate

DR. SAFRAJ S

Senior Research Associate Public Health Foundation

of India for generating the world maps.

ACKNOWLEDGEMENTS

We are delighted to offer this preface to the second edition of A race against time. It is invigorating to see that a new generation of investigators and au-thors has picked up the leadership of this project. We are confident that this edition will further advance the field of global chronic disease public health and further influence the global priorities of the assistance community. We are particularly appreciative of the efforts of Dr Harikrishnan, Dr Prabhakaran, Dr Mark Huffman and Dr Jeemon.

There is one area in which we would like to offer an argument for greater at-tention. The academic public health community needs to embrace chronic disease with far greater vigour going forward than it has done in the past. We posit that this engagement will require far more complex changes in curriculum than adding new courses and new datasets for new diseases. As the faculty of Columbia’s Mailman School of Public Health (1) and we (2) have argued, public health must migrate from the paradigm of medical care to population intervention. It must go upstream, and far upstream, to confront the societal drivers of cardiovascular disease (CVD) and cardiac disease risk factor behaviour. Further, it must proactively seek a seat at the “big table” of national policy regarding drivers of population health. Health care delivery, if it is to be effective, will be expensive everywhere and the health budget cannot be viewed as simply a ministerial line item in a national budget. We would argue that every ministry needs to have a health-related portfolio as part of its overall mandate.

Schools of public health in the United States tend to be “soft money” schools, with most faculty funded primarily by external grants. The current grant climate for global health focuses on the triad of HIV/AIDS, tuberculosis and malaria, with HIV/AIDS holding an overriding dominance. According to data compiled by the Kaiser Family Fund, HIV/AIDS attracts more than 60% of all US global health funds and the triad receives upwards of 75% (3). Chronic disease gets little more than a rounding figure buried in the approximately 1% categorised as “other”. Faculty teach what they know, and their current roles are endorsed by the support of and recognition by the leading funding organisations. And to be sure, these three diseases are not unimportant problems, and, until recently, HIV/AIDS was the critical public health

HIGH-INCOME COUNTRIES For the 2015 fiscal year, The World Bank divides the economies of countries according to 2013 GNI (gross national income) per capita, per annum, calcu-

lated using the World Bank Atlas method. A country is considered high income if its GNI per capita is more than $12,746. According to the World Bank, there were 75 high-income countries

in 2015 fiscal year.

MIDDLE-INCOME COUNTRIES Middle-income countries are further classified into lower middle-income

(per-capita GNI, $1045-$4125) and upper middle-income groups (per-capita GNI, $4125-$12,746).

In 2015 fiscal year, there were 50 lower middle-income and 55 upper middle-income countries according to the World Bank.

LOW-INCOME COUNTRIES A country is considered as low-income if the per-capita GNI is $1,045 or

less. There were 34 low-income countries in 2015 fiscal year.

DEVELOPING COUNTRIES OR ECONOMIES Low-income and middle-income countries are sometimes

referred to as developing countries or economies.

DEFINITIONS USED IN THIS REPORT

THE NEED TO ALIGN THE ACADEMIC GLOBAL PUBLIC HEALTH CURRICULUM WITH GLOBAL PUBLIC HEALTH REALITIES

Henry Greenberg, MD, Susan U. Raymond PHD, Stephen R. Leeder MD, PHD, FRACP

PREFACE

RACE AGAINST TIME 1

issue of the age.HIV has become a chronic disease, and it is being tackled successfully as such. Ac-

cording to UNAIDS (4), and supported by data used by others, the incidence of HIV/AIDS is falling, survival rates are increasing, mother-to-child transmission is begin-ning to plummet, and the proportion of eligible patients being treated with antiret-roviral therapy is nearly 50% in sub-Saharan Africa. And crucially, more than 50% of the funding for HIV/AIDS in developing countries is supplied by these countries themselves. The trajectories of all these data curves point to an ultimate “win”. The disease will not disappear tomorrow, there remains much to do, unforeseen barriers will no doubt emerge, and funding will always be tenuous and will rarely meet need. In addition, there are regions or countries with significant under-reporting or seri-ous pockets of unrecognised disease. Treatment and management will arrive late, although much of this may not require external assistance for control. But the over-whelming success of the recent past will prevail and this optimism is perpetuated by the data from the HIV/AIDS research communities.

At an accelerating pace since first brought to attention of the public health world by Omran in 1971 (5), chronic diseases, particularly the cardiovascular constella-tion of conditions, which includes diabetes mellitus and cancers, have assumed an ascending and now dominant role in emerging economies. The Global Burden of Disease series, first in the 1990s (6) and recently in 2012 (7), and our own work in the first edition of A race against time (8) has documented this. It is now uni-versally recognised that these conditions are the planet’s dominant health issues. For example, in India, with a median age of a youthful 26 years, chronic disease accounts 53% of mortality and the CVD risk factor profile points to a rapidly in-creasing proportion (9). Even more dramatic is a recent report from Tanzania show-ing that the age-adjusted stroke rate in Dar es Salaam exceeds that of New York City’s Harlem (10).

The disconnect between the almost explosive emergence of chronic diseases in the developing world and the lack of funding to address them is both striking and disheartening. However, there are signs that the barriers may be breached. The UN General Assembly highlighted chronic diseases in 2011, only the second time a health issue has been the central topic of a high-level general assembly meeting. The wide, positive reception of the 2012 release of the Global Burden of Disease may initiate a new intensity of examination. The addition of significant anti-tobacco funding from the Bloomberg foundation augments the impact of the World Health Organization Framework Convention on Tobacco Control, now approved in more than 175 countries (11).

What if a change happens? What if data, problem recognition, and focused en-ergy all converge and chronic diseases assume their rightful place in global health and the donor community decides to embrace the problem? Where are the cadre of public health professionals who can lead this assault?

It is not beyond imagination that the funding community will pivot rapidly to embrace chronic disease. And while “rapidly” is likely wishful thinking, the transition will surely occur over the next decade. Whether the trajectory is steep or gradual, will schools of public health be prepared to meet this challenge?

One argument might be to use the workforce trained in HIV/AIDS, as they have the experience is dealing with chronic disease. We would argue that the skillsets required for HIV/AIDS are inadequate to the task and will be unlikely to transfer effectively to the new demands of CVD or cancer. HIV/AIDS management is chronic disease man-agement but is linear and narrow – getting the systems right for medication delivery. This success, to be sure, is a major contribution to all of global health. HIV/AIDS has learned to focus educational expertise on schools and select populations in the com-munity, to align drug production, pricing, and delivery, to begin to reduce the stigma of the diagnosis, and to create a bottom-up series of activities that help sustain robust funding. However, the scope of CVD risk factor modification is vastly more complicated than this and requires a far broader array of skills.

CVD risk reduction will require intervention on all sorts of levels. Public health professionals will need to engage tax policy, trade policy, agricultural subsidies, ur-ban planning, socioeconomic patterns of behaviour, the impact of commercial ad-vertising, as well as the complex issues that surround health care financing, patterns of health care delivery and determination of priorities.

This will require new patterns of public health education with a curricu-lum that may well extend well beyond the confines of a school of public health. Not only the medical school, but also the schools of business, law, interna-tional affairs, architecture and urban planning, and departments of communica-tions, sociology, anthropology and economics will be able to contribute to this curriculum and will likely even be necessary for this education to attain a ro-bustness needed to produce an effective 21st-century public health profes-sional. Mid-career, retooled HIV/AIDS workers may not find a warm welcome or firm embrace.

How should schools of public health proceed? Few, if any, can fund new depart-ments and create new concentrations of study. Students still look forward to global health careers in HIV/AID and other, even more traditional infectious diseases. There are no quick, easy answers, but there are steps to take. We offer several suggestions.

First, the schools individually and collectively through the organisations that bind them need to approach the dominant funding organisations and make the case for the future.

Second, the various national and international cardiac, cancer, and pulmonary organisations and their alliances can be approached and mobilised to support this effort, and these organisations themselves may be able to initiate training grants and pilot studies.

Third, curriculum initiatives that highlight the coming epidemic of chronic dis-

RACE AGAINST TIME 3

ease can begin to tilt student interest toward these problems. These initiatives can encompass a broadening of the core curriculum to emphasise chronic disease as well as engaging faculty from within the university to offer new elective courses that are tied to the new core curriculum and supported at the highest levels of the schools.

Without abandoning the commitment to the problems of the present, the schools can begin to assume a leadership role in creating a professional public health workforce committed to the future.

Dr. Henry GreenbergColumbia University, Mailman School of Public Health &College of Physicians and Surgeons St. Lukes and [email protected]

1. Fairchild AL, Rosner D, Colgrove J, Bayer R, Fried LP. The exodus of public health: what history can tell us about the future? Am J Pub Health 2010; 100: 54-63.

2. Greenberg H, Raymond SU, Leeder SR. The prevention of global chronic disease: academic public health’s new frontier. Am J Pub Health 2011; 101: 1386-91.

3. The Henry J Kaiser Family Founda-tion. US Global Health Policy. Kaiser Slides. www.kff.org. (accessed Feb 2013).

4. UNAIDS. Global report: UNAIDS report on the global AIDS epidemic 2012. www.unaids.org/en/resources/publications/2012/name,76121,en.asp (accessed Jul 2014).

5. Omran AR. The epidemiologic transi-tion: A theory of the epidemiology of population change. Milbank Mem Fund Q1971; 49: 509-38.

6. Murray CJL, Lopez AD. Global Burden of Disease Series. Lancet 1997; 349: 1269-77, 1347-53, 1436-43, 1498-505.

7. Horton R. GBD 2010: understanding disease, injury, and risk. Lancet 2012; 380: 2053-4.

8. Leeder S, Raymond S, Greenberg H. A race against time. New York: The Earth Institute, Columbia University, 2004. www.earth.columbia.edu/news/2004/images/raceagainsttime_FINAL_051104.pdf (accessed Jul 2014).

9. World Health Organization. Country profile: non-communicable diseases. www.who.int/countries.ind (accessed Feb 2013).

10. Walker R, Whiting D, Unwin N et al. Stroke incidence in rural and urban Tanzania: a prospective, community-based study. Lancet Neurology 2010; 9: 786-92.

11. World Health Organization. Parties to the WHO Framework Convention on Tobacco Control. 2014. www.who.int/fctc/signatories_parties/en/index.html (accessed Jul 2014).

REFERENCES

RACE AGAINST TIME 5

By a curious coincidence, just as I set out to write this foreword to the second edition of A race against time, another request for a foreword landed with me, accompanied by a book written by senior Indian journalist Dinesh Sharma. In the preface to that book, Know Your Heart, Sharma writes of a media workshop he attended 10 years ago, in which my colleagues and I engaged Indian journalists on issues related to the rising threat of CVD in India. He candidly states that he later discarded the several WHO documents and journal articles he received in his kit but preserved one book – the first edition of A race against time. That book stimulated him to delve more deep-ly in to the course and causes of the calamitous rise of cardiovascular diseases in India. Sharma’s book, which provides a serious sociopolitical analysis of the problem, is a fitting tribute to his distant mentors who published A race against time in 2004.

Indeed, the first edition of A race against time had that kind of an impact on many individuals and institutions – health professionals, policymakers, health advocates, international organisations, foundations and, of course, the media and lay reader-ship. It not only laid out the stark statistics of the mounting numbers of death due to heart disease in different regions globally, but also made a compelling case for urgent action by highlighting the disastrous economic costs of continued neglect. There is no doubt that the book proudly influenced global health debates and led to the World Bank and the United Nations revising their previous positions on the global threat of non-communicable diseases (NCDs).

The second edition of A race against time is also well timed. While the Political Resolution of the UN in September 2011 recognises the threat posed by NCDs to global development and acknowledges the bi-directional links between NCDs and poverty, national and global responses have been feeble so far. The multisectoral policy alignment needed to protect and promote cardiovascular health as well as the integrated health system responses required to provide a wide range of services across the life course are not yet a feature of national planning or global funding. The replacement of the Millenium Development Goals in 2015 by the Sustainable Development Goals (SDGs) offers an opportunity to firmly position CVD and other NCDs in the evolving global development agenda. The updated information and fresh analyses provided in this second edition will help to inform the diverse stake-holders engaged in the development of the SDGs and make a strong case for the clear positioning of NCD prevention and control in the health SDG.

This new edition not only sounds a fresh alarm about the advancing tsunami of global CVD, but also provide a road-map for how to counter and contain that threat. It presents new data on global trends in CVD, while using five countries as exem-plars of different regions. Building on evidence from several countries, it provides the course coordinates for concerted actions which are needed both for population

FOREWORDhealth and individual protection. While warning against the costs of inaction, it pro-vides a template of cost-effective interventions which can save millions of lives and billions of dollars. If we have to win the race against time, this is the GPS which we must use to speedily steer our collective response to the global CVD epidemic.

K. Srinath ReddyPresident, Public Health Foundation of IndiaPresident, World Heart Federation

RACE AGAINST TIME 7

The first edition of this report (1) was derived from a project conducted at

Columbia University during 2003, which examined the economic and social con-sequences of CVD in developing econo-mies. The project followed on from the work of the Commission on Macroeco-nomics and Health (CMH), chaired by Professor Jeffrey Sachs. The principal investigators on the project were Ste-phen Leeder, Susan Raymond and Henry Greenberg. Hui Liu was a research associ-ate, and Kathy Esson served as a research associate and as contributing editor. The report was published in 2004.

This second edition is an update and incorporates new data published since 2004, and new developments in CVD prevention in the past 10 years among the countries reported in the first edition. The current report examines the social and economic impact of CVD in one low-income and four middle-income countries, now and for the next 40 years. It also reviews strategies for the prevention of CVD in terms of their costs and benefits, where such data exist.

CVD is the number one cause of death globally (2). More than 80% of CVD deaths take place in low- and mid-dle-income countries and occur almost equally among men and women (3). CVD includes coronary artery disease (including acute coronary syndromes – unstable angina and myocardial infarc-tion), congestive heart failure, stroke, chronic kidney disease, and peripheral vascular disease.

The origins of CVD are located in society. High levels of CVD are found in environments where there is an abun-dance of unhealthy food, where tobacco smoking is prevalent, where people do not exercise much and where various stresses operate. The dominant risk fac-tors for CVD are either modifiable or not. Non-modifiable risk factors include age, sex, and genetic predisposition. The most important modifiable risks are to-bacco use, high blood pressure, altered blood lipids (dyslipidaemia), obesity, and lack of exercise. Systemic hyperten-sion alone contributes to 51% of deaths due to strokes and 45% of deaths due to coronary heart disease (2).

AINTRODUCTION

Adults with diabetes have heart disease death rates about two to four times higher than those without (3). The risk for stroke is two to four times higher among people with diabetes (4). Further, one risk factor predisposes to the development of another. For exam-ple, between 2005 and 2008, among adults aged 20 years or older with self-reported diabetes in the US, 67% had high blood pressure (4). The American Heart Association also considers dia-betes mellitus and its precursor condi-tion pre-diabetes – abnormal glucose metabolism due to insulin resistance as seen especially in the metabolic syn-drome discussed later – to be major risk factors for CVD, including kidney dis-ease (5,6). Their increasing prevalence among children and adults in associa-tion with rising levels of obesity is of special concern.

These risk factors for CVD also con-stitute diseases in their own right; hy-pertension, dyslipidaemia, obesity and abnormal glucose levels are disorders that require medical intervention. These precursor conditions are major targets of CVD prevention in both populations and individuals. They accelerate the progression of pathological processes in vascular, cerebral and myocardial biol-ogy that over decades lead to end-organ diseases such as stroke, myocardial in-farction and kidney failure, as well as the fatal arrhythmias that account for many of the sudden deaths that occur due to coronary heart disease.

The above risk factors account for the vast majority of coronary heart dis-ease (7). Data from the INTERHEART

study convincingly demonstrated that conventional risk factors account for 90% of the CVD risk in all populations (52 countries) where the study was con-ducted (8). There is widespread agree-ment that risk factors are appropriate foci of preventive efforts in relation to CVD in both developed and develop-ing countries, because to the degree that an individual’s risk factor profile is reduced, his or her susceptibility of developing end organ disease also de-creases. The ability to treat these risk factors in individuals does not exclude the importance of counteracting ad-verse societal forces in society that lead to the CVD epidemic.

These adverse social factors or “causes of causes” lie within the do-main of social policy and relate to ag-riculture, commerce, market forces, global covenants, legal frameworks and the environment, among others. In ad-dition, prenatal factors, environments during gestation and factors during the postnatal and early childhood periods may be critically important determi-nants of later risk (9). Job strain, job demands and decision latitude has also been shown in the Whitehall studies of British civil servants to be additional determinants of CVD risk (10). There is no reason to suppose that these risks are peculiar to one cultural context or one occupation.

The ageing of all populations height-ens the importance of CVD both in peo-ple of working age and in those who are beyond working age. Given the ageing of the world’s population from 1990 to 2050, we examine in detail the implica-

RACE AGAINST TIME 9

tions for selected developing countries. By 2030, the median age of the popu-lation in much of the developing world will begin to approach that of high-in-come countries. In several developing countries this will create an age profile much like that of the West, but in so-called “young” countries – those with a higher proportion of people younger than 65 than found in, say, Europe – it will first produce a bulge of people of working age. The world has paid little attention to the chronic disease and dis-ability profiles of the labour force in the developing world. Even less attention has been paid to the economic implica-tions of failing to stem current trends in the development and expression of these diseases.

There is an urgent need to act to stem the tide of risk factors that lead to CVD, to prevent a massive increase in the number of people with end stage illness. In our estimation, in young coun-tries, while the levels of CVD risk factors are high, a two-decade window of op-portunity exists to reduce their progres-sion to end organ disease. If successful, the future costs of death and disability due to CVD will not become an intoler-able burden. We have called this inter-val “a race against time” to emphasise the importance of taking action now to prevent catastrophic levels of CVD 10 to 20 years hence.

Fortunately, demonstrably effective interventions are already available for individuals at high risk of CVD. These dis-ease prevention and management strat-egies slow the progress of risk factors and prevent or postpone expression of their

most serious end-organ consequences. In addition, affordable public health and other public policy measures can readily be applied at the level of the population to ameliorate the effects of CVD. These measures have been used to good effect in curtailing CVD in countries such as the US, Australia, the United Kingdom and other European nations since the mid-1960s (11-14).

We explore the significance of CVD from both an epidemiological and an economic perspective. In reconciling the epidemiological projections with their likely economic consequences, we address the macroeconomic question: what will be the likely cost to nations of CVD if we do nothing about it? Be-cause there are now effective strategies for preventing and treating CVD, health officials can take decisions about invest-ment in these strategies by considering the costs and benefits of intervention versus the costs and savings of doing nothing.

Assuming that these explorations fa-vour investment in intervention, health officials can make microeconomic choices – such as drug therapy or pub-lic health measures or a combination of both – based on cost-effectiveness data. They can choose among alternate investment strategies and determine budgets. We do not provide a detailed costing of the microeconomic implica-tions of specific interventions to reduce CVD in this study. However, we do ex-amine the limited evidence available in relation to both the cost and feasibility of individual and population-based in-terventions, and locate it within the con-

text of national government macroeco-nomic decision making. For a complete analysis, we would need a lot more data on costs, especially those that concern the impact of CVD on the workforce.

The document begins by reviewing the derivation of this project from the work of the WHO Commission on Mac-roeconomics and Health (CMH). It then assesses the global significance of CVD. Five developing countries provide a case study to view the prevalence of CVD in low- and middle-income countries. Next, the macroeconomic implications of CVD are examined. Possible strategies to reduce the impact of CVD are then explored. And finally, we offer an agenda for action.

A1. Origins and rationale of this report In December 2001, the WHO received the report of its CMH (15). The then Director-General of the WHO, Gro Har-lem Brundtland, had established the Commission to produce a comprehen-sive analysis of the relation between health and economic development. Seven working parties performed this work, and the CMH published a principal report with six supplementary volumes. Jeffrey Sachs, a professor of econom-ics and then director of the Center for International Development within the Kennedy School of Government at Har-vard University, oversaw the work of the Commission as its chair. More than 500 experts in health and economics con-tributed.

The Commission strongly linked health to a macroeconomic perspec-tive, portraying both health and health

care as critical elements in country de-velopment, sufficiently important to engage the close attention of those re-sponsible for overseeing each country’s macroeconomic agenda. This departs from a conventional view of health ex-penditure that sees it as a sunk cost, and then assigns decisions about health ser-vice spending to the ministry of health, which then makes microeconomic choices about how best to invest the al-location they have received.

Central to the purpose of the CMH report is the question so often asked by governments – why should we invest in health? Competition for public money is intense, even when it is for indisput-ably humane purposes. If investments in health and health services are to be justified, then the likely yield from those investments should compare favourably with benefits that would follow from the commitment of these funds to other purposes, including education, urban de-velopment, public transport, trade and industry, and defence.

Investments in health not only re-duce the burden of disease, but also stimulate economic growth, which in turn raises a society’s ability to invest in public health. On the other hand, lack of investment in health, due to overall eco-nomic impoverishment, has devastating consequences. The CMH report focused much of its attention on the urgent pub-lic health crises of sub-Saharan Africa, a region deeply wounded by HIV, malaria and tuberculosis. It argued that increas-ing investment in health, harnessing a country’s own resources and drawing on foreign aid when required, is essential if

RACE AGAINST TIME 11

the world’s poorest nations are to break out of a never-ending cycle of poverty.

The CMH report argued that to im-prove economic wellbeing, many coun-tries would need to invest more in public health measures, including immunisa-tion, and in primary health care. It also confronted the uncomfortable reality that the necessary investment to achieve health gains and subsequent economic improvement is beyond the capacity of many of the poorest nations. In these cases, donor nations who sense the hu-mane, economic and strategic impor-tance of helping these countries out of their poverty must match or exceed the national financial contributions. The re-port thus called for a manifold increase in donor commitment.

Whatever the source of the increased investments in health and health care, their management necessitates the in-volvement of ministries of finance and development, and even presidential/prime ministerial commitment to better health. The report called on all nations to consider establishing their own commis-sions on macroeconomics and health, where ministers of health and finance and their bureaucratic counterparts can meet to establish agendas for health and development. Notably, several countries (e.g., Cambodia, Caribbean Community, Ghana, China, India, Indonesia, Mexico, Sri Lanka and Thailand) have done this, but there are several others that have yet to do so.

We are at a strangely paradoxical historical moment with regard to global health. Old problems coexist with new ones, and solutions to yesterday’s cri-

ses provide the vehicle for tomorrow’s threats. For example, under-nutrition remains by far the greatest risk fac-tor for premature mortality among the world’s least-developed countries (16). Improved nutrition has played a major role in health gain and economic de-velopment in many low- and middle-income countries. Yet now, excess and unbalanced nutrition threatens the health and wellbeing of many millions of people, a surprising number of whom live in countries that are not affluent. To this must be added one of human-ity’s greatest follies – tobacco smok-ing. The prevalence of tobacco use, which is now declining in developed countries, is increasing in many devel-oping countries (17), bringing with it death and disease.

The major NCDs that account for the vast bulk of the worldwide burden of illness, including CVD, often have their origins in lifestyles and socioeconomic conditions. These conditions reflect both individual and societal choices, the latter made at high levels both inside govern-ment and beyond.

We can make a strong case to extend the macroeconomic approach to include a consideration of these disorders. These have a close connection with agricultur-al policy, food marketing, tobacco pro-duction and sale, urban planning, em-ployment, and education. This is not to argue that individual choice is unimpor-tant in relation to lifestyle, but to rec-ognise that the social, educational and economic context in which individuals operate, powerfully shapes the degree to which they can exercise choice.

1. Leeder S, Raymond S, Greenberg H. A race against time. New York: The Earth Institute, Columbia Univer-sity, 2004. www.earth.columbia.edu/news/2004/images/raceagainsttime_FI-NAL_051104.pdf (accessed Jul 2014).

2. World Health Organization. Cardio-vascular diseases (CVDs). Fact sheet no. 317. March 2013. www.who.int/media-centre/factsheets/fs317/en/index.html (accessed Sep 2013).

3. World Health Organization. Global atlas on cardiovascular disease preven-tion and control. 2011. www.who.int/cardiovascular_diseases/publications/atlas_cvd/en/ (accessed July 2014).

4. American Diabetes Association. Statistics about diabetes. http://www.diabetes.org/diabetes-basics/statistics/?loc=DropDownDB-stats (ac-cessed Feb 2013).

5. Mokdad AH, Bowman BA, Ford ES, Vinicor F, Marks JS, Koplan JP. The continuing epidemics of obesity and diabetes in the United States. JAMA 2001; 286: 1195-200.

6. Reaven G. Metabolic syndrome: pathophysiology and implications for management of cardiovascular disease. Circulation 2002; 106: 286-8.

7. Magnus P, Beaglehole R. The real contribution of the major risk factors to the coronary epidemics: time to end the “only-50%” myth. Arch Intern Med 2001; 161: 2657-60.

8. Yusuf S, Hawken S, Ounpuu S, Dans T, Avezum A, Lanas F, et al. Effect of potentially modifiable risk factors as-sociated with myocardial infarction in 52 countries (the INTERHEART study): case–control study. Lancet 2004; 364: 937-52.

9. Cohen MS. Fetal and childhood onset of adult cardiovascular diseases. Pediatr Clin North Am 2004; 51: 1697-1719.

10. Kuper H, Marmot M. Job strain, job demands, decision latitude, and risk of coronary heart disease within the Whitehall II study. J Epidemiol Commu-nity Health 2003; 57: 147-53.

11. Stamler J. The marked decline in coronary heart disease mortality rates in the United States, 1968–1981; sum-mary of findings and possible explana-tions. Cardiology 1985; 72: 11-22.

12. Mirzaei M, Truswell AS, Arnett K, Page A, Taylor R, Leeder SR. Cerebro-vascular disease in 48 countries: secular trends in mortality 1950–2005. J Neurol Neurosurg Psychiatry 2012; 83: 138-45.

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B1. What are the global data?CVD is the number one cause of

death globally (1). Of the 52.8 million deaths in 2010, ischaemic heart dis-ease (IHD) and stroke killed 12·9 million people (Figure B1). These two diseases accounted for one in four deaths world-wide in 2010, compared with one in five in the 1990s (2). Low- and middle-income countries are deeply affected (3) 82% of CVD deaths occur in low- and

middle-income countries almost equally in men and women (3,4). The distribu-tion of IHD and stroke deaths in World Bank income groups and WHO regions in men and women is depicted in Fig-ure B2. By 2030, 23.6 million people are predicted to die from CVD (5). While CVD continues to be the principal cause of death and of much morbidity in in-dustrialised nations (5-7), evident from Figure B2 is the fact that low- and low-

BTHE PROBLEM ANDTHE GLOBAL DATA

FIGURE B1. World map showing age-standardised ischaemic heart disease (IHD) and stroke mortality rates (rates are deaths per 100,000 population). Source: Institute for Health Metrics and Evaluation. GBD Compare 2010. http://viz.healthmetricsandevaluation.org/gbd-compare (accessed 29 Mar 2014).


middle income countries are the leading contributors worldwide to CVD deaths.

The largest percentage increase of mortality due to CVD is predicted to occur in the WHO Eastern Mediterra-nean Region, and the largest increase in number of deaths will be in the South-East Asian Region. In developing coun-tries, CVD represents three-quarters of the mortality from NCDs, and already accounts for 10% of the developing world’s burden of disability (4).

In less economically developed countries, 46% of people who died from CVD-related causes were economi-cally productive, younger than 70 years of age. In addition, 79% of the disease burden attributed to CVD is in this age group (5).

An important parameter used to measure the potential impact of any disease is the disability-adjusted life-year (DALY). The latest Global Burden of Disease (GBD) data shows that IHD was the leading cause of DALYs worldwide in 2010 (up from fourth rank in 1990, increasing by 29%), while stroke-related DALYs ranked third, (fifth in 1990; a 19% increase). Thus, CVD has emerged as one of the major contributor to DALYs (Figure B3).

Projections suggest that for IHD, the mortality for all developing countries between 1990 and 2020 will increase by 120% for women and 137% for men. Predictions for the next two dec-ades include a tripling of IHD and stroke mortality in Latin America, the Middle East and sub-Saharan Africa, a rate of increase that exceeds that for any other region, except for Asian and Pacific Is-

land countries. By contrast, the increase in CVD deaths in more-developed na-tions, largely attributable to an expan-sion of the population of older people at risk, will range between 30% and 60% (6).

With regard to stroke mortality and burden among 192 WHO mem-ber states from 1970 to 2008, a 42% decrease in incidence was observed in high-income countries (HICs), but more than 100% increase in stroke incidence was noted in low- to middle-income countries. Between 2000 and 2008, the overall stroke incidence rates in low- and middle- income countries have, for the first time, exceeded the level of stroke incidence seen in HICs, by 20%. Rates of stroke mortality and DALY loss were highest in Eastern Europe, North Asia, Central Africa, and the South Pa-cific. National per-capita income was the strongest positive predictor of mor-tality and DALY loss rates (p< 0.0001), even after adjustment for cardiovascular risk factors (p< 0.0001) (6-8).

B2. Potential reasons for the epidemicThe rise in CVD prevalence is directly proportional to the prevalence of the major risk factors for CVD, such as to-bacco use, hypertension, dyslipidaemia and diabetes mellitus.

A systematic review of 139 studies on adult smoking prevalence found that more than 1.1 billion people worldwide smoke, with about 82% of smokers re-siding in low- and middle-income coun-tries (9). In low-income countries, the leading causes of death among the 1.3 million male tobacco deaths were CVD

(0.4 million), in contrast with HICs (10). The data from the global youth tobacco survey, which collected data from youth aged 13–15 years in 100 country sites, revealed an increasing prevalence of to-bacco use among adolescent girls (11). Recently, a report from India showed an increasing prevalence of smoking especially among young people aged 15–24 years (12).

Globally, the overall prevalence of raised blood pressure among adults aged 25 years and older was around 40% in 2008. The number of people with hyper-tension rose from 600 million in 1980 to nearly 1 billion in 2008 (13). In an analysis of the prevalence of hyperten-sion in 2000, Kearney et al calculated that by the year 2025, approximately one in three adults aged over 20 years – 1.56 billion people worldwide – will have hypertension (14). Most of this increase will occur in economically developing

regions, and by 2025 three-quarters of the world’s hypertensive population will be in economically developing countries. They predict that the number of people with hypertension in these regions will increase by 80%, compared with a much smaller 24% increase in economically developed regions (14).

Diabetes is rapidly emerging as a global health problem that threatens to reach pandemic levels by 2030. The global prevalence of diabetes in 2008 was about 10% among adults aged 25 years and older (13). The number of people with diabetes worldwide is pro-jected to increase from 377 million in 2012 to 552 million by 2030 (15).

This increase will be most notice-able in developing countries, where the number of people with diabetes is expected to increase from 84 million to 228 million. More than 80% of people with diabetes live in low- and middle-

FIGURE B2. Distribution of ischaemic heart disease (IHD) and stroke deaths in World Bank income groups and WHO regions in men and women. HIC=high-income countries. UMIC=upper middle-income countries. LMIC=lower middle-income countries. LIC=low-income countries. WPR=Western Pacific Region. EMR=Eastern Mediterranean Region. SEAR=South East Asian Region.


income countries. Most people with dia-betes in low- and middle- income coun-tries are middle-aged (45–64 years) (16).

Obesity has reached epidemic pro-portions globally – more than 1 billion adults are overweight and at least 300 million are clinically obese. The WHO defines overweight as a body mass index (BMI) greater than or equal to 25 kg/m2, and obesity as a BMI greater than or equal to 30 kg/m2 (16a). It is a major contributor to the global burden of chronic disease and disability. Obesi-ty often coexists with under-nutrition in developing countries, making the issue more complex (17,18).

Childhood obesity is an emerg-ing problem in the developing world. For children aged between 5 and 19 years, the WHO defines overweight as one standard deviation higher BMI for age and sex, and obese as two stand-ard deviations higher BMI for age and sex (18a). The increasing prevalence of childhood obesity is seen in develop-ing countries: 41.8% in Mexico, 22.1% in Brazil, 22.0% in India, and 19.3% in Argentina. The secular trends in child-hood obesity indicate increasing preva-lence rates in these countries: 4.1% to 13.9% in Brazil from 1974 to 1997, 12.2% to 15.6% in Thailand between 1991 and 1993, and 9.8 to 11.7% in India from 2006 and 2009 (19). The time trends among women in 39 low- and middle-income countries (1991–2008) indicates an increasing burden of overweight among lower wealth and education groups (20).

As Popkin put it, “dietary changes

appear to be shifting universally toward a diet dominated by higher intakes of animal and partially hydrogenated fats and lower intakes of fiber” (21). Physi-cal activity patterns are also equally shifting rapidly toward reduced energy expenditure. Large-scale decreases of prices of some foods and the availability of processed food and the urbanisation of both urban and rural areas are some of the reported key underlying factors in this regard (21).

The rise in CVD incidence reflects a significant change in dietary habits, physical activity levels and tobacco con-sumption worldwide as a result of in-dustrialisation, urbanisation, economic development and food market globali-sation. Unbalanced nutrition, reduced physical activity and increased tobacco consumption are the key lifestyle fac-tors. These risk factors tend to cluster.

B3. The decline of cardiovascular disease in the developed world and the lessons learnedWhile CVD is a global killer, since the mid-1960s, deaths from heart attack have declined by more than 50% in many industrialised countries includ-ing the US, Finland and Australia (22-24), and similar declines have occurred for stroke (25). Data from Canada from 2011 show that heart disease and stroke mortality have declined significantly over the past 40 years – 25% over the past 10 years, 50% over the past 20 years, 70% between 1956 and 2002 (26).

The most recent data from the US in-dicate that from 1998 to 2008, the rate

of death attributable to CVD declined by 30.6%. During the same period, the mortality related specifically to stroke fell by 34.8% (27).

Similarly, data from the European Union (that exclude the Russian Federa-tion and former Soviet republics) show that mortality due to coronary heart disease and cerebrovascular diseases de-clined by 30% between 1981 and 2004 (28). Figure B4 shows that countries with high-income indices showed a decline in CVD mortality, while low-income coun-tries had no significant change.

The positive effects of action against CVD are readily apparent in industrial-ised nations, where government agen-cies, medical leadership, and civic organ-isations have increased public awareness and widespread action concerning the major CVD risk factors. Campaigns fo-cused on diet, smoking and exercise, to-gether with treatment of hypertension and high cholesterol levels, and surgical interventions when needed, have com-

bined to have a major effect on CVD, re-ducing its mortality overall, and pushing it back from middle age to old age as a cause of death. Decisions taken at high levels of eco nomic and legislative deci-sion making in sever al countries have contributed to these positive effects on cardiovascular health, although the spe-cific causal relationships remain uncer-tain.

CVD in these countries is now con-centrated among older people, lower socioeconomic brackets, and racial and ethnic minorities. These higher rates are likely due to disparities that need to be eliminated. Some policy decisions have profound effects even among those without risk factors. For example, recent bans on smoking in public places in many countries have been associated, perhaps causally, with decline in acute myocar-dial infarction (AMI) risk of up to 17% overall (IRR, 0.83; 95% CI, 0.75–0.92) in exposed population (29).

Bruthans et al reported that 52% of

FIGURE B3. World map showing age-standardised ischaemic heart disease (IHD) and stroke disability rates (rates are in disability-adjusted life-years lost per 100,000 population). Source: Institute for Health Metrics and Evaluation. GBD Compare 2010. http://viz.healthmetricsand-evaluation.org/gbd-compare (accessed 29 Mar 2014).


the reduction in coronary heart disease (CHD) mortality in the Czech Republic between 1985 and 2007 was due to re-duction in risk factors, while 43% could be attributed to improvements in treat-ments (30). According to research from the US and Canada, half the reduction in CHD mortality can be attributed to policy measures comprising of preven-tive education programs, tobacco con-trol and the encouragement of healthy lifestyles to reduce cardiovascular risk factors in the populations. The other half is ascribed to progress in medical and surgical care, especially recently. This includes invasive and non-invasive methods of treatment concentrated on those with clinically expressed disease, and new and highly effective medica-tions with which to treat hypertension and dyslipidaemia (31-33).

B4. The need and means for control of cardiovascular diseaseLife-table analyses on the elimination of specific causes of death suggest that the gains from effective prevention and con-

trol of CVD would exceed those of any other cause of death: life expectancy would rise by almost 7 years, but only 3 years if cancer were eliminated as a cause of death (34).

Those who have already had heart attacks and strokes are at high risk of recurrences and death. Thus, second-ary prevention becomes an important aspect of reducing CVD impact. This risk can be substantially lowered with lifestyle modifications and a combina-tion of drugs – statins to lower cho-lesterol (35), aspirin and blood-pres-sure lowering drugs. However, when such treatment efforts are applied in practice, the percentage of the popu-lation attaining treatment targets is dismally small (36,37). In a study from Sweden, 50%–80% of eligible patients received appropriate therapy, and fewer achieved therapeutic end-points (38). By using the IMPACT CHD model (a validated model that combines data on CHD patient numbers, medical and surgical uptake levels and treatment ef-fectiveness), Bjork at al calculated that

increasing the proportion of eligible pa-tients with CHD who receive evidence-based treatment could have doubled the observed mortality reduction (38).

Another problem is the availability, and more importantly affordability, of those drugs. For example, nearly 80% of patients in low-income countries, and nearly 70% in lower middle-income countries (LMICs), do not receive medi-cations after heart attack or stroke, and cost is a factor (35). The PURE Study also showed that the use of secondary prevention drugs in LMICs is dismally low (38a). With the availability of ge-neric drugs for CVD, including statins and anti-hypertensives and the po-tential availability of generic polypills (fixed-dose combinations of multiple drugs: see later), there is renewed inter-est in the use of drugs for these high risk patients (39,40). All of these methods depend on the identification and treat-ment of individuals at high risk and cost may limit their applicability in resource-poor settings.

However, the most cost-effective methods of reducing risk among an entire population are population-wide inter-ventions, combining effective risk reduc-tion policies and broad health promotion policies. According to the WHO, these should be the first to be considered in all settings. Population-wide efforts have set out to encourage reduced expo-sure to risk factors through multiple economic and educational policies and programs.

In essence, the effect of falling CVD mortality rates in the US and similar countries has been to move the burden

of CVD and other chronic diseases up the age ladder, with the positive impact of prevention manifest mostly in younger adults in their economically productive years. The less advanced the disease, the greater the impact of prevention, with risk factor reduction in younger people bringing the best results. Hence, the most appropriate markers of a suc-cessful CVD prevention program will be a reduction in mortality overall, a shift in the peak burden of disease to older individuals (in terms of both mortality and morbidity), and control of the risk factors that lead to heart disease.

CVD and diabetes are major causes of morbidity and disability as well as mortality. Levels of disability vary. A person with disability may simply be un-able to work, or may require the support of family members. In such a situation, the costs to the person and to the soci-ety are substantial. In developed coun-tries, social security systems frequently bear much of the burden. In developing countries, where institutional care op-tions are often lacking, and social securi-ty is less assured, care most often comes from another adult family member who is withdrawn from the workforce, or from a child, often a girl kept home from school. Indices of disease impact suggest that disability is as great a social and economic burden as premature death, and that CVD accounts for 10%–12% of all the DALYs (13).

The cost of CVD treatment to an individual can be high. Usually after an attack of ACS or stroke, expenditure is sudden and substantial. In the devel-oping world, where 80% of the health

FIGURE B4. Trends in-age standardised mortality statistics of ischaemic heart disease (IHD) and stroke in countries grouped based on income inequality indices (Y axis = deaths per 100,000 population). GHI=Global Hunger Index.


spending is out-of-pocket, this pushes many families into poverty (41). As seen in the CREATE registry from India, poor people who are admitted with an acute coronary syndromes (ACS) epi-sode frequently miss out on evidence-based treatments because neither the individual nor the public can pay for it, and they experience higher death rates within the first year or two after the at-tack (42).

The growing burden of CVD in low- and middle-income countries follows the success of earlier public health initi-atives. As Reddy and Yusuf point out, life expectancy in India increased from 41.2 years in the decade 1951 to 1961, to 61.4 years for the 1991–1996 period, thus ex-panding greatly the population at risk of mortality and morbidity from all chronic diseases, including CVD (43).

In 1971, Omran introduced the con-cept of the global health transition from communicable diseases to NCDs as ma-jor causes of death (44). He described the evolution of dominant societal health problems from infectious diseas-es and acute illness in the young to the NCDs and chronic diseases, including CVD, which are common in older people. Fox documents a longer history of NCD prevalence in the US, dating back to the turn of the 20th century (45). He also notes a puzzling avoidance of proposals for the prevention of NCDs by health policy leaders.

The epidemiology of the health tran-sition, and the particular role of CVD (including diabetes mellitus) world-wide, has been documented by mul-tiple organisations and institutions.

Foremost among these are the GBD project sponsored by the World Bank and the Bill and Melinda Gates Founda-tion, the Health Sectors Priority Review, also sponsored by the World Bank, and the MONICA project sponsored by the WHO (46-48). The US National Institute of Aging has supported several studies. Investigators from Canada, India, Aus-tralia, New Zealand, Mexico, and the US have also made substantial contribu-tions to the growing database (22,49-51). Yusuf et al explored the status of the epidemiological transition from infectious disease to NCD dominance (24). They also drew attention to the explosion of NCDs as a cause of mor-tality and burden of disease in most of the world (52).

The level of international atten-tion paid to CVD in low- and middle-income countries has not matched its significance. This is, in part, because CVD has few of the features that attract international sympathy or support. CVD is commonly seen as an affliction of affluence occurring in late middle and old age, a regrettable but inevitable feature of growing old, and sometimes associated with victim-blaming as it is associated with smoking, overweight and alco-holism that are defined as matters for which individuals are responsible. This view persists despite the fact that mil-lions of people, especially the poor, die from CVD in their forties and fifties, and the social gradient in CVD is such that it is the poor, not the rich, who are generally most at risk. In countries with emerging economies, the onset of CVD

occurs among even younger people (43). This is evident from the global

funding allocation to CVD compared with that to HIV/AIDS (53). Chronic diseases are the least-funded area of donor assistance for health (54). An analysis by the Center for Global De-velopment shows that only 2.3% of the $22 billion per year in international donor assistance in health is devoted to CVD and other chronic diseases, while chronic diseases contribute 69% of deaths (55).

However, there are encouraging signs of international recognition and action. The WHO declared a Global Strategy for the Prevention and Con trol of Non-Communicable Diseases in 2000 and the Medium-Term Strategic Action Plan (2008–2013) for the Global Strategy for the Prevention and Control of Non-com-municable Diseases. Now the 2013-20 WHO NCD action plan has been initiated. The National Programme for the Preven-tion and Control of Diabetes, Cardiovas-cular Diseases and Stroke initiated in In-dia in 2008 is an example of a national response.

A special session of the UN General Assembly in September 2011 devoted to NCDs was a major landmark of progress. We will discuss the new initiatives towards the end of this publication, in the chapter “Rays of Hope”.

As mentioned earlier, Raymond showed that the first few decades of the present century offers a window of opportunity for much of the de-veloping world to both manage con-temporary chronic diseases in general

and CVD in particular, and to respond energetically to the challenge of risk reduction to avoid unparalleled de-mands of chronic diseases among those aged 60 years and older in the 20 years’ time (56).

During these 20 years, while birth rates are falling and the number of peo-ple aged 60 years and older has not yet risen to the expected one billion, there will be a period when CVD is causing its principal social problems among those of working age. With decreased infant mortality and no substantial increase in the number of older people with disabil-ity attributable to chronic disease, the temporal and fiscal opportunity to set in place preventive and supportive health care systems is substantial. So this peri-od must not be viewed passively: it is an opportunity requiring action of the high-est order. We, those who are concerned with and those responsible should really race against time!


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CVD STATUS AND PROJECTIONSIN FIVE DEVELOPING COUNTRIES

TABLE C1. Current populations, gross national income (GNI) per capita, adjusted to purchas-ing power parity (PPP) in US dollars, and health expenditure as a proportion of gross do-mestic product (GDP) for the five study and two comparator countries. Source: World Bank. http://data.worldbank.org/indicator/SP.POP.TOTL/countries (accessed 19 March 2013).

C1. Methods and demographic profiles This section describes the role of

CVD in the death patterns of one low- and four middle-income countries, at present and in the future. These coun-tries are Brazil, India, China, Russia and South Africa. We chose these countries to reflect the spectrum of CVD in mainly lower middle-income developing econo-mies. Russia has the highest rate of CVD among these nations, while South Africa has the lowest. Brazil, India and China are on the cusp of a serious CVD prob-lem (1,2). We chose emerging economy

countries with large populations and statistical collections that include social security and workforce data, however limited. We used the data from the 2010 Global Burden of Disease (GBD) study, WHO Burden Of Disease database and data available to us from national da-tabases through our contacts (see ac-knowledgments at the beginning of the report and elsewhere).

We have used Portugal and the US as two industrialised, high-income comparator countries. Portugal has the lowest CVD death rates in the

BRAZIL CHINA INDIA RUSSIA S.AFRICA PORTUGAL USA

Population 19,66,55,014 1,34,41,30,000 1,24,14,91,960 14,19,30,000 5,05,86,757 1,06,37,000 31,15,91,917

2011 GNI per 11420 8390 3590 20560 10710 24440 48820

capita, PPP (current

international $)

2011 (Total Health 9 5.1 4.1 5.1 8.9 11 17.9

expenditure,

total (% of GDP)


C

European Union, especially among those aged under 65 years. The US has high-quality health and economic data, and has had, for several decades, aggressive CVD management and prevention pro-grams. The process by which the US has driven down CVD rates provides a back-drop for future action on the part of the five study countries analysed.

We obtained CVD mortality patterns for countries from the 2010 GBD study (3) and WHO World Mortality Statis-tics 2008 (4). To predict CVD patterns at the national level over the coming three to four decades, we used popula-tion projections (by age and sex) from the World Bank Development Indica-tors (5). We used the year 2008 as the base year. We calculated death rates for CVD by age and sex from these ta-bles and applied them to data from the demographic profiles of the study countries. In some instances, we

compared these data with data sup-plied by Dr. Colin Mathers (see ac-knowledgement) adjusted for under-reporting and misclassification. We intentionally and consistently erred on the side of being conservative in our estimates.

First, with regard to mortality, we used only published data on registered deaths and accepted the data at face value for each cause of death without attempting to reclassify deaths into CVD from the category of uncertain causes. Second, we used only current death rates in our projections, assum-ing that future CVD death rates would not rise. We took this conservative po-sition because we know that the data are weak. The real state of affairs thus would be at least as serious as our calcu-lations portray.

After examining current and project-ed CVD mortality figures for these coun-

tries, and exploring specific topics such as CVD mortality among women, we provide CVD projections for India, based on three sets of assumptions: things getting worse (risk factors increasing); steady state (2008 rates apply); and things getting better (based on the im-plementation of risk control strategies).

Table C1 indicates the range of wealth of the five study countries, from Russia and Brazil, which are the most af-fluent among the study countries in per capita terms, to China and India, which are the least affluent. All study countries had significantly lower per-capita gross national income (GNI) purchasing power parity (PPP) than the US and Portugal. The study countries varied in popula-tion size from moderate (South Africa) to very large (India, China).

Next, we evaluated the popu-lation trends in the study coun-tries to predict what will be the impact of population changes in the prevalence of CVD. Projected changes in population distribution in the developing world due to ageing are stag-gering.

Figure C1 illustrates the increase in numbers of people aged 65 years and over in more-, less-and least-developed countries, between 1990 and 2050 (6). All three groups of countries have experi-enced and will continue to experience an increase in the population aged 65 years and over. This is especially dramatic for those countries defined as less- (but not least-) developed. This category, which includes the five study countries, will ex-perience a more than twofold increase of the population aged 65 years and older

by 2030 from the baseline of 2010 and a more than fourfold increase by 2050, to almost 1.1 billion people. The number of people aged 65 years and older will increase more slowly in the more-devel-oped and least-developed countries. By 2050, the total number of citizens aged 65 years and older in more developed countries will be less than one-third of the number in less-developed countries.

Figure C2 provides data on in-crease in population for those aged between 35 and 64 years, the peak productive years (6). This figure indi-cates a levelling of the working age population in more-developed countries. While the numbers remain relatively small in least-developed countries, they increase dramatically in less-developed countries, to almost 3 billion in 2050. By 2050, the number of working aged peo-ple in less-developed countries will be more than six times the number in more-developed countries, and the number of working age people in least-developed countries will approach the number in more-developed countries.

Turning to the five study and two comparator countries, World Bank figures indicate that population changes will vary across the five study countries in the next 40 years (5). India’s popula-tion, on current indications, will increase to 1.6 billion by 2050, and will rival that of China. Populations in South Africa, Brazil and China will steadily increase, and Russia will decrease.

Table C2 compares the current and projected population aged 35–64 years and 65 years and older in the five study and two comparator countries for 2010,

FIGURE C1. The population aged 65 years and older in the more-, less- and least-developed regions between 1990 and 2050. Source: World Population Prospects: The 2010 Revision. www.un.org/en/development/desa/population/publications/trends/population-pros-pects_2010_revision.shtml (accessed 23 Jul 2014).


2030 and 2050, expressed as percentage of the total population.

The patterns emerging here reflect those outlined for less-developed coun-tries. Two trends stand out. First, while

at present the proportion of people aged 35–64 years is much lower in three of the four study countries (excluding China) than in Russia or the two com-parator countries, by 2050 the seven

FIGURE C2. Projected change in the population (thousands) aged 35–64 years, 1990–2050 in more-, less- and least-developed countries. Source: World Population Prospects: The 2010 Revision. www.un.org/en/development/desa/population/publications/trends/population-prospects_2010_revision.shtml (accessed 23 Jul 2014).

TABLE C2. Current and projected population percentages by age group (35–64 years, and 65 years and older) for 2010, 2030 and 2050 for the five study and two comparator countries. Source: Population Prospects 2012. www.un.org/en/development/desa/population/theme/trends/index.shtml (accessed 23 Jul 2014).

% Population 35-64 BRAZIL CHINA INDIA RUSSIA S.AFRICA PORTUGAL USA

2010 33 40.68 28.84 41.42 27.76 41.44 39.14

2020 38.17 41.23 32.34 43.18 29.02 43.8 37.68

2030 40 42.91 36.28 43.05 30.66 41.86 36.37

2040 42.8 39.2 39.68 40.94 32.88 38.76 36.48

2050 41 39.09 41.26 38.23 35.15 35.66 37.06

% Population 65+

2010 6.89 6.35 4.91 12.9 4.6 17.85 12.95

2020 9.56 11.65 5.88 15.44 6.26 20.59 16.1

2030 13.65 15.9 8.39 19.38 7.84 24.45 19.76

2040 17.65 21.52 10.71 20.46 8.54 28.75 20.98

2050 22.53 23.28 13.74 23.43 9.83 32.11 21.57

countries will have roughly equivalent percentages in this age group (between 35% and 42%).

Second, while all countries show an increase in the numbers of people aged 65 and older, in 2050 there will still be differences among them in the percent-age of older people. South Africa and In-dia will remain “young” countries, with only 9% to 14% of their population aged 65 and over. China, Brazil and Russia will both cross the 20% mark for this age group, and the US and Portugal will be more than 20% and 30%, respectively. Here, the distinction between the ageing of the population and increases in the number of elderly people is impor-tant. Ageing implies that the propor-tion of older people is increasing and that life expectancy is increasing, but in “young” countries, this will mani-fest itself first in increased numbers of

young adults and middle-aged people, rather than in increased numbers of old-er people.

Both these trends reflect different effects of ageing in the five study coun-tries. Because CVD mortality increases as population longevity increases, this will have implications in particular for China and Russia, and to a lesser extent for India, Brazil and South Africa. Two implications of these trends are less well recognised.

The first factor is the dependen-cy rate – the number of people aged younger than 15 years plus those aged 65 years and older (the numerator), who depend on the workforce aged 35–64 for support (the denominator). Dependency will stress the economy of these countries (Figure C3). Across the five study countries, the depend-ency rates will fall slightly in India and

FIGURE C3. Percentage of population under 15 years and 65 years and older (dependent) projected to 2050 in the five study countries. Source: Population Prospects 2012. www.un.org/en/development/desa/population/theme/trends/index.shtml (accessed 23 Jul 2014).


South Africa, but it will rise in Brazil, China and Russia.

Second, however, assuming pre-sent trends continue, the increase in the working age population in the five study countries will be accompanied by increasing levels of CVD risk factors and end organ disease in that age group. CVD mortality and morbidity is already high in this age group in those countries, and its rise will have serious implications for both health costs and productivity, not just in the next 20 years, but be-yond. We explore the labour force im-plications of current and projected CVD rates later.

C2. Overall CVD experience in the five study and two comparator countries Table C3 presents a coarse-grained pic-ture of CVD mortality in the study coun-tries using age-standardised death rates for CVD per 100,000 population as the summary statistics for CVD mortality in

2010. We can see that CVD mortality rates in all five study countries are much higher than the comparator countries, the US and Portugal. If we compute the proportions of CVD death rates over to-tal death rates, we can see that the rates are higher in the study countries except India and South Africa.

However, as rates in industrialised countries decline, CVD death rates in middle-income countries are high.

Figure C4 indicates that the age-ad-justed CVD death rates are high in the study countries compared to US and Portugal. Projections of the number of deaths attributable to CVD in 2050 are even more deeply disturbing. We ap-plied current age-specific mortality rates to the expected populations of the study countries for the next 40 years. A com-parison of the age-standardised death rates due to cardiovascular and circula-tory diseases in the five study countries and the comparator countries are given

TABLE C3. Current crude cardiovascular disease mortality and crude all-cause mortality in the five study and two comparator countries. Source: Global Burden of Disease study – 2010. Country profiles, data. www.healthdata.org/results/country-profiles (accessed 18 Mar 2013).

Indicators Brazil China India Russia S.Africa Portugal USA Age-standardised 225 230 171 504 222 163 162cardiovascular and circulatory diseases death rate per 100,000 (2010*) Age-standardised 670 607 1097 952 1266 468 516all-cause death rate per 100,000 (2010**) CVD mortality as 33.5 37.8 21.1 52.9 17.5 34.8 31.3percentage of total mortality

FIGURE C4. Deaths per 100,000 attributed to cardiovascular and circulatory diseases, based on age-standardised estimates. Source: Global Burden of Disease Study 2012. http://viz.healthmetricsandevaluation.org/gbd-compare (accessed 20 Mar 2013).

FIGURE C5. Percentage change in mortality due to coronary heart disease (CHD), 2008 to 2050, for the five study and two comparator countries (courtesy of Dr. Colin Mathers).


C3. Labour force implications However, these disquieting figures of rising CVD burden in whole popula-tions quickly pale in comparison, when we examine the patterns within CVD death rates relative to age groups. There, CVD in the five study countries is not a scourge of the aged. Rather, it is a burden for the workforce right now, as we write.

C3A. Mortality concentrations among people of working age Table C4 shows that in four of the five study countries (all except China), age-specific (35–64 years) working age CVD death rates among men and women are significantly higher than in the US or Portugal. Among working-age popula-tions of these countries, mortality rates

from CVD are often equal to or greater than rates for the same age group in the US before it embarked on the aggressive CVD prevention and management ini-tiatives that have reduced its CVD mor-tality. In India and South Africa, wom-en’s workforce death rates from CVD are also higher than those that US women experienced in 1950. Men and women aged 35–64 years in Brazil experience CVD mortality rates similar to those in the US 30 years ago (8,9).

These numbers highlight what may happen in relation to CVD in less-devel-oped economies. The technical capacity of their workforces will improve as less-developed economies grow. Members of these workforces require investment in training, and their loss in midlife through death is expensive to employers.

Figure C6 indicates that the pro-

below in Figure C5.As Figure C5 shows, even if we as-

sume no increase in CVD risk factor prev-alence, the total number of deaths due to CVD will rise greatly in four of the five study countries relative to the US and Portugal. This is mainly because of their changing population structures and also increases in the CVD risk factors. Russia is the exception because demographers predict that its population structure will not change over this period, and CVD mortality is already very high in that country.

As Mathers and Loncar reported, “for non-communicable diseases, demo-graphic changes in all regions will tend to increase deaths substantially by 2030, with offsetting reductions in projected death rates in all regions. Population growth and population ageing both act to increase NCD deaths in all regions, al-though the impact of population ageing is generally much more important than population growth. Population growth has the largest relative impact for low-income countries, and the smallest for lower-middle-income countries” (7).

FIGURE C6A. Percentage of cardiovascular deaths among men (number of deaths in the specified age group/total number of deaths) in the five study and the two comparator coun-tries (courtesy of Dr. Colin Mathers).

FIGURE C6B. Percentage of cardiovascular disease deaths among women (number of deaths in the specified age group/total number of deaths) in the five study and the two comparator countries (courtesy of Dr. Colin Mathers).

TABLE C4. Cardiovascular disease age-specific mortality in the working age population (35–64 years) in the five study and two comparator countries, 2008, expressed as a rate per 100,000 population (courtesy of Dr. Colin Mathers).

Gender South Africa Brazil China India Russia USA Portugal

Men 119.14 102.05 45.33 207.89 483.02 98.46 49.08

Women 58.54 46.29 25.91 92.21 122.1 34.16 11.61


portion of deaths attributable to CVD among men is approaching or has sur-passed that for the US and Portugal, in the case of Russia, India, China and Bra-zil. Among women, the proportion of deaths from CVD is consistently higher in most of the study countries than in the US and Portugal, indicating that women are more disadvantaged than men relative to their counterparts in the US and Portugal.

Another way of examining work-ing age CVD deaths is to look at the percentage of deaths attributable to CVD rather than to other causes. Figure C6 illustrates this for five of the study countries and the two comparator countries for men and wom-en in the age groups 35–39,45–49 and 55–59 years.

CVD is already making inroads into the youngest workforce age group (35–39 years) that we studied. In Portugal, CVD represents 11% of deaths among men and women in this age group. The comparable proportions in Brazil are 12% among men and 18% among women, while it is 15% among both sexes in China.

In South Africa, HIV/AIDS is both the principal cause of death at all ages (41% in 2010) and the cause of the most years of life lost (40% in 2010), but CVD of all forms accounted for 13% of all deaths in 2010. The South African picture is further illustrated in Figure C7, which shows that NCDs such as CVD make up an increasingly large proportion of causes of mortality as the population becomes older, and outstrip HIV/AIDS after the age of 45.

Figures C8A and C8B provide yet another illustration of CVD mortal-ity rates in the five study countries. It presents the percentage differences in age-specific death rates among men and women in the study countries when compared with those in Portugal and the US in 2008. Thus as illustrated in figures C8A and C8B, death rates among men in India at age 35–44 years were 230% higher than rates in US, and 725% higher than those in Portugal. For women, the comparable figures are 200% and 600%, respectively. In the case of Brazil, the CVD mortality was 180% higher for men aged 35–44 years than in Portugal. For

women, CVD death rates in Brazil were higher (225%–600%) than those of sim-ilarly aged women in Portugal.

Although we do not present data be-yond age 65 years, CVD deaths appear to concentrate in people of working age (35–64 years) in the four study countries to a degree not seen in industrialised na-tions. There is variation among countries, and presumably within countries such as India (10) and China, but the sampled countries may not be the extreme. The four countries have 30%–40% of their CVD deaths occurring in people of work-ing age. This is attributable to two fac-tors – first, these countries have higher age-specific mortality rates for those of working age and, second, they have larg-er populations of working age at risk, and smaller older populations compared with the US and Portugal.

In addition, while CVD occupies a variable position in the death pat-terns of working age men, in nearly all

equivalent age groups CVD accounts for a greater portion of deaths among women than in the US or in Portugal. We address the consistent and striking importance of CVD for women’s health in section C3C.

C3B. Higher morbidity among people of working ageWe know that CVD is accompanied by significant morbidity in the develop-ing world (11,12). Due to increasing stroke incidence and other factors, the neurological disability in developing countries like India may soon reach epidemic proportions (13).

The years of life lost due to disability (YLD) estimates for the five study and two comparator countries show that the morbidity due to CVD and other cir-culatory diseases is more in these five countries than among the comparator countries in the younger ages (Figure C9). We have data from Brazil (14) that

FIGURE C7. Percentages of deaths due to HIV, other infectious diseases, non-communicable diseases (NCDs) and injuries in South Africa. Source: Global Burden of Disease Study 2012. http://viz.healthmetricsandevaluation.org/gbd-compare (accessed 20 Mar 2013).

FIGURE C8A. Using US cardiovascular disease death rates as a base, comparisons age-specific death rates among men and women in India, China, Brazil, South Africa, and Russian Federa-tion in 2008.

Perc

enta

ges

of d

eath

s


show that CVD leads to significant mor-bidity, as evident from the temporary disability benefit claims and early re-tirement disability payments. Azambuja et al reported that in March 2006, over 300,000 disability retirements attrib-

uted to underlying CVD causes were be-ing paid for by the National Institute of Social Security in Brazil (14). This num-ber corresponded to 20% of the severe CVD cases estimated for the population aged 35–64 years. Considering an aver-

age retirement period of 3.7 years, the average annual payments computed to came as R$1,496 million or US$744 million. Among the temporary disability claims (with an average duration of one year) which were paid in 2004 in Brazil, 8.4% were attributed to CVD, corre-sponding to 144,984 benefits. Further, the data from Brazil show that in 2004 there were more than 1.5 million admis-sions attributed to CVD in both private and governmental institutions (14). If we presume 15 days sickness absentee-ism per admission, this amounts to 23 million productive days lost.

Hospital admission is only one ele-ment of morbidity, and much hyper-tension and CVD goes undiagnosed and untreated. The data from a community screening study from Trivandrum by Thankappan et al shows that less than 40% of people with elevated blood pressure in the surveyed population were aware of their hypertension, 30% were receiving therapy and less than

10% of the population had achieved good control (15).

C3C. CVD and women’s health Health experts and the media rarely por-tray CVD as a women’s global health problem. In developing nations, global health efforts have more frequently, and often exclusively, concentrated on wom-en’s maternal and reproductive functions. Examining working age data by gender, however, raises a caution about that fo-cus and forces a reconsideration of its ex-clusivity. The impact of CVD on women is both direct, when they experience the ill-ness themselves, and indirect, when their educational and economic circumstances are affected by death or disability due to CVD of family members.

For the five study countries, CVD can be seen as important, or more important, a cause of morbidity and mortality in women as it is in men, especially relative to population structure. For example, in Brazil, China, Russia, and South Africa,

FIGURE C9. Years lost due to disability (YLD) estimates – YLD per 100,000 population due to cardiovascular and circulatory diseases – among three working age groups, 35–39, 45–49 and 55–59 years. Source: Global Burden of Disease Study 2012. http://viz.healthmetricsandevalu-ation.org/gbd-compare

FIGURE C10. Proportion of age-standardised deaths attributed to cardiovascular disease among men and women. Source: Global Burden of Disease study. 2010. http://viz.healthmet-ricsandevaluation.org/gbd-compare FIGURE C8B. Using cardiovascular disease death rates from Portugal as a base, comparisons

of age-specific death rates among men and women in India, China, Brazil, South Africa, and the Russian Federation in 2008 (courtesy of Dr. Colin Mathers).


CVD in 2010 accounted for a higher pro-portion of all deaths for women than for men. India, as we know,still has a high maternal mortality (Figure C10).

If we compare the total number of deaths caused by CVD versus communi-cable diseases combined with maternal and perinatal problems, (Figure C11), we can see that Brazil, China and Russia have higher number of women dying due to CVD than communicable and mater-nal and perinatal problems combined.

Referring to Figure C12, although women in the five study countries had lower CVD death rates than men, wom-en in these countries had significantly higher death rates than comparable women in the US and Portugal as of 2010. The reasons may be multifacto-rial. Inadequate diagnoses and subopti-mal management among women might have resulted in poor outcomes (16). Over recent decades, mortality rates

in men have steadily declined, while those in women remained stable (16). A lower index of suspicion of CVD among women, both by the population and the treating physician community, might also contribute to the problem.

The differences between women in the five study countries and their coun-terparts in industrialised countries are also illuminating when measured not as overall death rates, but as the impor-tance of CVD in the mortality patterns of younger women (Figure C13). We can see that the mortality of women aged 15–49 years in the five study countries is much higher when compared with the US and Portugal.

It is also important to view CVD within the context of women’s health in the childbearing years and during the years of family formation and develop-ment that follow prime childbearing years. In the study countries, CVD ap-

pears to be on its way to playing a much more important part in those years than has been recognised to date. In all five countries studied, CVD accounts for a larger portion of overall deaths among women than conditions related to child-bearing, a point that often goes unrec-ognised due to the stereotype of CVD as a disease only of older women.

Table C5 shows that except in the case of India and South Africa, in the other three study countries at this younger age CVD-related mortality is higher than that due to maternal diseas-es. In China, the number of CVD deaths among women aged 20–29 years is twice that from pregnancy-related causes. In the case of Brazil it is 1.5 to two times. In Russia, the differences are greater. CVD deaths among women aged 20–24 are three times the pregnancy-related deaths and among women aged 25–29 years, it is five times. These are clear im-plications for definitions of health risk to

women in developing countries. Global health analysts should reconsider the current narrow definition of health risks to women in developing countries, and move beyond an exclusive concern with maternal and reproductive problems to include the profound impact of chronic diseases such as CVD. CVD should be-come a new priority for women’s health.

C3D. WidowhoodCVD deaths among working-aged men also cause havoc for married women by making them widows. Notwithstanding the death toll among women, the higher heart disease rates among young men in the prime of life mean that CVD is cre-ating an equivalent cohort of widows who need support for decades. When 40%–50% of men die before age 64, but only 25% of women die by age 64, the consequences are self-evident.

The study of widowhood and poverty is minimal in the developing world. Data

FIGURE C12. Age-standardised cardiovascular disease death rates (per 100,000) among men and women in the five study and two comparator countries. Source: Global Burden of Disease Study. http://viz.healthmetricsandevaluation.org/gbd-compare (accessed 24 March 2013).

FIGURE C11. Mortality (age-standardised) among women due to cardiovascular disease vs mortality due to communicable and maternal and perinatal conditions. Source: Global Burden of Disease Study 2012. http://viz.healthmetricsandevaluation.org/gbd-compare (ac-cessed 24 March 2013).


from the US indicate, however, that the earlier women are widowed, the more likely they are to live in poverty at older ages. In the US, nearly 35% of women widowed at age 55 whose widowhood lasts 6 to 10 years live in poverty, com-pared to 10% of women widowed at age 65 (17). There are no comparable data for developing countries. The 2001 cen-sus data (the latest available as of 2013) from India shows that 58.6% of all wid-ows in the country are younger than 65 years, and 52.8% are aged between 35 and 64 years (18). US Census Bureau data indicate that 66.4% of women aged 60 and over are widowed (19). Data from the WHO SAGE study reveal a large proportion of women are wid-owed above 50 years (Table C6) (20).

Widowhood increases the all-cause mortality of the bereaved partner to varying degrees. The death of a prec-

edent spouse from any cause increased the widow’s cause-specific mortality for almost all causes, including CVD (21). Urbanisation will matter greatly in this phenomenon. In India, where labour force participation rates among females is only 17.9% in urban areas (22), the loss of men of working age is devastat-ing to household viability. As reported in a study about coping strategies af-ter an acute episode of CVD from India, some households were found to employ “masked” strategies to check the drain on household reserves (23). Children had to discontinue their education or were transferred from private schools to free government schools and fami-lies had to move from expensive rental accommodation to cheaper ones. Nine-ty-three per cent of primary care givers, mostly females who reported an adverse impact of the illness on their employ-

ment had to take-up a job for the very first time to support their families (23). As urbanisation grows, and CVD death increases, the loss of men will have heavy impacts on women.

C3E. What will happen if cardiovascular risk factors get better or worse? The increases in mortality attribut-able to CVD that we have projected for men and women in developing coun-tries during their working years assume that nothing else gets worse. But, over time, the prevalence of many CVD risk factors is also likely to increase in these

countries. In particular, higher levels of smoking, overweight, diabetes and high blood pressure will put people at even greater risk than they are at present. A range of factors contributes to this trend in developing countries, including the adverse side effects of industrialisation, urbanisation, globalisation and increas-ing wealth.

Increased urbanisation is associated with a growing labour force and an age-ing (although not necessarily old) popu-lation. One of the reasons why urbanisa-tion has been possible is the spectacular increase that has occurred in efficiency

TABLE C6. Widowhood in SAGE countries, 2007–2010. Percentage of widows in the respec-tive age groups. Source: www.who.int/healthinfo/systems/sage/en/index.html – accessed via www.census.gov/prod/2012pubs/p95-12-01.pdf.

China Ghana India Mexico Russia South Africa

50 years and above 11.7 25.9 23.9 15.5 29.1 23.9

70 years and above 32.2 40.9 46.9 38 56.9 41.8

TABLE C5. Mortality rates due to cardiovascular disease (CVD) and maternal causes for 2010 (per 100000 population for two childbearing age groups, 20–24 and 25–29 years). Source: Global Burden of Disease Study. http://viz.healthmetricsandevaluation.org/gbd-compare.

20-24 year age group 25-29 year age group

Maternal CVD Maternal CVD

Brazil 3.1 4.8 3.5 7.3

China 1.6 3.1 2.1 4.5

India 26.4 10.3 24.5 10.8

Russia 1.7 4.9 2.1 10.1

South Africa 27.0 23.0 19.0 24.2

Portugal 0.3 1.5 0.3 10.6

USA 1.1 3.0 1.3 4.6

FIGURE C13. Cardiovascular disease (CVD) death rates among women aged 15–49 years in the study and comparator countries 2010. Source: Global Burden of Disease Study. http://viz.healthmetricsandevaluation.org/gbd-compare (accessed 7 Sep 2013).


of agricultural production. This has had two major effects, the first being to re-lease a substantial rural workforce that can now devote its labour to tasks in cit-ies. Second, food consumption patterns are changing. Food and Agricultural Or-ganization of the United Nations pro-jections estimate that for example, the incidence of under-nourishment should fall from 17% of the population of de-veloping countries at present to 11% in 2015 and just 6% in 2030 (24). By 2030, average energy intake in the whole of the developing world be nearly 2960 kcal per capita per day and 3070 by 2050 (25).

Urban populations are increas-ing (Figure C14). Urbanisation though linked with economic growth, is also directly linked to the increase in chron-ic diseases including CVD, as seen in China (26). Recent data from India also reveals a significant urban–rural difference in the conventional CVD risk factors (27).

Figure C14 indicates that for four of the study countries, there will be a steady increase in the percentage of the population living in urban areas between 2000 and 2050, especially in Brazil and South Africa, but also in China and India; Russia is already urbanised. This reflects, a trend that has occurred for several decades. In Brazil, already predomi-nantly urban, 90.7% of its population will be urban by 2050. Brazil’s urbani-sation has occurred at all levels of city size and throughout large sections of the country. By 2050, 76.8% of the popula-tion in South Africa will be urban, 77.3% in China, and 51.1% in India. In 1970,

there were only three cities with more than 10 million people. Now there are 32, and three of these have more than 20 million (28).

The move to cities is an important factor influencing CVD and its risk fac-tors. In India, risk factor profiles are far more intense in urban populations. Both the prevalence and clustering of car-diovascular risk variables were higher in urban areas than in villages in India, and were higher in the cities than in the towns (29). It is reported in a recent study from India, that a relationship ex-ists between urban living and NCD risk factors.

Among men, urban living was posi-tively associated with smoking, higher BMI, higher blood pressure and lower physical activity; among women, it was associated with low physical activity and higher BMI (30). This is despite the fact that rural to urban migration ap-pears to be associated with both posi-tive (higher fruit and vegetables intake) and negative (higher energy and fat in-take) dietary changes as reported from India (31).

In South Africa, a survey of north-eastern rural areas found that CVD mortality rates were 40% lower among those aged 55–74 years than South Af-rica’s overall rates (32). The awareness of hypertension and its prevention, treatment and control remain very low in Africa, even though recent surveys show an increasing prevalence of the disease consistent with the nutritional and epidemiological transition in the re-gion (33).

The latest GBD study shows that

as of 2010, the three leading risk fac-tors for global disease burden were high blood pressure (7.0% of global DALYs), tobacco smoking including second-hand smoke (6.3%), and alcohol use (5.5%) (34). Dietary risk factors and physical inactivity collectively accounted for 10.0% of global DALYs in 2010, with the most prominent dietary risks be-ing diets low in fruits and those high in sodium (34). We know from the INTER-HEART study that conventional risk fac-tors account for 90% of the burden of CVD in the world (35).

Saturated fat intake, sodium intake (as measured by urinary sodium), and BMI all appear to be rising in develop-ing countries (36), with higher rates in urban areas than in rural. In many countries, urbanisation is associated

with steadily increasing rates of obesity (37), not least because that environ-ment enables individuals to respond to market pressures to consume more food than they need and to exercise less than they need. Data from China show that between 1992 and 2002, the prevalence of overweight and obesity increased in all gender and age groups and in all geographic areas (38). The combined prevalence of overweight and obesity increased from 14.6% to 21.8% in Chi-na. The annual increase rate was high-est among men aged 18–44 years and women aged 45–59 years (38).

During the past four decades, the rates of stroke in southern India and rural South Africa have approximately doubled, whereas stroke rates in more economically developed nations have

FIGURE C14. Percentage of population living in urban areas by decade 1950–2000 and projected to 2050. Source: Population Prospects 2012. www.un.org/en/development/desa/population/theme/trends/index.shtml (accessed 23 Jul 2014).


decreased. The more distressing fact is that the rates of disability and mortality arising from stroke are at least 10 times greater in medically underserved regions of the world compared with the most developed nations (39).

In a study from India that reported secular trends in diabetes, the preva-lence of diabetes increased by 72.3% in 14 years (40). Recent estimation of dia-betic status for the whole of India stood at 62.4 million people with diabetes and 77.2 million people with pre-diabetes (41).

The assessment of the direct bur-den of smoking for CVD, fatal ischaemic heart disease and stroke (haemorrhagic

and ischaemic) for all 38 countries in the WHO Western Pacific and South East Asian regions showed that up to 30% of cardiovascular fatalities can be at-tributed to smoking (42). According to the WHO, each year, the global tobacco epidemic kills nearly six million people, including more than 600,000 who die from exposure to passive smoking. It is estimated to kill more than eight million by 2030, by which time approximately 80% of the deaths would occur in low- and middle-income countries.

In developing countries, risk factors often increase with rising incomes (hy-pertension and obesity) in part attribut-able to a changing diet that has more fat,

salt and calories, and to increasing body weight and less exercise. CVD risk fac-tors, including obesity, are rising in the developing world faster than they did in western societies (43). The transition is affecting women in particular, and increases in risk factors are more marked among those receiving lower incomes in growing economies than among the wealthy (43).

These factors are generally more common in urban than in rural com-munities, as we have seen earlier. Over time, experience in Western countries suggests that the more affluent sec-tions of society adjust their lifestyles in directions that favour heart health, with CVD risk then concentrated among the less advantaged (44).

These figures do not mean that CVD is not, and will not be, an increasing problem in rural areas. In rural India, the prevalence of coronary artery heart dis-ease increased from 2% in 1970 to 4.5% in 2000 (45). Still, there are indications that CVD patterns for cities are higher than for rural areas. Although migration from rural to urban areas by sick peo-ple seeking care may explain part of the rural–urban gradient, it does not explain much of it. Most is due to changes in diet and physical exercise.

One can estimate broadly the im-pact of a combination of ageing, a grow-ing urban workforce and rising CVD risk factors on CVD morbidity and mortality. Based on past trends and projected in-creases in risk factors in China, Moran et al have calculated that there will be 7.8 million excess coronary heart disease events (a 69% increase) and 3.4 mil-

lion excess deaths from coronary heart disease (a 64% increase) in the decade 2020–2029 compared with 2000–2009 (46). To further examine the likely im-pact in the five study countries, we estimated future CVD mortality in In-dia based on increased, decreased and steady state CVD death rates. Figure C15 illustrates these three future sce-narios for India.

We assumed that due to increase in CVD risk factor prevalence, the 35–64 years age group in India would experi-ence a 2% increase in CVD mortality rate per year over 20 years. Assuming a constant 2% annual increase in CVD mortality rate, the labour force by 2030 will experience 109% increase in CVD deaths. The top line in Figure C15 represents this scenario. Given the certainty of rising risk without pre-vention, CVD rates will increase, and without preventive disease manage-ment these rates will lead to new waves of excess morbidity and mortality. Returning to the middle line of Figure C15, if we apply the current rate of age-specific CVD mortality rates, still there will be a 42% increase in the number of deaths by 2030, due to demographic changes. Failure to hold cardiovascu-lar risk factor and disease rates to even their current high levels will exact a tre-mendous price in developing countries, especially in the Indian workforce over the next two decades.

The bottom line in Figure C15 uses 2% annual decline in CVD death rate scenario, which is consistent with the average decline in CVD death rates in US from 1950s to 1980s and as per the rec-

FIGURE C15. India: Annual cardiovascular disease (CVD) deaths in India among men and women aged 35–64 years in 2010, 2020 and 2030, under conditions of constant 2010 CVD death rates, increased rates (2%) and decreased rates (2%).


ommendations of several international agencies for control of CVD. We might expect that these rates would apply to countries that instituted similar CVD control programs to those that were as-sociated with these declines in the US. If we assume that India instituted con-trol programs that achieved an annual rate reduction of 2% of deaths among men aged 35–64 years, this would re-sult in only a 5% decline in the num-ber of CVD deaths from 2010 to 2030. The denominator at risk will continue to increase due to demographic fac-tors, and a 2% annual decrease will be cancelled out by a 1.7% annual in-crease in population growth rate in India. This holds numbers of deaths rela-tively steady, as indicated by the third and lowest line in Figure C15.

These data illustrate the need to act now to forestall future national catastro-phe due to increases in CVD mortality.

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DTHE MACRO AND MICROECONOMIC

CONSEqUENCES OF CVD

The previous sections outlined the potential economic costs of CVD

and its risk factors. In this section, we explore the costs of CVD more closely. To develop an estimate of the macro-economic consequences of CVD, we have calculated the years of productive life lost due to deaths from CVD occur-ring among members of the workforce, also known as potentially productive years of life lost (PPYLL) (Table D1). We calculated these estimates by ap-plying age-specific CVD mortality rates to the demographic data for the study countries. We have supplemented these calculations by referring to estimates of productivity loss attributable to disabil-ity due to CVD as measured in disabil-ity-adjusted life-years (DALYs). DALYs are the sum of years of life lost (YLL) and years lost due to disability (YLD), or DALYs = YLL + YLD.

We then created cost estimates re-

lating to outpatient medical and hospi-tal-based care for people with CVD. Data for these costs are difficult to procure from many countries, especially those that are still developing their health sys-tems. We have used data from each of the study countries wherever available but recognise the limitations due to in-complete data.

In addition to the direct costs of medical care, we have sought to de-velop estimates of the indirect costs of CVD. These are difficult to determine even in countries with well-developed health and social security systems. So once again, we have only been able to produce partial estimates based on few available publications and the data available online. The costs to families of caring for people with CVD vary im-mensely by social custom and by the extent to which publicly funded social security systems operate.


D1. Potentially productive years of life lost due to cardiovascular diseaseParticular interest in this analysis is the potential effect of CVD on the economy, given the importance of CVD among labour force-aged cohorts who may experience premature death and dis-ability. While caution is recommended in assessing the impact of years of life lost, it is possible to estimate the mac-roeconomic impact of CVD using two measures as already mentioned, PPYLL and DALYs. Costs to the economy can then be extrapolated. Usually costs are broken into direct, indirect, and so-cial welfare costs, the last of which is difficult to estimate.

A measure of PPYLL is most rel-evant to the arguments in this report because it focuses on loss among the

working age population. We calcu-lated PPYLL for the five study and two comparator countries commenc-ing at age 35, assuming a retirement age of 65, and taking the midpoint of each group (35–44, 45–54, and 55–64 years) as the central measuring point. By this means, each death in the first age group counted as 25 years lost (i.e., 65 – 40 = 25, between 40 and 65 years), each death in the second group counted as 15 years lost, and each death in the third group counted as 5 years lost.

We applied these assumptions and the prevailing age-specific CVD death rates to the demographic projections for each country for 2008 and 2050. In Tables D1 and D2, mortality projec-tions assume no change in the rates

TABLE D1. Potentially productive years of life lost (PPYLL) due to cardiovascular disease (CVD) among the populations aged 35–64 years for the five study and two comparator coun-tries for 2008 and 2050, assuming current CVD mortality trends continue.

2008 TOTAL 2050 TOTAL

SOUTH AFRICA 117,963 199,694

BRAZIL 466,987 741,065

CHINA 1,915,517 2,247,802

INDIA 5,724,975 11,920,506

RUSSIAN FEDERATION 1,683,343 1,362,436

SUB TOTAL 9,908,785 16,471,503

USA 784,173 909,251

PORTUGAL 12,209 10,052

SUB TOTAL 796,382 919,303

of CVD or any other illness (e.g., HIV/AIDS) in each country. In the case of CVD, we have already demonstrated that without preventive interventions, risk factors are projected to increase in most of the study countries with possible increases in age-adjusted CVD mortality. The numbers below may be therefore underestimates if current risk factor and treatment trends continue.

Table D1 presents our estimates of PPYLL due to CVD among people aged between 35 and 64 years for the five study and two comparator countries for 2008 and 2050.

As explained in chapter C, calcula-tions for age-specific CVD mortality vary according to the accuracy of pub-lished mortality data and also vary be-cause of inherent differences in CVD mortality rates. Thus, when these data are incomplete, our estimates of lost productive life will be low, sometimes considerably so, compared with the real losses and those calculated on the basis of death data adjusted for under-regis-tration and misclassification.

Table D1 shows that the total PPYLL for the five study countries is already high, and will increase from 9.9 million in 2008 to 16.4 million in 2050. Recall that we have assumed stable CVD age-specific death rates, so the increase is due solely to increasing population sizes at risk. Data from India demonstrate an increase in the prevalence in CVD in as-sociation with urbanisation (1). The CVD prevalence is likely to rise in India and China in the future, as rural to urban mi-gration is rising in both the countries (2).

Table D1 also shows that PPYLL will

increase in three of five study coun-tries between 2008 and 2050 at a much greater rate than rates projected for the two comparator countries.

Compared to 2008, the PPYLL from CVD will increase in 2050 by 15% in the US and decrease by 16% in Portugal, compared with 70% rise in South Africa, 17% in China, 59% in Brazil, and 108% in India. Of the study countries, only in Russia are the estimated PPYLL pro-jected to decrease, largely due to high death rates due to CVD at present and a shrinking population.

Table D2 demonstrates age-strati-fied PPYLL estimates to calculate which age groups will bear the largest burden of PPYLL. Fewer years of productive life are lost in the five study countries and in the US and Portugal among the young-est age group (35–44 years), consistent with the mortality rates presented for this age group in Figure C9. The increase in years lost between 2008 and 2050 for this age group is huge, particularly in In-dia, where an additional million years of life lost is anticipated in this young age group between 2008 and 2050.

The oldest decade (55–64 years) accounts for the highest proportion of PPYLL for all countries. Projections to 2050 suggest that this age group will continue to have the highest proportion of PPYLL in all five study countries and both comparator coun-tries. In India, we estimate a doubling of PPYLL in all age deciles between 2008 and 2050.

In contrast, Russia shows a decline in CVD mortality over these decades, likely due to high premature CVD mortality


TABLE D2. Potentially productive years of life lost due to cardiovascular disease (CVD) by labour force age group (years) in 2008 and 2050, assuming population trends and current CVD mortality rates continue.

FIGURE D1. Burden of disability-adjusted life-years (DALYs) attributable to non-communica-ble diseases (NCDs), communicable diseases, and injuries in five study and two comparator countries in 2010. Source: Institute for Health Metrics and Evaluation. GBD Compare 2010. http://viz.healthmetricsandevaluation.org/gbd-compare (accessed Jul 2014).

FIGURE D2. Age-weighted disability-adjusted life-years (DALYs) due to non-communicable diseases (NCDs), communicable diseases and injuries based on World Bank income groups. Source: World Health Organization. Projections of mortality and causes of death, 2015 and 2030. 2008. www.who.int/healthinfo/global_burden_disease/projections/en/index.html (ac-cessed 7 June 2012).

rates at present. Significant increases are also projected for the US, but the mortality rate is predicted to decline in Portugal. The decline in CVD mortality in China is surprising, but can be explained by the ageing of the population.

D2. Macroeconomic consequences of disability-adjusted life-years lost due to cardiovascular diseaseA second way to examine the cost of CVD is to estimate DALYs. One DALY represents the loss of one year of full

2008 2050

35-44 45-54 55-64 35-44 45-54 55-64

South Africa Men 15,353 37,902 53,255 22,791 64,597 87,388

Women 7,266 16,177 23,443 9,840 23,480 33,320

Total 22,619 54,079 76,698 32,631 88,077 120,708

Brazil Men 78,733 150,989 229,722 86,788 233,225 320,013

Women 33,492 64,685 98,177 34,930 94,392 129,322

Total 112,225 215,674 327,899 121,718 327,617 449,335

China Men 322,832 511,202 834,034 222,191 545,208 767,399

Women 178,556 294,842 473,398 125,108 318,883 443,991

Total 501,388 806,044 1,307,432 347,299 864,091 1,211,390

India Men 1,424,460 1,893,654 3,318,114 2,364,028 3,794,130 6,158,158

Women 365,554 652,621 1,018,175 608,338 1,320,053 1,928,391

Total 1,790,014 2,546,275 4,336,289 2,972,366 5,114,183 8,086,549

Russian

Federation Men 241,683 699,436 941,119 212,662 436,523 649,185

Women 51,057 147,253 198,310 41,310 79,973 121,283

Total 292,740 846,689 1,139,429 253,972 516,496 770,468

USA Men 118,095 281,670 399,765 138,734 302,270 441,004

Women 37,395 90,949 128,344 41,753 90,138 131,891

Total 155,490 372,619 528,109 180,487 392,408 572,895

Portugal Men 1,832 4,677 6,509 1,232 3,759 4,991

Women 617 932 1,549 397 700 1,097

Total 2,449 5,609 8,058 1,629 4,459 6,088


FIGURE D3. Disability-adjusted life-years (DALYs) projections for the years 2015 and 2030, based on World Bank income groups. (Age weighted, 3% discounting.) Source: World Health Organization. Projections of mortality and causes of death, 2015 and 2030. 2008. www.who.int/healthinfo/global_burden_disease/projections/en/index.html (accessed 7 June 2012).

health. This measure includes the im-pact of premature mortality and dis-ability (e.g., inability to work, prolonged illness). DALY estimates from the WHO and the Burden of Disease study were used in the analysis.

DALYs attributable to communi-cable diseases and NCDs are shown in Figure D1. According to the WHO DALY estimates for 2008, the age-adjusted burden of NCD is greater in lower and middle-income countries (LMICs) than in high-income countries (HICs), as shown in Figure D2. The projections for 2015 and 2030 reveal that the DALY burden in the HIC will remain the same, but will rise significantly in LMIC (Figure D3).

DALYs lost secondary to coronary heart disease (CHD) in India have been

predicted to increase from 7.7 million to 14.4 million among men and 5.6 mil-lion to 7.7 million among women from 2000 to 2020 (4). The DALY estimates (not discounted nor age weighted) for China due to CHD is projected to double from 8.0 million in 2000 to 16.4 million in 2030 (5). Assuming that the average individual income is INT $1,000 per an-num (an assumption made in the Com-mission on Macroeconomics and Health (CMH) report (6)), the indirect costs due to CHD-related morbidity and mor-tality in India will be 22 billion in 2020 and 16.4 in China in 2030.

What is the impact of CVD on pay-rolls? Disaggregated data on CVD are available for India. It is possible to es-timate costs from these data using sev-eral assumptions. From the PPYLL data

due to CVD for India (2008), we calcu-lated the loss of wages due to CVD. We used the 2012 declared minimum wages for the semi-skilled construction worker as the average for urban (262 INR per day) and the minimum wages for the semi-skilled agricultural worker (183 INR per day) as the one representing rural population (7).

Assuming 30% of the population is in urban areas, the loss of wages due to CVD in 2008 comes to US$224 million in urban areas and US$366 million in rural areas, respectively. The total loss of wages due to CVD is thus US$590 million. The loss of wages will likely in-crease substantially as CHD prevalence is expected to rise in India.

To summarise, CVD is a major cause of PPYLL and DALYs among five middle-income study countries (Bra-zil, South Africa, India, Russia and China), with higher levels in 2008 and higher projections for 2050 than two high-income comparator countries (US and Portugal). The loss of productivity is attributable both to the mortality and to the morbidity of CVD, which have substantial potential macroeconomic consequences. Those responsible for macroeconomic decisions in developing countries need to consider CVD when determining their policy agendas.

D3. The toll of disability associated with cardiovascular disease There are few comprehensive data avail-able on the toll of disability associated with CVD in the developing world, but CVD creates high disability costs for both social payments and household

support. For example, data from the Trivandrum Stroke registry in India sug-gest that the case fatality at 28 days was 27%, with 58% of stroke survivors bedridden or moderately disabled at 28 days (8). The proportion of stroke survi-vors needing care varied between 20% and 39% in Latin American sites but was higher in rural China (44%), urban China (54%) and reached up to 73% in rural India (9).

In a 2009 study, Harikrishnan et al evaluated 500 survey respondents 3 to 15 months after their first hos-pitalisation for acute coronary syn-drome or stroke, and found that 87% of the respondents had to limit their work activities or experienced diffi-culty in their work after hospitalisation. Nearly half (45%) reported difficulty in performing activities that required moderate exertion (10).

Huffman et al evaluated the micro-economic impact of first hospitalisa-tion of CVD (acute coronary syndromes, stroke, heart failure, or peripheral ar-tery disease) in four LMICs (Argentina, China, India and Tanzania) and found that 42%–97% of the study population across different socioeconomic positions had difficulties in performing moderate or vigorous physical activity (11). Re-garding productivity, 70%–100% of the study population had to decrease their work time. The impact on the house-hold was also significant. Nearly 14% of the household members increased their work time or took up new work to compensate. The percentage of house-hold members who had to stop work or reduce their work time to look after the


TABLE D3. Direct and indirect costs due to cardiovascular disease in the European Union (EU) and the United States of America (USA). * British Heart Foundation (19). ** American Heart Association (16).

CHD STROKE

DIRECT INDIRECT DIRECT INDIRECT

Lost productivity

due to morbidity

Cost of informal

care

Lostproductivity

due to mortality

Lost productivity

due to morbidity

Cost of informal

care

Lostproductivity

due to mortality

EU 23.98 12.3 4.3 9.1 18.5 4.78 3.68 11.1(Billion Euros)*

EU 37.17 19.06 7.13 14.1 26.7 7.41 5.7 17.2(Billion 2006 Int Dollars)

USA 96 11.3 69.8 -- 48.2 7.5 18 --(Billion 2010 Int Dollars)**

sick was 12% (11).As developing countries grow

wealthier, disability payments may in-crease. Even though this can be con-sidered as more investment in social services, ultimately it might become a growing budgetary burden. Thus, the investments that governments make in CVD prevention will likely help reduce the burden of disability and economic costs on society and on the govern-ments themselves.

D4. Direct and indirect health care costs for cardiovascular disease Health care costs can be divided into di-rect and indirect costs. Direct costs are the costs of medical care in relation to prevention, diagnosis, and treatment of

disease. They include costs such as am-bulances, inpatient or outpatient care, rehabilitation, community health servic-es, and prescription medications. Indi-rect costs are the costs due to the loss of human resources caused by morbidity or premature death. Morbidity costs repre-sent the value of foregone earnings from lost productivity due to CVD. Morbid-ity costs include three components: (1) work loss among currently employed in-dividuals; (2) home productivity loss (de-fined as the value of household services performed by household members who do not receive pay for the services); and (3) work loss among individuals too sick to work (12). Mortality costs represent the value of foregone earnings from pre-mature mortality due to CVD (13).

The indirect costs of CVD are gen-erally far greater than the direct costs, and it is to be emphasised that it is much more difficult to measure these than direct costs (14). Estimates of the direct costs of CVD and its precur-sors are useful primarily in giving a sense of the enormity of the burden of these conditions on health systems. But it is arguable that direct costs estimates may lead to underestimation, as they obscure the proportion of people who do not access health care due to costs or accessibility, which is an important con-sideration in the developing world (14).

Several studies in HICs estimate di-rect health care costs of CVD and its clinically expressed risk factors. Kiiski-nen et al from Finland reported that even when CVD mortality rates fall, costs may remain nearly static (12), in part because technological options for postponing mortality are themselves in-creasingly costly (see below).

Data from the developed world show that those countries spend staggering amounts of money to cover the costs to CVDs and that those costs are steadily increasing. Data from 2006 show that CVD costs the UK economy £30.7 billion per year. Of the total cost of CVD to the UK, around 47% is due to direct health care costs, 27% to productivity losses, and 26% to the informal care of people with CVD (15). Of the total £14 billion direct health care costs, 72% of this cost was for hospital care, whereas 20% was the cost of medications (15).

The American Heart Association (AHA) estimated that in 2010, the di-rect health care costs for CHD was

$50.8 billion, $18.1 billion for stroke, and $15.6 billion for hypertension (16). The American Diabetes Association sets the direct costs of diabetes at $116 bil-lion in 2007, of which approximately one-third (35%) is due to CVD (17). Recent projections of CVD costs in the US to 2030 (based on 2010 data, as-suming current prevalence) suggest that the total health care costs (direct and indirect) will double in the 18–44 and 45–64 years age groups. The increase in direct costs over these 20 years is estimated to be 200% (projected total of $818 billion) and the increase in indi-rect costs to be 61% (projected total of $276 billion) (13).

The 2013 annual statistical update (18) from the AHA estimated that the total direct and indirect cost of CVD and stroke in the US for 2009 was $312.6 billion.

Table D3 shows the direct and in-direct costs of CVD in the US (16) and the European Union (19) for the year 2006 and 2010, respectively, in Inter-national Dollars. These figures indicate that developed economies are spending huge sums of money to tackle CVD. For LMICs, with limited resources and infra-structure, the burden may be relatively greater. Recent World Bank estimates show that health care spending in China, India and Russia currently represents 4%–5% of GDP, in contrast with the US, where health care expenditure is more than 17% of GDP. These data point to the pressures that health systems in developing countries may experience if the incidence and prevalence of CVD (and other chronic conditions) increase


tiary hospital, and 10 to 15 times those of an average patient in a district or regional hospital (25).

There is also an urban–rural divide in health expenditures due to CVD. In urban settings, access to care is often greater than in rural areas. Total patient expenditures for health services in urban areas of India are higher than in rural ar-eas, for both hospital stays and illness treatment, and for services in both gov-ernment and non-government facilities. Urban households spend more on health care than their rural counterparts do at all income levels, and, except for the poor-est, this expenditure is a greater portion of urban household incomes than in ru-ral areas. Patient expenditures are 20% higher in urban than in rural areas, even where government facilities are the locus of care (26).

D4A. Indirect costs of cardiovascular disease The effects of CVD on costs extend well beyond the health sector. This is espe-cially true for the five countries studied in this report, where there is a dispro-portionate impact on the labour force, and hence a greater overall economic price to pay from long-term disability and early death. The aforementioned data of costing of CVD in the UK and US reveals that costs related to loss of pro-ductivity and other indirect costs added together will come to almost the same the direct CVD treatment costs (Table D3). In a study from UK, the employ-ment and other costs of informal care provided by the family for CVD patients were almost four times the size of direct health care costs (27).

In a recent assessment of the eco-nomic implications of NCD in India

and political commitment to pay for care increases. The indirect economic costs of CVD in LMICs may be relative-ly higher than in HICs, in part because of the younger age of onset of CVD, on average.

Acute coronary syndromes and chronic stable angina absorb resources, both private and public, in societies that can and do choose to treat them. Expensive procedures, such as cardiac catheterisation and coronary and pe-ripheral angioplasty, drug-eluting st-ents, implantable defibrillators, coro-nary, carotid and peripheral vascular surgery can prolong life and enhance its quality. In many patients, these pro-cedures will be essential to prolong life and also improve the quality of life. The increasing use of these services and pro-cedures will lead to increase in the direct health care costs, as is occurring in LMICs. For example, data from India show that there is an increase of 34% in the number of coronary angioplasties in the 3 years from 2008 to 2011 (20).

A study that analysed the cost of inhospital treatment of CHD from Bra-zil reported that the costs of ischae-mic heart disease management were INT$3,522 and INT$8,747 for the pub-lic and private sectors, respectively (21). The two main determinants of relatively high costs in Brazil are ad-mission with instability of the disease and the chronic pharmacological ther-apy (22,23). For China, estimates from 1998 indicate that hospital costs at-tributable to CVD conditions totaled over $9.6 billion, or nearly 20% of all hospital costs (24).

In South Africa, the average cost of hospital treatment of a CVD patient (based on an insurance data sample) illustrates the relative importance of CVD within the cost structure of inpa-tient care. On average, insurance pay-ments for CVD inpatient care involved a modest average length of stay of 3 days, although the overall length of stay in all types of hospitals was up to twice as long in central hospitals in towns in South Africa’s provinces. However, the cost per admission for CVD was two to three times the average cost in a tertiary care hospital, and six to seven times the average cost of an admis-sion in a regional or district hospital. CVD treatment costs escalate not nec-essarily because CVD patients are in hospital longer, but because resource consumption for CVD patients is much more intense than for non-CVD pa-tients. Costs per bed day were six times those of the average patient in a ter-

TABLE D4. Out-of-pocket (OOP) expen-ditures for CVD as a proportion of overall OOP health expenditures, 2007 (29).

FIGURE D4. Dependency projections for 2050 showing rise in dependency due to rise of peo-ple above the age of 65 in all the five study countries. Source: World population prospects: the 2010 revision. http://esa.un.org/wpp/Documentation/WPP%202010%20publications.htm (accessed Jul 2014).

Brazil 59%

China 92%

India 90%

Russia 83%

South Africa 30%

Portugal 77%

U.S. 23%


that was published by World Bank, Mahal et al reported that assuming that all caregivers and sick individu-als above the age of 15 years were productive, the predicted annual income loss from NCDs was of one tril-lion INR (US$18 billion) in 2004 (28). More than one-third of all the income losses were due to CVD and hyperten-sion (28).

D4B. Impoverishing effects of cardiovascular diseaseCVD treatment is known to be costly. The majority of patients affected by CVD bears the cost of treatment (i.e., through out-of-pocket [OOP] health spending). Data from the study countries show that the OOP health spending for CVD out of total OOP health spending var-ies from 30% in South Africa to 92% in China (Table D4) (29).

OOP health expenditure frequently leads to impoverishment. The overall positive relationship between propor-tion of households experiencing cata-strophic health expenditure (CHE) and the share of OOP expenditure in total health expenditure has been well es-tablished. Three key pre-conditions reported for CHE include: (1) health services that require payment; (2) low capacity to pay; and (3) lack of prepay-ment or health financing mechanism (30). OOP health expenditures lead-ing to impoverishment is well known (31). One-quarter of those hospital-ised in India are impoverished due to OOP health expenditures (31). This high prevalence is particularly relevant, as low socioeconomic status was found

to be a major predictor of CHE and the poor have higher risk, tend to be less able to access timely medical care and develop rapidly progressive disease with early and sudden fatal outcomes (32,33).

Xu et al estimated in 2007 that 150 million people suffer from financial ca-tastrophe (defined as annual health spending >40% non-food income) due to OOP spending on health care (30). Mahal et al report that the odds of incur-ring catastrophic hospital spending due to CVD or injuries in India are about 30% greater compared to communicable dis-eases that result in hospital stays (28).

Huffman et al assessed CHE and distress financing, or risky financial ac-tivities in recently hospitalised CVD patients in Argentina, China, India, and Tanzania (11). Risky financial activities include borrowing money from relatives or friends, taking loans from banks or other lenders, or selling assets related to the patient’s most recent hospitali-sation. The authors found that the pa-tients bear high OOP payments after CVD hospitalisation, with lower rates of CHE and distress financing if they have access to private or social insurance and higher income.

Huffman et al found that the 15-month OOP CVD expenditures var-ied considerably across countries and across income groups within countries (INT$374 [Tanzania, low-income] to INT$2,917 [India, high-income]). These data contrast with 2007 US estimates of INT$1,229 for annual OOP costs after CVD hospitalisation (11).

The group posited that as CVD prev-

alence increases in LMICs, the household economic impact of CVD may worsen if alternative health spending models that enhance patients’ capacity to pay or without more active policies to prevent or at least postpone the onset of CVD in LMICs are not developed (11).

Impoverishment also results in grossly inadequate treatment. The PURE study, which recruited 153,996 patients from 17 countries, found that the use of drugs for secondary prevention of CVD among patients with coronary artery disease or stroke was highest in HICs (antiplatelet drugs, 62%; β-blockers, 40%; angiotensin-converting enzyme [ACE] inhibitors or angiotensin II recep-tor blockers [ARBs] 50%, and statins 67%) and lowest in low-income coun-tries (9%, 10%, 5%, and 3%, respective-ly) (34). The primary reason for these gaps appears to be unaffordability of the medications, even though access, knowledge, and other barriers may also play a role.

D5. Household viability and dependency due to CVDAs noted in the earlier discussion of wid-owhood (chapter C), death of the bread-winner affects the future of an entire household. This is true whether the in-dividual dies of HIV/AIDS, an accident,or CVD. Using mortality and employment data from India, and assuming an urban household size of 5.8 and a rural house-hold size of 5.5, we calculated that CVD deaths among the 35–64 age group af-fect as many as 5 million members of Indian households (35). A study in Ben-gal found that when there is an adult

death in a household, a child young-er than 2 years has a 12-fold higher probability of death (36).

National expenditure figures can un-derstate the effects of health care costs at the household level. Indian National Sample Survey Organization data from 2007–2008 indicate that Indian house-holds allocate 5%–6% of household income to health care costs (37). In-creased morbidity and mortality from expensive illnesses such as CVD may push those allocations upward. In turn, such costs may take household resourc-es away from savings and other areas of consumption and investment.

Some elements of the impact of CVD on households are not easily measured, but their consequences hint at the seri-ousness of the trends. When a member of an extended family is disabled, there are few systems of care available in developing countries. People with dis-abilities reside with their families. Fre-quently, young girls provide necessary care, often at the cost of their schooling. The developing world overall has made great strides in recent years in expand-ing young girls’ schooling and women’s literacy overall. UNESCO data from 2005–2008 states that the female lit-eracy rate in the developing world was 73% (38). However, if young girls are withdrawn from school to care for disa-bled adults or to pursue menial labour to supplement the household incomes of their widowed mothers, this chain of success will be broken with poten-tial consequences extending beyond the classroom and the hospital ward.

Data from the central Asian state


of Tatarstan confirm that disability disrupts households. In 2002, among the working population, the second most important stated reason for dis-ability payments to the working popu-lation was “looking after patients”. Taking care of someone who was ill was second only to being ill with respiratory diseases, as a trigger for be-ing off work temporarily and for receiv-ing direct disability payments. These caretaker roles represented 16% of the entire temporarily disabled population, whose disability was attributable to disease. As disability rises, therefore, its economic effect will be magnified, since disability will also pull caretakers from both employment and education (39).

CVD deaths among men of working age also affect households indirectly through dependency. Three-quarters of India’s elderly population are economi-cally dependent on their children. More than 86% of urban elderly Indian wom-en are fully dependent on their children. More than 90% of India’s urban elderly people live with their families, and the proportion is nearly as great in rural ar-eas (40). As the population ages and the dependency rate rises (but now skewed toward the old rather than the young), the impact of the early death of wage earners will be profound, with extensive repercussions on household viability and elderly women. As indicated in Figure D4, dependency will rise between 2010 and 2050 as the number of older per-sons increase (41).

The greatest proportion of depend-ents will not be children, but will be individuals 65 years and older in Brazil,

China and Russia. The number of per-sons worldwide aged 65 years or older is projected to reach more than 1.5 billion by 2050, with most (1.2 billion) being in the less developed regions of the world (41). A dependent elder is clearly not equivalent to a dependent child. Older people typically incur more short-term health care costs. In industrialised coun-tries, health care for those over the age of 65 years is three times as costly as for those under the age of 65, and for people over the age of 80 years, three times again as expensive as for those under 80 years. Dependency in old age also exacts other economic costs includ-ing social security payments, increasing probabilities of disability, and increasing needs for investments in technologies that enable older people with disability to perform acts of daily living. Data from Canada indicate that dependency on activities of daily living was 11% due to heart disease and 29% due to effect of stroke in a household population 65 years or older (42). The coming tide of elder dependency makes the current CVD problem in developing country set-tings even more ominous.

The positive news from the devel-oped world is that CVD mortality and risk factor levels can be significantly improved through effective public health and clinical measures. Detailed discussion of this topic and the exam-ples of successful programs that have effectively decreased CVD prevalence is in chapter E.

To summarise, the costs of CVD are incurred both among mid-life and older adults. In developing coun-

tries, CVD is a potent cause of death and disability among people of work-ing age. It will become a major cause of disability among older people, whose numbers are set to rise over the next 40 years.


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In contrast to the grim news about its frequency and social and economic

cost, the good news about CVD is that we can do much to prevent and amelio-rate it. Those interested in these goals can assess the merits of different forms of prevention, their costs, and their po-litical and economic feasibility. They can relate them to estimates of costs of CVD and its management, and ap-ply them as they see fit. There are very good examples of the benefits of differ-ent preventive strategies for CVD – the story of Finland is one (see below).

The terminology about prevention is confusing, and it is important for us to clarify it before we proceed. This confusion arises because public health practitioners and clinicians use the same term – primary prevention – for different things.

Prevention can seek to rid a society of CVD, so that in a long life, CVD never presents as a clinical problem. Public health professionals usually call this pri-mary prevention. It implies the eradica-tion of the primary causes of CVD, that

is, of the conditions that produce the risk factors that predispose people to ar-terial disease.

Alternatively, prevention can aim to postpone the presentation of CVD from young or middle adulthood to old age. This enables the individual to live a full life, participate in the workforce, and ex-perience a healthy old age, prior to the clinical onset of disease. It seeks to re-duce risk factors and ameliorate their ef-fects. Public health practitioners refer to this as secondary prevention. However, the clinical literature often calls this pri-mary prevention.

To avoid this confusion, we refer to prevention that aims to lower or eliminate risk factors as commu-nity-based prevention, and preven-tion pursued by clinical treatment of people with elevated risk factors or ex-pressed CVD as clinical treatment and prevention.

When countries that make up the Organisation for Economic Co-operation and Development (OECD) have brought CVD under control, they have used

these preventive approaches in combi-nation. Declines in CVD mortality have run in parallel with decades of decreas-ing consumption of animal fat, decreas-ing tobacco consumption, and growing community awareness about CVD risk factors and heart health consciousness. As well, medical and surgical treatments have improved in efficacy. These range from pharmaceuticals that lower blood pressure and cholesterol to surgical pro-cedures or percutaneous catheter-based interventions. Most estimates of the effects of these interventions conclude that half the decline in CVD mortality observed in many OECD countries is due to population level changes in risk fac-tors and half to treatment (1). In other instances, changing macroeconomic conditions have contributed to changes in CVD risk (2).

However, the countries that have ex-perienced declines in national CVD mor-tality have not seen the benefits spread evenly among all groups in their socie-ties. CVD manifests a strong social class distribution, with disease concentrating among the more socially disadvantaged, even in countries that have halved over-all mortality from CVD (3,4).

E1. Levels of prevention of CVD Broadly speaking, there are three levels at which to implement CVD pre-vention.

E1A. Macroeconomic and whole-of-government interventionsThis report seeks to locate CVD within a macroeconomic context, positing that CVD has a serious impact on workforce

productivity in developing countries. We support that claim by our analyses and those of others of the effect of CVD on workforce productivity, deaths in young adults, impact on women’s health, and widowhood. The financial costs amount to tens of billions of dollars a year in China and India and less in the other study countries, but are so huge as to fully justify the attention of those con-cerned with macroeconomic policy in middle-income countries (5).

There is another aspect to the mac-roeconomic significance of CVD, and that is what macroeconomic policy can do to contribute directly to its ameliora-tion. CVD takes its origin from the so-cieties in which it manifests, the major risks having to do with diet, tobacco, work, wealth (or lack of it), education and physical exercise. Officials would be wise to assess the health impact of all public policies that concern diet, nutri-tion, agriculture, trade, education, to-bacco, the physical environment, town planning and transport, on CVD.

Macroeconomic interventions thus include governmental policies in a range of fields in which national treasuries have an interest, and that affect CVD and its risk factors. They are matters that affect a country’s macroeconomic agenda. They include policies and pro-grams such as: • tobacco production and consump-

tion – including subsidies, taxes, ad-vertising and control strategies, and incentives to grow crops other than tobacco;

• nutrition – including food produc-tion, processing and marketing sub-


INTERVENTION STRATEGIES TO REDUCE THE IMPACT OF CVD

E

sidies and taxes, such as those in relation to animal or vegetable fats, and the salt content of foods;

• education – including decisions about curricula in schools and work-places (e.g., physical education, nu-trition and cooking) and assistance in managing stress; and

• urban planning – including that for recreational spaces, trans-port systems, and city/town/village design that encourages healthy physical interaction with the environment.

Macroeconomic interventions usu-ally derive from ministries other than health (such as finance, transport, education or urban development), and exert their impact on non-health sectors of the population (e.g., dairy producers). They are implicitly political in nature.

An example of a macroeconomic intervention that occurred in parallel with changes in CVD rates comes from Poland. In the early 1990s, after separa-tion from the USSR, heart health stead-ily improved in Poland, in contrast with other former Soviet republics. Between 1992 and 1994, mortality from heart disease, based on official statistics, fell by 25% from a high in the decade up to 1991 (6). The fall in heart disease deaths coincided with a switch in Po-land from consuming animal fats to vegetable fats. This resulted not primar-ily from health promotion initiatives, but from a government decision to cut subsidies for animal fats and impose taxes, thus raising the price of animal fats to consumers and making vegetable

oils more competitive. There followed a 23% decline in the availability of animal fat products and a 48% increase in the supply of vegetable fat prod-ucts. Margarine manufacturers pushed strongly to sell products with vegeta-ble fat in Poland. At the same time, the government opened markets to oranges, bananas, kiwi and grapefruit year-round.

Whether these dietary changes alone accounted for the entire decline in CVD mortality is unclear, but it must have had a major impact. Monitoring of risk factors through the two Polish MONICA centres in Warsaw suggests that be-tween 1987 and 1992 blood pressure and female smoking decreased, but not average cholesterol levels, which were already low (7). Huge discrepancies were noted between official and MONICA 10-year average CVD mortality rates. Nevertheless, macroeconomic policies made it easier for Poles to consume a healthier diet (6). Economic policy alone can sometimes help in promoting heart health, but it is most effective when combined with other social policies, in-formation and legislation.

E1B. Population-based interventions Governments and other interested agencies direct health promotion inter-ventions at broad populations, address-ing the structural and behavioural de-terminants of health and illness. Unlike macroeconomic policies that have to do with revenue and general government outlays, these interventions have an ex-plicit health goal. They bring awareness of the value of good health, and create pathways to it for as large a population

as possible. The methods used include media projects and advocacy together with enabling social programs about how to maintain health and reduce or avoid risk. For CVD, these comprise in-formation and other programs address-ing: the risks of smoking, the value of smoking avoidance, excise and taxes aimed at reducing smoking uptake and intensity, restrictions on smoking in public places and smoking advertising and smoking cessation treatments; the causes of high blood pressure, including consumption of salt (8), and the benefits of control strategies; the causes of hy-perlipidaemia and dietary recommenda-tions; the importance of good nutrition and the dangers of obesity and warnings about diabetes; the importance of physi-cal activity in weight control and cardio-vascular health; and stress reduction in the workplace. It has been shown that the curative-based medical model is in-sufficient to reduce the use of tobacco, and that this will only be achieved by prevention and public health measures (9). An immense literature documents the steady reduction in tobacco con-sumption in developed countries that has followed the introduction of com-prehensive tobacco control strategies involving public education, tobacco ex-cise and tax, bans on advertising and re-strictions on smoking in public transport, restaurants, bars and places of assembly. Health promotion has been essential to this process.

We can consider tobacco taxation as a macroeconomic intervention because of its relation to major sources of na-tional revenue in many countries. Jha et

al examined the economic consequenc-es of instituting comprehensive tobacco control strategies (10). These strategies include an imposition of excise duty on the sale of tobacco to citizens. Tobacco taxation can raise substantial revenues. Jha et al calculated that in China, a 10% increase in cigarette tax would decrease tobacco consumption by 5%. It would also increase tobacco revenue by 5%, sufficient to finance a package of essen-tial health services for one-third of Chi-na’s poorest 100 million citizens (10). This work gives the lie to the myth that only rich countries can afford to intro-duce tobacco control strategies.

A good example of tobacco legisla-tion leading to positive effects in CVD control is the banning of smoking in pub-lic places. Reports from Italy showed an immediate reduction in acute myocardi-al infarction admissions after the smok-ing ban introduced in 2003 (11). In a sys-tematic review, Myers et al found that banning of smoking in public places lead to reduction of myocardial infarction by 17% and the reduction was most appar-ent in the young and non-smokers (12).

The Framework Convention on To-bacco Control, adopted at the World Health Assembly in May 2003, requires signatory countries to promote public awareness using multiple communica-tion methods (13,14). As smoking is avoidable, the habit and its initiation and perpetuation could yield to a suc-cessful combination of macroeconomic, population based and health worker initiatives. This initiative, which entered into force in 2005,is receiving strong in-ternational support with more than 179


parties (as of October 2014) associated with it currently.

Excessive dietary salt may be a ma-jor cause of raised blood pressure, and a reduction in salt intake may reduce the CVD burden (16). A recent mod-elling study from India found that re-ducing intake by 3 g/day over 30 years (–0.1 g/year, 25% reduction) would re-duce annual myocardial infarctions by 350,000, strokes by 48,000 and deaths by 81,000 among Indian adults aged 40–69 years (17). The WHO 25/25 goals also identifies salt restriction as an important measure.

Many countries, including Japan, Finland and the UK, have reduced the amount of salt being consumed by a combined policy involving the food in-dustry in decreasing the amount of salt added to foods, clear labelling on food products, and increasing public aware-ness of the harmful effects of salt on health (18). In many developing coun-tries, most of the salt consumed comes from salt added during cooking or from sauces; therefore, public health cam-paigns are needed to encourage con-sumers to use less salt (18,19). Initiatives such as World Action on Salt and Health (WASH) which is a coalition of health professionals from different countries may help in this regard (18).

In relation to nutrition, agriculture and food production, governments have developed hundreds of policies and pro-grams in developed countries to modify dietary consumption of fat, especially animal and trans fats. Their potential for benefit is huge because they aim at the entire population, seeking to achieve

small reductions in risk for everyone. The effects of these small reductions in risk can be substantial when multiplied across entire populations (20). For ex-ample, Oster and Thompson estimated that a minimal (1%–3%) reduction in dietary saturated fat in the US would reduce coronary heart disease events by 30,000–90,000 a year, thus avoiding between $4.1 billion and $12.7 billion in medical and productivity costs (21).

Chapter 5 of The world health report 2002 uses published evidence to assess a wide range of health pro-motion interventions highly pertinent to CVD. The chapter carefully presents the costs and imputed benefits of these programs. The analyses should prove useful to countries concerned to invest wisely in achieving control over CVD (22).

From Finland comes a major ex-ample of population-based dietary in-terventions that have had beneficial effects on CVD prevalence, although in ways perhaps not originally antici-pated. Finland experienced high death rates from heart disease after World War II. Public concern about the fre-quency of heart attack deaths led to a regional experiment to prevent them – the North Karelia Project, which began in 1972. Because of the association of high serum cholesterol levels and heart risk, cholesterol in the diet was one of the major targets of the prevention pro-gram. Puska et al developed a series of community-based strategies designed to change dietary behaviour. These in-cluded media campaigns, collaboration with the food industry and agricultural

policy changes (23). The initial impact was a decrease in

CVD incidence in the North Karelia re-gion compared to a control region. How-ever, the differences between the two regions – and between North Karelia and the rest of Finland – decreased after the first 5 years, mainly because people in the control region also changed their behaviour (23). As dietary preferences changed, the food industry perceived new opportunities and developed prod-ucts with less oil. Agriculturalists devel-oped a type of rapeseed that grew well in the cold northern climate of Finland. The local rapeseed oils sold well and cook-ing with vegetable oil became popu-lar in Finnish kitchens, so that the market proportion of unsaturated to saturated fats increased. Food pro-ducers reduced the salt in their products. The availability of products lower in salt and saturated fats made it easier for people to comply with health messages.

North Karelia and Poland demon-strate the ability to change diet through macroeconomic and health promo-tion interventions. Mauritius has used nationwide programs since 1988 that have employed price, policy and edu-cational efforts along with community education and changes in cooking oil from palm to soy. Although obesity in-creased slightly over the first 5 years of the program, other CVD risk fac-tors including blood pressure, choles-terol, smoking and lack of exercise all changed favourably (24).

The evidence in relation to pop-ulation-based dietary interventions to reduce CVD is nonetheless mixed.

Regional population-based CVD control programs in the US have not been successful (25). A critical appraisal of community based interven-tions by Ebrahim and Smith was not en-couraging (26).

Kiiskinen et al reviewed more than 50 community-based interventions that have ameliorated CVD in developed countries for their applicability in low- and middle-income countries (27). They question whether the evaluative studies have been large enough to detect small changes. They also ask whether the extent of the intervention (the dose), compared with the massive advertising budgets of the food industry, has been anywhere near large enough to effect substantial change. For programs to suc-ceed, the authors, mention the necessity of community endorsement, adequate intensity of intervention, corroborative national policy development, evalua-tion, and where warranted, generalisa-tion and international sharing.

Trans fats are another risk factor for CVD. A 2% increase in energy intake from trans fats has been associated with a 23% increase in cardiovascular risk. Denmark has shown that it is possible to eliminate all industrial trans fats from food items (28). But moves toward the elimination of trans fats, for which no lower dose has been shown to be safe, are incomplete. The American Heart Association recommends limiting trans fats to < 1% energy. The US Food and Drug Administration labelling rules al-low products containing < 0.5 g trans fat per serving to claim zero trans fat. Many products with 0.5 g trans fat per


serving, if consumed over the course of a day, may approximate or exceed the 2 g maximum recommended, while claiming to be trans-fat “free” (29).

Pérez-Ferrer et al analysed trans-fat regulation in the economically develop-ing world, taking Mexico as an example (30). They reported that the food indus-try and government resisted the need for regulation, and there was no organ-ised health or consumer lobby to coun-ter this. The authors argued that this will be likely to be the case in other middle- and low-income countries too.

Another issue is coexistence of under-nutrition and malnutrition-re-lated NCDs, as seen in China and India, for example (31). In these countries, under-nutrition and its problems exist in some areas (rural areas, urban slums), while some regions have problems of over-nutrition. This can lead to problems in implementation of programs in im-proving the dietary pattern in the com-munity as a whole.

In many developing countries, serum cholesterol levels often increase as diets change, although the dynamics of agri-culture and food production differ from country to country. Kim and colleagues described the rapid nutrition transition observed in South Korea since the 1970s and presented a detailed analysis of the social environment and nutritional be-haviour of South Koreans over the study period (32). Although there has been a large increase in the consumption of animal products and a fall in cereal in-take, fat intake has not increased mark-edly and obesity rates have not risen as much as in similar countries. Govern-

ment-directed national efforts towards maintaining elements of the traditional Korean diet, which is lower in fat and has generous portions of vegetables, together with widespread instruction in healthy cooking, are credited with the benefits. The authors suggested that other developing countries might learn powerful lessons from South Korea (32).

It is reported that consumption of foods complying with the criteria for a front-of-pack label could contribute moderately to cardiovascular risk reduc-tion via influencing blood lipids (33). Nu-tritionists and economists have estimat-ed the costs and benefits of mandatory labelling of all prepackaged food with nutritional information. They predicted that labelling would save the US $4.2 billion over 20 years through health gain at a cost of $1.5 billion. The health min-istry in Canada calculated that labelling would save the country $5.3 billion in direct and indirect health costs over 20 years, at a cost of $300 million to indus-try. In Australia and New Zealand, man-datory nutrition labelling is projected to prevent 400 deaths a year, with savings to the health system between $47–$67 million (34). Given that in countries such as India and China currently most people consume homecooked food, the benefits of food labelling may not be immediately evident. However, with advancing nutri-tional transition and easy availability of processed foods in many urban locations in these countries it will be imperative for these countries to address transfat reduction with energetic vigour.

Psychosocial stress is increasingly be-ing recognised as a risk factor for CVD

(35,36). Stress reduction by meditation and yoga has shown to control risk fac-tors like hypertension and reduce the CVD risk (36).

When we evaluate population-based macroeconomic and health promotion approaches to changing smoking and diet, causal relationships are difficult to establish because opportunities for randomised controlled experiments are few. And yet, using other analytic and descriptive approaches, in the devel-oped world, associations among reduc-tions in smoking, animal fat intake, salt and excess carbohydrates, with reduced rates of CVD mortality are consistently evident. These are so notable that many governments continue to embrace strat-egies that reduce exposure and attempt to influence individual behaviour, and the WHO continues to include these strategies as an important and cost-ef-fective element in comprehensive pre-vention initiatives (37).

E1C. Provider-based prevention As risk factors accumulate and become more prominent in the population, CVD prevention must shift to more individu-alised interventions, including the treat-ment and counselling of individuals in relation to risk factors such as smoking, hypertension, dyslipidaemia, diabetes, and obesity (38-42). The more risk fac-tors a patient has, the more intense interventions must be, to prevent end-organ CVD. In many instances, health authorities and physician associations have developed clinical practice guide-lines that specify best practice for the management of patients at high risk

or with established disease. The treat-ment of risk factors, as indicated, con-stitutes prevention or postponement of end-organ CVD.

Trials of therapy begun even when end-organ disease (myocardial infarc-tion, the onset of congestive heart failure, or renal insufficiency) is overt demonstrate strong benefits for pa-tients (43,44). Clinicians can slow the rate of progression of early coronary or cerebrovascular disease or con-gestive heart failure by medical and surgical intervention. Moreover, we now know that a combination of medicines and behaviour modification can prevent much of the end-organ damage of diabetes. Results from clinical prevention trials of pharma-cological treatment for hyperlipidae-mia show a substantial reduction in both ischaemic heart disease (IHD) and cerebrovascular disease in those at high risk (39).

In practice, however, reducing risk in the clinical setting is not straightfor-ward. The 2005 WHO-PREMISE study of 10,000 patients with coronary heart dis-ease (CHD) and cerebrovascular disease in 10 low- and middle-income countries, showed that unhealthy lifestyles and high levels of risk persisted in many de-spite best efforts. About 47% of patients had at least two or more modifiable risk factors (smoking, physical inactivity, hypertension, diabetes or hypercholes-terolemia). Thirty-five per cent did not follow a heart-healthy diet and 12.5% continued to use tobacco. A significant proportion of patients did not receive appropriate medications – only 29.1%


of the CHD patients used statins. The study concluded that there are many missed opportunities for prevention of recurrences in those with established CVD in low- and middle-income coun-tries (45).

Another recently published study of more than 15,000 patients from 39 countries across the globe reaffirms the above fact when it showed that even though most of the patients were on drugs for secondary prevention, the ma-jority of the patients were not achieving the targets of secondary prevention (46).

Hypertension is the precursor for two-thirds of strokes, half of coronary disease, and three-quarters of conges-tive heart failure. Although hyperten-sion is an appropriate target for all three types of prevention, once established it is most responsive to pharmacological intervention (47).

Analyses of 316,000 men observed for years in MRFIT, a study conducted in the 1980s, showed strong graded re-lationships between serum cholesterol above 4.65 mmol/L (or 180 mg/dL), sys-tolic blood pressure above 110 mmHg and diastolic blood pressure above 70 mmHg, and mortality due to CHD (48). MacMahon et al conducted a me-ta-analysis of nine major observational studies of 420,000 patients and found that a sustained 10 mmHg lower diastolic pressure was associated with 56% fewer cerebrovascular disease events and 37% fewer coronary events (49). Another meta-analysis of trials of about 960,000 patients showed that all the classes of blood pressure-lowering drugs have a similar effect in reducing CHD events

and stroke for a given reduction in blood pressure and the proportional reduction in cardiovascular disease events was the same or similar regardless of pre-treat-ment blood pressure (50).

Using an observational database of one million adults, Lewington and col-leagues showed a profound impact of blood pressure on cerebrovascular deaths, coronary deaths, and other CVD for men and women of all ages down to a level of 115/75 mmHg (51). In an analysis from an Asian and Pacific co-hort study conducted in the age groups < 60, 60–69, and 70 years and older, Lawes and colleagues showed that if systolic blood pressure were 10 mmHg lower, the epidemiologically expected mean reduction in risk of stroke would be 54%, 36% and 25% respective-ly at these ages, and the risk of IHD would be reduced by 46%, 24% and 16%, respectively (52).

Simple interventions, such as dietary sodium restriction, have been found to not only reduce blood pressure, but also to cause reduction in all CVD endpoints, as evidenced in the TOHP I and TOHP II studies (53). A recent position state-ment from the Pan American Health Or-ganization/WHO Regional Expert Group on Cardiovascular Disease Prevention through Dietary Salt Reduction con-cludes that the benefits of salt reduction are clear and consistent, and has called for a population reduction in salt intake to prevent strokes, heart attacks and other cardiovascular events (54).

As a starting point for treating individ-uals with elevated risk factor levels, hy-pertension control should be the forerun-

ner. A clinician can enter an individual’s world through this door. Hypertension is easy to identify and universally recog-nised as a determinant of risk. Beyond the individual, the clinician can use the measurement of blood pressure to re-cruit families to broadly based preven-tion programs. The clinician can then add other treatments or life style modi-fications aimed at other risk factors as necessary.

Dyslipidaemia plays a causal role in vascular disease and reduction in cho-lesterol levels has been found to reduce both IHD and stroke rates (55). In MRFIT, there was a fivefold increase in coronary mortality between the lowest and high-est decile of total cholesterol (48).

Individual assessment of cholesterol level is expensive because it involves blood tests and individual patient access to them. Because of its responsiveness to dietary manipulation, hyperlipidae-mia is an appropriate target for all three types of intervention. However, research suggests that it is especially sensitive to pharmacological intervention (56).

A meta-analysis of the major pri-mary prevention trials conducted before 2008, using statins, showed a significant reduction in major coronary events and reduction in all-cause mortality (57). These studies were spread among pa-tients with normal or high cholesterol levels. Despite the impressive benefits observed with total cholesterol and low-density lipoprotein cholesterol (LDL-C) reduction attempt to increase high-density lipoprotein cholesterol (HDL-C; “good cholesterol”) by drug therapy has not been successful.

To simplify the management of indi-viduals who require medication for CVD, Wald and Law proposed a combination pill (polypill). They proposed that the polyp-ill would contain contain hydrochloro-thiazide or atenolol or enalapril to lower blood pressure, simvastatin to lower cholesterol, together with folic acid (to reduce homocysteine lev-els) and aspirin to inhibit platelet function (58). Wald and Law reasoned from clinical trial data that if everyone aged 55 and older took the pill (age be-ing the strongest predictor of CVD risk) in high-risk populations, together with younger patients at high risk or with es-tablished CVD, the polypill could reduce IHD events by 88% and stroke by 80%. In the UK, despite recent declines in CVD mortality, 96% of people who die of CVD are aged 55 years and over.

Wald and Law argued that treating everyone aged 55 and older (or younger if at high risk) is justified, without meas-uring risk factors before treatment or monitoring the effects of treatment. The intention is to shift the distribution of the principal risk factors in the popula-tion, reducing the population mean val-ue for each and reducing the risk of the entire (“sick”) population. They estimat-ed that one-third of people aged over 55 taking the polypill would benefit, gaining an additional 11 years of life free of IHD events or stroke. The number of patients needed to treat to achieve a substantial benefit was just three. The estimated rate of side effects was 10%, but serious consequences would be much rarer (58).

But the age of 55 and older suggest-ed by Wald and Law for at-risk popula-


tions in economically advanced nations may be too high in the developing econ-omies described in this report as by this age, the disease or its risk factors may be well established.

Several versions of the polypill have been successfully developed by pharma-ceutical companies from India (59). The combination of drugs is reported to be free of pharmacokinetic drug-drug inter-actions among the ingredients, and their bioavailability well preserved (60).

One polypill (Polycap – Cadila Pharamceuticals, India) has been test-ed in India using a factorial trial to assess its impact on risk factor reduction and it was found to efficacious and safe (61). Another study which was done un-der the auspices of the WHO in Sri Lan-ka, reported that both the patients and treating doctors found the polypill to be safe and effective (62).

The UMPIRE trial, conducted in Europe and India, tested polypill in patients who already had estab-lished vascular disease (63). Recently published results from UMPIRE showed that the polypill increased the adherence to therapy by 33% (64). As we know, ad-herence to therapy is a major problem in treating chronic diseases, especially in the developing world (65).

There are other studies currently in progress on different polypill ver-sions with different combinations in different countries, among them are Kanyini-GAP, conducted in Australia, and IMPACT, which is ongoing in New Zealand. TIPS2 is another trial that tested a high-dose polypill against the low-dose polypill, developed by

another Indian pharmaceutical compa-ny. (As all these polypills use generic ver-sions, they have a huge market potential for scaling up).

A recent critical analysis of the ef-fects of the polypill reported that while patients at higher risk showed reduc-tions in systolic blood pressure of up to 28.8 mmHg and in LDL-C of up to 54 mg/dL, correlating with 62% and 60% rela-tive reduction in risks of CVD and stroke, respectively, the reductions among pa-tients at lower risk were modest (66). Polypill therapy is expected to be cost-effective. In a recent trial from the Neth-erlands, polypill therapy was found to be cost-effective, which indicates that it can be useful even in the developed world (67). Even though polypill strat-egy has its own benefits, the difficulty to titrate the dosage of drugs and the need for withdrawal of the combination pill in response to side effects of one of the components is a concern. Further re-search is needed to provide a definitive verdict in the case of polypill therapy.

Obesity is now a worldwide epidem-ic, with massive increases in prevalence in countries of many different levels of development. This has led to a surge in the incidence of the metabolic syn-drome, which often precedes diabetes, and to the recognition that in younger individuals this leads to a more rapid development of CVD endpoints. The 2007–2008 estimates of age-adjusted prevalence of overweight (BMI > 25 kg/m2) was 69.4% in the US. A recent study from India found the prevalence of metabolic syndrome in an urban setting to be 45% (68).

Clinicians have shown that the meta-bolic syndrome is reversible. Weight loss and change in caloric intake can abolish insulin resistance, hypertension, hyper-lipidaemia, and the other metabolic dis-orders that define this syndrome. Dia-betes prevalence falls following weight loss and dietary change. Tuomilehto et al showed that lifestyle changes in a middle-aged Finnish diabetic popula-tion led to a reduction in the prevalence of diabetes by 58% over 4 years (69). The average weight loss was 4.7%. We know that reducing the preva-lence of diabetes also reduces the risk of CVD. For example, the landmark UK Prospective Diabetes Study, car-ried out in the 1970s and 1980s, showed that strict drug control of diabetes led to a reduction in complica-tions, such as CVD (38).

The impact of weight gain on the incidence of diabetes is profound. Esti-mates of increasing risk of diabetes over 10 years for a 1 kg increase in weight range from 4.5% to 12% (70). In the US Nurses Health Study, over 90% of type 2 diabetes appeared to be preventable if the nurses maintained healthy body weight and attended to lack of exercise, poor diet, smoking, and alcohol (71). The absolute risk for a major coronary event in a person with diabetes without known coronary disease is nearly as high as that of a person without diabetes who has established heart disease (72).

Despite frequently being available, fruit and vegetable consumption is well below the desired levels in the develop-ing world. The INDEPTH-HDSS study evaluated six Asian countries (73) and

found inadequate fruit and vegeta-ble consumption in 63.5% of men and 57.5% of women.

A meta-analysis of cohort studies has shown that increased fruit and vege-table intake in the range commonly rec-ommended is associated with a reduced risk of stroke. The authors conclude that this data provide strong support for the recommendations to consume more than five servings of locally available, seasonal and inexpensive fruit and vege-tables per day, which is likely to cause a major reduction in strokes (74). Another meta-analysis has shown that fruit and vegetable consumption is inversely as-sociated with the risk of CHD (75).

There are data to show that chang-ing diet following a heart attack may confer a benefit. The Lyon Diet Heart Study compared a Mediterranean diet with a prudent Western diet among patients who had survived a first myo-cardial infarction, although the results of this study have been criticised. The authors claimed that the diet reduced death, non-fatal myocardial infarction, and various other endpoints including stroke, over the 4-year follow-up period (76). The PREDIMED study also showed that a Mediterranean diet is beneficial (76a).

Two post-myocardial infarction tri-als, one in India and one in the UK, have also demonstrated beneficial outcomes based on dietary advice (77,78). The Framingham Study had earlier observed the independent value of dietary fruit and vegetables (79). The British study looked at three regimens – fat reduc-tion, enhanced fish intake, and increased


fiber. Only the high fish diet was effec-tive in reducing all-cause mortality over 2 years. These examples, however, may overestimate the effect of short-term dietary interventions.

There was an interesting pro-posal for a “poly-meal” similar to the “polypill”, which promises to be an effective, non-pharmacological, safe, cheap, and tasty alternative to reduce cardiovascular morbidity and increase life expectancy by 6.6 years among men and 4.8 years among women (74).

Tobacco is widely recognised as the single most important risk factor for chronic diseases of various kinds includ-ing CVD. In MRFIT, smoking of up to 26 cigarettes a day tripled the risk of ischae-mic heart disease (48). Tobacco’s reach is far beyond CVD, playing major roles in cancers and lung disease (80). Smokers develop coronary events a decade earlier than non-smokers do, and patients with heart attacks who resume smoking are four times as likely as those who stop to sustain a second one. Smoking increases worker absenteeism and reduces produc-tivity, both of which improve after ces-sation (81). CVD reduction is one among many powerful arguments that have led to successful tobacco control strate-gies in many different countries and to recent concerted international action. Smoking is responsive to all three types of interventions although macroeco-nomic and health promotion initiatives tend to be most effective. Nonetheless, while concentrating on prevention, we note that the effects of smoking ces-sation are strong and immediate, and clinicians need to build smoking cessa-

tion into clinical risk reduction. Clinicians should urge all people who smoke to quit and assist them in doing so to reduce their chances of CVD. Those at elevated risk because of age or other risk factors should receive the most energetic and supportive encouragement to quit.

Even though the patient will be most receptive (regarding advice regarding smoking cessation) following an admis-sion for an acute coronary syndrome (“teachable moment”) the percentage of patients receiving an advice regarding smoking cessation is very low. It is found that a simple advice by the physician will improve the quit rates and offering and providing assistance by physicians to quit smoking generate more quit at-tempts (82).

But the availability of organ-ised smoking cessation programs in the developing world is very limited (82) and these may need to be strength-ened. However, it is also much easier for a smoker to quit when there are social restrictions on smoking and a prevailing attitude that favours not smoking.

E2. Practicalities of cardiovascular disease prevention Policies for people at low risk of CVD should seek to diminish or avoid tobacco use, to favour the production and use of vegetable oils over animal fats, and to encourage physical activity especially in urban areas. The goal is to alter the fac-tors that determine negative behaviour patterns within the population of those not yet at risk or at minimal risk. How-ever, people at high risk will also benefit from these policies, finding it easier to

change their behaviour if there is social support for doing so.

Once there is clinical evidence of markedly elevated CVD risk factors, treatment is required. High-risk groups require more resources for prevention per person than do large-scale inter-ventions with those at lower risk. The economics of these two approaches are not straightforward, however. A low-risk group, being large in number, can rapidly multiply an intervention of low unit cost to create a large total cost. About half of all CVD mortality occurs among those with low levels of identifiable risk, and it is to this population that health promo-tion addresses its efforts. The 10% of the population who have the most risk fac-tors for CVD contribute less than 50% of disease events including death from IHD though this has been questioned (82a).

Primary health care is the form of health care delivery preferred for the clinical treatment and prevention of CVD, a preference based on both equity and efficiency. The CMH Report refers to primary health care as close-to-client services (83). Primary care provides local health services to communities, and is essential for high-quality management and clinical prevention of most illnesses. In comparison to the low cost of a pri-mary health care infrastructure (includ-ing drug therapies, where necessary), the expense of comprehensive medical and surgical interventions to treat es-tablished end organ CVD is very high. The world health report 2008, subtitled Primary health care – now more than ever, recognised the renewed importance of primary care in the new age (84). The

Global status report on noncommunica-ble diseases 2010 endorses the impor-tance of primary care, stating “Primary health care is clearly identified as the best framework for implementing rec-ommended interventions [for NCDs] on an adequate scale” (85). We support this view, for using primary health care to meet the needs of those with NCDs as well as communicable diseases, al-though this has been questioned (82a).

It is important to emphasise, lest there be any misunderstanding, that the conquest of CVD does not require mul-tiple, independent, free-standing hospi-tal facilities. Most medical problems are best served by a stable and adequately funded primary care system. Primary care is a desirable method for organis-ing health services for multiple purpos-es, and while its pedestrian appearance means that it is not attractive to donors and others who wish to identify their gifts with tower block hospitals and electronic devices, it nevertheless repre-sents excellent value for money.

Sophisticated hospital services for CVD in developing countries are gen-erally limited to those who can pay. It would be unfortunate if the provision of services for those with the capacity to pay distracted attention or resourc-es from establishing first-line primary care capacity to manage CVD risk for whole populations.

The provision of services for those at elevated risk through primary care is, like the provision of antiretroviral drugs to patients with HIV, a lifelong com-mitment. CVD control programs are for the long haul and in committing to


them, no government or interest group should think otherwise. Clinical pre-vention aimed towards individuals at high risk requires an enduring, lifelong, relationship between the patient and the person treating them, unlike sin-gle or discrete repetitive interventions such as vaccination or treatment for short-term illness.

Besides drug costs, infrastructure and management systems are impor-tant components of clinical secondary prevention programs. A comprehensive primary care service depends on a distri-bution system for the supply of diagnos-tics, pharmaceuticals and educational materials. The treatment of CVD risk factors also requires trained personnel, simple screening tests and cheap and effective interventions. Components in-clude: • a stable government and a civ-

il society, creating a context in which it is safe to visit a clinic, and where disease and medical disorders are free of stigma and individual blame;

• a national, regional, and/or urban primary care system, together with equitable financial arrangements for care;

• public educational programs avail-able in print and other media;

• a national and regional supply dis-tribution system for diagnostic tests and medications;

• Enough trained health professionals to do the work and continuing edu-cation for all of them;

• reliable, affordable, and predictable access to effective medications;

and• a referral system for those with

clinically expressed end organ dis-ease that may require hospital or special care.

Almost as a parenthetic comment, we note that there is another impor-tant aspect of clinical prevention to keep in mind. That is the natural his-tory of deferred CVD. In the US, the number of heart failure admissions tri-pled from 1979 to 2004. Lloyd-Jones et al also reported that though IHD mortality was reduced in the last two decades of the last century, it was ac-companied by an increase in hospital admissions for congestive heart failure, a long-term sequel of IHD, by 155% (86). Congestive heart failure is now the most common cause for hospital ad-mission among older US people and is an emerging epidemic.

E2A. The costs of clinic-based risk factor interventions What would a basic, first-step clinical intervention program look like and what would it cost? It is extremely helpful if a country has a publicly funded pri-mary care clinic system as the starting point for clinical interventions directed against CVD. This provides an excel-lent base for the detection and recruit-ment to treatment of those at high risk. It can also serve as a springboard into the community to boost health promo-tion initiatives, which can address both social structural impediments to heart health (local attitudes to smoking, pro-vision of adequate recreational space) and individual behavioural determinants

(attitudes towards nutrition, obesity, to-bacco smoking).

The world health report 2002 ad-dressed the costs of clinic-based risk fac-tor interventions and provided a range of helpful analyses relating the evidence of effectiveness in relation to probable costs in a range of countries (22). The proposed working model was as follows. A clinician would check each patient medically four times a year and a health educator would meet each patient at least once a year. Those managing the patients would perform annual laboratory tests. Health manag-ers would link the clinical preventive approach to population-based strat-egies relating to tobacco, exercise and diet (including salt). Contrary to expectations perhaps, many of the interventions yield an excellent return on investment.

The report goes on to state that the most attractive strategy is the combi-nation of salt reduction at a popula-tion level through legislation or volun-tary agreements, with health education through the mass media focusing on blood pressure, cholesterol and body mass, plus the implementation of an ab-solute risk approach to managing CVD risks (22).

Cost analysis of a similar CVD pre-vention strategy as described above us-ing a regimen of aspirin, statin and anti-hypertensive agents in those people at high cardiovascular risk (people with a 10-year cardiovascular risk equal to or above 15%), or those patients who have suffered a previous cardiovascular event, found it very cost-effective. They calcu-

lated that by providing such a regimen to the above groups between 40–79 years of age, we can possibly avert about 20% of cardiovascular deaths in the next 10 years, with 56% of deaths averted in people younger than 70 years. With ef-fective management, the average yearly cost per person of implementing such a regimen has been estimated to range a modest cost from US$0.43 to US$0.90 in low-income countries and from US$0.54 to US$2.93 in middle-income countries (87).

We endorse this general approach. In the basic version we propose, doctors or other health workers would meas-ure the blood pressure of everyone who uses health clinics for any reason at all (“opportunistic screening”) – upper res-piratory infection, arthritis or well baby check-ups. They would invite patients identified as hypertensive to participate in a risk factor modification program, of which smoking cessation advice and help would be central. The clinicians would also invite family members for screening. Possibly, if finances and fa-cilities permitted, a single, non-fasting blood drawn for blood glucose, choles-terol and creatinine levels would provide a more complete risk profile and permit drug therapy to be fitted to the patient’s condition. By way of an example, such a blood test would cost 200 INR ($4) in In-dia. We recognise that even these costs may not be tolerable to the poorest of the poor in the developing world.

In relation to the pharmacological treatment of hypertension, multiple, cheap medications are now available and it has been shown that they are


all equally effective (50). The avail-ability of generic drugs is a blessing to those needy in the developing world. Many of the pharmaceuticals in nearly every class of drug used for CVD are now off-patent. The Indian govern-ment, for example, has enacted certain rules to control the prices of essential drugs which include most cardiovascular drugs (88).

For hypertension alone, the clinician might prescribe a thiazide diuretic and a dihydropyridine calcium-channel block-er or an ACE inhibitor. Thiazides and cal-cium blockers or ACE inhibitors would cost about $1 per person per week in India. If cholesterol were also elevated, clinicians could add a statin. In India, the prices of statins have come down. For a week’s maintenance dose of simvastatin of 10 mg, it will cost only about a dollar per week in India.

We estimate that a regional pur-chaser could negotiate price reductions of 75% now and 90% in the near future, especially as more and more of these drugs come off patent. Tax exemption to these drugs will also help. In India, medical shops run by government agen-cies have tax exemptions, so that poor people get the drugs at a lower cost. Clinicians might also consider adding aspirin, which is very cheap, to those at the highest risk and when it is not con-traindicated.

With the addition of more drugs to the patient’s regimen, the mar-ginal costs and benefits become criti-cally important. In the UK, Marshall examined the additional benefit bought by adding drugs sequentially to achieve

a reduction in CVD risk. If clinicians in the UK were to add simvastatin to a regimen of antihypertensive agents, $250,000 would purchase a reduction of 1.2 coronary events in those patients at a 15% 5-year risk of a coronary event. The same amount of money, spent on aspirin for a much larger group of indi-viduals at a 5-year 10% risk, could pre-vent 30 such events (89).

Incremental cost-effectiveness cal-culations are critically important in settings where money to spend on in-terventions is very limited and must be used to the best community effect. The total cost for treatment using antihyper-tensive medications, aspirin and statins, would be about $2 per person per week in India.

The use of a polypill strategy will reduce the cost further. This is possible because the drugs used in the polyp-ill (e.g., which was tested in UMPIRE study) – simvastatin, hydrochlorotiazide or atenolol, aspirin and lisinopril are off-patent drugs. Other polypills will also be similarly priced.

Pharmaceutical treatment of CVD, given the large number of individu-als who need it, poses a major prob-lem for many countries. This is similar to the problem faced by countries that need antiretroviral therapy for patients with HIV/AIDS. Seeking external aid to achieve coverage may well be an ap-propriate response for many countries faced with a mounting toll of CVD.

Health service administrators and others can use available cost-effective-ness data to calculate the likely benefits that would accrue from such programs

in their country. These therapies, as al-ready stated, may be outside the range of financial possibility for many citi-zens and governments in low-income countries. Nevertheless, they are likely to be within the capacity of affluent citizens to pay, especially those who, unless treated, might consider highly expensive treatment (including surgery or angioplasty) when their CVD mani-fests. For these individuals to pay for their own treatment may be accept-able if national health service financing recognises the need of others for sup-port. This is desirable for equity and achieving social justice goals through health service provision.

Two other elements of a basic clinic-based prevention program for CVD are important. First, continuing education in relation to CVD prevention for the pro-fessional staff would be essential. This need not be expensive. Local health pro-fessional associations could incorporate it into ongoing professional education programs, assisted by health profession-als from OECD nations and elsewhere volunteering their time. Unfortunately, the medical and allied health curricula in less economically advanced countries often treat preventive aspects of chronic diseases lightly, or not at all.

Second, and in parallel with the in-tervention, a public awareness campaign would enhance enrolment and partici-pation. The facts about CVD, and how citizens, government and the private sector can prevent and treat it, should be communicated to everyone in the communities under study using all af-fordable communication methods and

strategies as described in the health promotion literature. Government’s role as a communicator, and not only a provider of care, is critical for each country’s health future. Health experts need to inform society about the grow-ing magnitude of CVD and the factors that lead to it. Informed citizens can then press for administrative and gov-ernmental support, through policy and legislation, to assist citizens to make wise pro-health choices.

Whatever choices those responsible for health systems and macroeconomics make for CVD prevention, an essential parallel activity is outcome assessment, best conducted by independent asses-sors. Those implementing these pro-grams should also measure the economic costs and benefits. National or regional programs of prevention should include enough money to measure effectiveness, say 15%–20% of total program budgets. Governments and health profes-sionals can then identify unsuccess-ful programs early and alter or stop them, or they can enhance successful programs and then transplant them with due adaptation to where they are needed next.


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F1. The sociopolitical context: instituting change in civil societies

The preceding analyses have demon-strated the size of the problem that CVDs present both now and for the next 20–30 years in countries that have not yet attained the levels of affluence. It is much worse than that experienced in the US and similar economically ad-vanced nations. These latter countries have moved through the worst of the CVD epidemic, at least as a cause of death before the age of 65, although it remains a major cause of death and dis-ability in later years. What is required in sociopolitical terms to make such an achievement likely in economically de-veloping countries, beyond the technical insights that underpin prevention and treatment in their various forms?

The changes that have occurred with the end of the Cold War provide us with many challenges and opportunities. Civil societies have become more common. Originally “civil society” was used to

refer to open societies and open econ-omies where the rule of law, popularly endorsed and enacted through demo-cratic institutions subject to the will of the people, governed both societal and economic life. Currently, the term has taken on a limited meaning to embrace that group of community-based, not-for-profit, non-governmental institu-tions or movements that engage in ei-ther service provision to communities or public advocacy. This definition ex-plicitly excludes the private sector from the institutional mix constituting civil society because it makes profits (1). This is not our meaning, nor do we believe it is an accurate definition of the term. By civil society, we mean the uncoerced free association of the totality of law-abiding individuals and institutions pre-sent in open societies and open econo-mies irrespective of their economic rationale or role (2).

For the past few decades, peoples in every geographic region have been ex-

periencing more open economies and more open societies. Since 1955, Free-dom House has produced assessments of the progress and occasional regress of political rights and civil liberties in na-tions around the world. Between 1979 and 2012, the percentage of countries that are free or partly free, in the sense of there being respect for civil liberties, wide scope for open political competi-tion, and freedom of the media, rose from 65% to 76%. The percentage of the world’s population living in free na-tions rose from 35% in 1973 to 43% in 2012. In 1986, there were fewer than 70 elected democracies in the world; by 2012 there were 117 (3).

These trends present a challenge and an opportunity for the management of chronic diseases including CVD in devel-oping countries. The challenge occurs in those societies that are not open, where reaction remains firmly in the hands of a few who ration information and resourc-es as they see fit. By contrast, in civil societies, two elements create a great opportunity.

First, information is widely avail-able, whether issued by governments, dug up by journalists, unveiled at pro-fessional meetings, or accessed on the internet. There may be questions about its quality, but not about its quantity. Second, people have the ability to or-ganise, assemble, and speak out, and not only to do so quietly at the ballot box once every few years. An open media, increasingly based on the internet, and freedom of assembly, together with a competitive political playing field, en-able constant public challenge of any-

thing that compromises deeply held values or hopes. Knowledge can become the motivation for the creation of new organisations (e.g., disease advocacy as-sociations), or the spur to widespread public demand for change (e.g., as the ranks of widows grow). As knowledge drops into a civil society pool, the rip-ples of change move outward across the societal surface, touching and changing diverse sectors (4).

Citizens and citizen groups can ap-ply pressure to governments to create pro-health policies through taxes (e.g., an excise tax on tobacco) and regula-tions. When government in a civil soci-ety institutes such measures in response to community advocacy, it is possible to counter the argument that they are interfering with individual liberties. The restrictions, taxes, health information or other social instruments put in place are in response to pressure from an in-formed electorate, and not imposed pa-ternalistically by a “big brother” govern-ment or a “nanny state”.

It is also true, however, that in free societies people can choose not to com-ply, especially where individual behav-iour change is concerned. In a centrally controlled political system, if the opti-mal programmatic solution to the ero-sion of health status is physical exercise, the system can mandate exercise. In an open society, policymakers can mandate to their hearts’ content, but the people may or may not respond. The levers of change are no longer in the hands of ministries, but individuals. However, governments may create environments where individual pro-health decisions

FROM ANALYSIS TO ACTIONF


become easier choices, and the pressures of interests that promote unhealthy food or tobacco smoking (5) can be re-stricted through government action, mandated by the electorate, and incen-tives offered for health promoting be-haviour, mediated through the social and economic environment.

There is a final element necessary to institute change in CVD in develop-ing countries – trust. If the public is to accept interventions that favour healthy choices and limit their freedom, through tobacco control strategies, food subsi-dies and pricing, including those applied to alcohol, trust is crucial. Society must have grounds to trust government agen-cies, health officials, health care profes-sionals, academia, and the media. If the public is to trust information on differ-ent health risks (less animal fat, less salt, more fish) and treatments (medications for hypertension), the information must come from respected professionals, em-powered consumer groups and profes-sional bodies. The public must see the information as being free of political bias and of conflicted interest. Promo-tion of vegetarianism may receive sup-port from many religious groups who have influence in the society.

Trust also operates as govern-ments build relationships with new partners, including business, organised labour, social security systems, and insurers, which may all be critical partners in the fight against a ris-ing tide of chronic disease. Devel-oping country ministries or depart-ments of health will need to become more permeable to private initiative,

which currently accounts for half of all health care resources, as well as public concern (4,6). There is a realisation about the role of private health care systems in developing countries like India. The In-dian government has initiated programs that encourage public–private partner-ships in many health-related areas.

What does this mean for health care systems under conditions of a growing chronic disease burden, especially of CVD, and spiralling death rates within the working age population? To the ex-tent that civil society exists in a country, clearly, facts about CVD will become public knowledge and lead to public action, particularly among the best-in-formed at-risk population – urban fami-lies.

In societies with well-informed citizens, this in turn may lead to the emergence of interest groups, such as heart associations or anti-smok-ing lobbies. These groups represent a health system opportunity. Such interest groups and voluntary or-ganisations, ubiquitous in civil socie-ties in developed countries, provide both an outlet for information and public education, and a means for channelling individual concern into productive societal change. Inter-est groups can campaign for greater action, including support for all indi-viduals to have equitable access to essential medications that can substan-tially reduce risk.

But the problem of CVD in the de-veloping world lies in areas such as slums (both rural and urban), small rural townships and villages. Literacy levels in

these areas are low, so the penetration of information about CVD will be mini-mal compared to the developed world. This may perpetuate health inequities. Therefore an approach that reaches from the highest levels of macroeconomic de-cision making to individual citizen voli-tion, assuming realistic responsibility for their health, has much to commend it.

Interest groups can also be important conduits by which health systems can influence other sectors of government in support of health. They can carry the message to ministries of finance and other executive offices that the pub-lic values increased resource commit-ments to health care. In so doing, they can influence non-health settings to consider health impacts, and can do so perhaps at times more effectively than government advocates for health care budgets. Alongside this, they can also educate the public, motivate behaviour change and encourage compliance with therapeutic programs that prevent life-threatening incidents. Their presence, and their access to information and to large numbers of concerned individu-als, can result in heightened demands for government responsiveness and ac-countability.

In relation to chronic diseases such as CVD, governments in open societies in developing countries will increasingly find themselves held accountable for re-versing rising risk factor prevalence and death rates by coalitions whose con-stituents are most affected by CVD. The interest groups may also lobby them heavily to provide high-tech care. The citizenry will not just generally expect

accountability; it will specifically de-mand it. For government public health leaders, the existence of private interest groups and professional organisations dedicated to chronic diseases will result in public expectations of health policy and health service responses that are fo-cused and articulate.

In the case of CVD, where risk fac-tors are well recognised and a range of effective interventions available, there will be strong pressure on governments to respond. There is a growing literature on the process of translating knowledge of the environmental determinants of NCDs, especially CVD, into effective health policy. In civil societies, people do choose, but unless we take care in attending to the environment, broadly defined, then healthy choices become difficult choices (7). Part of the chal-lenge is to provide timely and convinc-ing information about these interven-tions, including the opportunity cost of intervening and not intervening, to those who are making public policy de-cisions day by day.

These responses require governments to move beyond the bounded notion of health systems and health departments populated by health professionals who operate solely in terms of their technical expertise. There has been a tradition in developing countries that governmental public health departments focus on con-trolling communicable disease threats (engaging in environmental control, running mandatory immunisation cam-paigns, isolating disease outbreaks to prevent their spread) and on improving access to clean water and healthy food.


However, with chronic disease, macroe-conomic decision making and individual behaviour and its social determinants are the principal concerns. In the future, public health departments will need to respond to NCD threats by participating in economic debates to help establish agendas that take due account of these health needs of the community.

Building relationships with new partners may prove difficult for some. But the need for change is also an op-portunity. The opportunity allows for the building of new coalitions for health and health care that are more powerful and effective than those that exist at present. Partners who speak from the podium of business, labour, and finance can raise the visibility of health care in arenas where policymak-ers make decisions about fundamental economic priorities and policies. That indeed would be a novel opportunity for global health.

F2. CVD as a macroeconomic challenge The first edition of this report grew out of the commission on macroeconomics and health. Our argument is that in low- and middle-income countries, NCDs should be included along with commu-nicable diseases when health is elevated to a matter of macroeconomic interest. We have shown that CVDs warrant in-clusion because of their immense impact as causes of death and disability, espe-cially among people of working age and among women. CVD hits the workforce directly and indirectly and undermines family viability in many developing countries, and these blows will fall more

heavily in the future. Retired people will experience CVDs as a cause of morbid-ity as population’s age and the ranks of those aged 65 years and older increase dramatically in the next 20–30 years. Health services and social security sys-tems will be especially affected.

We commend our report to the at-tention of those many interested in-dividuals in countries that are going to bear the brunt of CVD in the coming decades. They can do much to amelio-rate CVD, but it is a race against time: strategies to reduce risk exposure and treat those at high-risk need immedi-ate application to achieve their best effects, in the workforce now and with older citizens in the next two decades. Therefore, countries need to develop CVD control strategies now to maintain health and reduce costs. CVD control should therefore be an important part of a comprehensive macroeconomic approach to development. Economic benefits will flow from CVD prevention because of the immediate impact pre-vention will have on workforce mortality and morbidity.

What can prudent decisionmakers, such as those who work in the ministry of health and the ministry of finance, expect to gain from a CVD prevention program? Existing cost-effectiveness and economic data need to be refined country by country (7). A prudent course of action would be for every civil society to examine carefully the cardiovascular health impact of macroeconomic deci-sions that pertain to agriculture and food production and marketing, and tobacco control (8). Participation in international

efforts to curtail tobacco consumption has been justified in multiple analyses, and one of the benefits of smoking ces-sation is an immediate reduction in CVD risk (9).

We should approach this problem aiming for a long-term solution not as a problem of health care, but as a chal-lenge in which health is intertwined with economics, education, culture, and hu-man behaviour. The old mould of pub-lic health as a health sector function must be set aside and replaced with one that sees health as a critical invest-ment that reaches deeply into the econ-omy and larger community to involve both the leaders and the levers with influence on the origins and solutions to the problem.

F2A. Who should be at the table? A national CVD effort must involve health leadership, both from public health and from the medical services professions. But also (and equally) need-ed at the table are:• opinion leaders from all levels of

business, in recognition of the im-pact of CVD on the workforce and because some sectors (e.g., food production and sales) are important for CVD control;

• representatives from cooperatives, organised and unorganised labour;

• private financial institutions to ad-dress capital needs for health infra-structure;

• public financial institutions (minis-tries of finance and central banks; as the future of labour productivity is at risk, the costs of doing nothing

will be tremendous, and the policies that might be needed to alter the costs of risk behaviours are under the control of public finance);

• social security system managers and private insurers, who will pay the direct price of disease and dis-ability;

• representatives of the education sector at all levels (as prevention must start with behaviour change and behaviour change starts with knowledge and attitudes);

• community groups with particular levers on the problem (women’s groups, health lobby groups, ath-letic groups and clubs);

• communications firms or agencies, whose expertise will be an asset in any effort to change opinion, atti-tudes and behaviour; and

• professional associations of doctors, national regulatory agencies of doc-tors eg. medical councils, medical research donors and regulators.

F2B. What should be on the agenda? The national coalition brought together under the auspices of the national mac-roeconomic commission if it exists, or the mechanisms developed in response to the UN General Assembly resolution or a similar agency if the above does not exist, will need to address the CVD prob-lem in all its dimensions, from roots to consequences. Their discussions will not always be easy, and will risk a clash of vested interests.

An agenda would need to list the problem initially. This would involve: • determining its severity and spread;


• identifying its roots in the demogra-phy, culture and risk behaviours of that country; and

• identifying the policies, norms and economic and social structures that support those risk behaviours.

Attention could then turn to what has been done about the problem to date, and how much success or failure has followed. There should be care-ful study of what the citizenry know about CVD and what they do not know and should know.

It would also be important to focus on the vested interests that may aid or hinder the creation of a solution to the problem. These vested interests may include competing economic priorities (e.g., tobacco companies), private-sec-tor practices not conducive to health (5), health services themselves, and the structure of social security payments and the various social support systems (informal) that operate in that country. These will be difficult discussions and will raise questions of resources, costs, and burden sharing. They will require private and public collaboration and compromise. It would be desirable to enunciate all barriers, including those that are economic, that have to do with trade, that are cultural and political, and those that are due to prevailing regula-tory systems.

The group should then consider the costs of not acting – in human health and economic terms. Identi-fying political costs both of acting and of doing nothing may also prove to be helpful.

F2C. What resource pools do national leaders need to mobilise? We know that resources in the develop-ing world are limited (10), so they must be properly used. If these discussions are to be more than theoretical, those in charge of resources must put them on the table. These people must be rep-resented in, and see themselves as co-owners of, the solution. Resources con-cern and include more than just health budgets. They extend to those in minis-tries of social security and social welfare, industry, finance, labour, youth affairs, planning, housing, and agriculture. They also extend to the private sector, both private industries and financial houses.

Philanthropy is also a potential re-source. In many middle-income coun-tries, private philanthropy is emerging as a powerful force in community develop-ment and in health and education. Do-mestic philanthropy (and international, to the extent that it is interested) is a pool to be assessed and involved.

Where a country receives inter-national development assistance, the group in charge of NCD prevention and control should consider that as another resource. By and large, however, inter-national development agencies do not have health assistance policies that are conducive to public-private collabora-tion in chronic disease control. In most cases these activities will entail a change of policy regarding the definition of health care and what constitutes health leadership.

But, if a national macroeconomic commission and its opinion leaders can organise a coalition, define the problem,

commit to a solution, and mobilise lo-cal resources to begin to implement the solution, bilateral and multilateral agen-cies will have little option but to follow.

Different countries may take differ-ent approaches, combining population-based prevention and clinical prevention in unique ways. But to do nothing will put governments and their leaders in the untenable position of accepting high lev-els of death and disability both now and in future.


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Despite the alarming rise in the bur-den of CVDs in lower middle-in-

come countries, several well-established strategies and approaches to prevention provide us with rays of hope. Strong ad-vocacy by several non-government or-ganisations working together in the NCD Alliance (1) and concerned academics such as the Lancet NCD Action Group (2) with the support of many nations and the WHO culminated in a high-level meeting of the UN General Assembly concerning NCDs. Held in September 2011, the meeting led to the formula-tion by the UN and WHO of comprehen-sive goals and plans aimed at reducing the global burden of NCDs. In addition, the governments of the five countries examined in this report have signalled their intentions by either formulating programs or policies aimed at NCDs or by taking steps towards implementation of such policies.

This chapter highlights and analyses the potential impact of such initiatives.

G1. International initiativesUN initiatives G1A. High-level meeting of the UN General AssemblyThis was a landmark in the global fight against CVD and other NCDs. The Po-litical Declaration on the prevention and control of NCDs was adopted on 16 September 2011. This was just the sec-ond time when the UN had organised such a meeting on a health matter (the first being in relation to HIV), signify-ing the growing recognition of the im-portance of NCDs in the health agenda of the Member Nations. The gathering comprised high-ranking officials from 120 nations; several private players; in-ternational organisations, such as the WHO; and non-government organisa-tions, such as the NCD Alliance and World Heart Federation (as a member of the NCD Alliance) (3).

The declaration called on the UN General Assembly’s 193 Member States to draw up voluntary national plans to tackle NCDs and committed the WHO

REFERENCES


RAYS OF HOPEG

to establish a global surveillance network for a set of global targets before the end of 2012 to monitor trends and report progress on activities to reduce death and disability from NCDs (4). The dec-laration recognised the immense health and economic burdens imposed by NCDs on all nations, especially low- and middle-income countries (5).

The declaration incorporated rec-ommendations made by government and non-government organisations and stressed research, development and in-ternational cooperation in controlling NCDs (5). The UN Declaration implied that an operational partnership to this effect should be in place by early 2012. In addition, it proposed that existing mechanisms should be strengthened to assure cooperation within the UN sys-tem itself; that the active involvement and cooperation of the UN Develop-ment Programme, the Food and Agricul-ture Organization, UNICEF (the UN In-ternational Children’s Emergency Fund), and the International Labour Organiza-tion were vital to achieve the necessary multisectoral approach demanded by NCDs (5).

Following the mandate from the UN High-level Meeting, the WHO con-sulted with Member States and other stakeholders in 2012 around a set of ten suggested targets. This process cul-minated in a formal Member State con-sultation at WHO in Geneva during 5–7 November 2012 (6).

The session was attended by repre-sentatives of 119 Member States and many non-government organisations. The revised WHO discussion paper, de-

tailing a comprehensive global monitor-ing framework (including indicators) and a set of voluntary global targets for the prevention and control of NCDs as well as a report summarising the results of the discussions in each of the regional committees, were considered by Mem-ber States (6). The indicators and global targets agreed upon by consensus were integrated into a draft WHO Global Ac-tion Plan for the prevention and control of NCDs for 2013–2020 (6).

This plan was submitted to the 66th World Health Assembly, held on 27 May 2013, where the Member States adopt-ed an “omnibus resolution” on NCDs (7). This resolution included the endorse-ment of the WHO Global Action Plan for the prevention and control of NCDs from 2013 to 2020 (8).

The action plan comprised a global monitoring framework which, when adopted collectively by Member States, UN organisations, other international partners and WHO, will set the world on course to achieve nine globally agreed targets for NCDs. The plan also detailed ways for reducing premature mortal-ity from NCDs by 25% by 2025 and a monitoring framework including 25 indi-cators to track mortality and morbidity, assess progress in addressing risk factors and evaluate the implementation of na-tional strategies and plans (8).

The WHO developed the draft terms of reference for a global coordination mechanism through a consultative process and the document was accepted by the World Health Assembly in May 2014.

WHO is also tasked to provide tech-

nical support to Member States and to develop a limited set of indicators to inform on progress made with the im-plementation of the action plan in 2016, 2018 and 2021, during the 68th, 71st and 73rd World Health Assemblies (8).

The UN general assembly at its high-level review meeting on July 10 and 11, 2014, took stock of the progress achieved in the prevention and control of NCDs since September 2011. The meeting re-affirmed the commitment to address the global burden and threat of NCDs.

G1B. World Health Assembly endorsing new health goal (“25 by 25 goal”)The 25th session of the World Health Assembly took place in Geneva during 21–26 May 2012. It endorsed a new health goal pertaining to NCDs – to re-duce avoidable mortality from NCDs by 25% by 2025 – the “25 by 25 goal”. This builds on the UN General Assem-bly 2011 political declaration on NCDs though it is seen by many as highly am-bitious (9).

G1C. UN Conference on Sustainable Development – 2012 (RIO+20 – “The future we want”) The tight connection between the forces that threaten climatic sustainability and challenge equitable global development and the risk factors for NCDs and CVD in particular, meant that the Rio+20 agen-da was of great interest to NCD control advocates. The Rio+20 conference ac-knowledged that the global burden and threat of NCDs constitutes “one of the major challenges for sustainable devel-

opment in the twenty-first century”. The conference agreed to recommend strengthening health systems with the goal of providing equitable, universal coverage and to promote affordable ac-cess to prevention, treatment, care and support related to NCDs, including CVD and diabetes (10) not only for reasons to do with human health but because of the contribution that these changes could make to human flourishing and global sustainability more broadly.

G1D. UN Resolution on Global Health and Foreign Policy – 2012The 2012 UN resolution on global health and foreign policy also acknowledged the need to continue to promote, es-tablish or support and strengthen mul-tisectoral national policies and plans for the prevention and control of NCDs. The resolution recognised the importance of universal health coverage in national health systems in this regard.

WHO initiatives The WHO has been active for decades in proposing programs aimed at preven-tion and control of NCDs, as we elabo-rate below. These initiatives in the new millennium contributed substantially creating the background environment for the UN General Assembly Meeting on NCDs (see above).

G1E. Global NCD Action Plan This was endorsed by the World Health Assembly in May 2000. Its three foci were: (1) mapping the NCD epidemic and determinants; (2) reducing the level of exposure of individuals and communi-


ties to the major NCD risk factors; and (3) strengthening health system care for people with NCDs (11).

G1F. Global Strategy on Diet, Physical Activity and Health – 2004After six regional consultations held with Member States and organisations of the UN system, other intergovernmental bodies, representatives of non-govern-ment organisations, the private sector and a reference group of independent international experts on diet and physi-cal activity from the different WHO re-gions, a document on the Global strategy on diet, physical activity and health was promulgated in 2004 (12). The strategy addresses ways of modifying two of the main risk factors for NCDs, namely, diet and physical activity.

The document recommends a multisectoral approach that mobilises the combined ener-gy, resources and expertise of all global stakeholders (12).

G1G. 2008–2013 Action Plan for the Global Strategy for the Prevention and Control of Non-communicable DiseasesThis initiative from the WHO was di-rected at the international community as well as individual governments to sensi-tise them to the need for urgent action to enact chronic disease prevention and control programs. The document pro-vided a policy framework for action and outlined a series of objectives and action items for key stakeholder groups at vary-ing levels of the global health system.

It urged WHO Member States to develop national policy frameworks, es-

tablish prevention and control programs, share their experiences and build capac-ity to address chronic diseases. The plan focused on low- and middle-income countries. This action plan was endorsed by all 193 member states during the 61st World Health Assembly, held in May 2008 (13).

G1H. The Doha DeclarationIn May 2009, the Western Asia Ministe-rial Meeting, organised under the aus-pices of the UNESCO (UN Economic and Social Council), the WHO and the Social Commission for Western Asia (ECSWA), and hosted by the Qatar government, adopted the Doha Declaration on Non-communicable Diseases and Injuries. It also called for a review of international experience in the prevention, control of NCDs and injuries in low- and middle-income countries, including commu-nity-based programs, to identify and disseminate successful approaches for intersectoral action (14).

G1I. Framework Convention on Tobacco ControlThis treaty was adopted by the World Health Assembly in 2003 and has been ratified by more than 170 countries. The Framework Convention on Tobacco Control (FCTC) encourages the coun-tries to strengthen their tobacco control policies by enacting price regulations, taxation, regulatory, and social meas-ures to reduce demand. The treaty rep-resents a major milestone in the global fight against tobacco and has prompted much international collaboration around tobacco control (15).

Currently, 170 countries are sig-natories to the WHO FCTC, covering 87% of the world’s population. A top priority of the UN High-level Meeting on Non-Communicable Diseases was to strengthen political resolve for more complete implementation of FCTC and to adopt its protocols with the ambi-tious goal of a world essentially free of tobacco (prevalence < 5%) (2).

G1J. The MPOWER InitiativeMPOWER (WHO, 2008) builds on the WHO-FCTC guidelines with six prov-enly effective policy recommendations. The six recommendations (the first let-ters of which roughly form the acronym MPOWER) are: • monitor tobacco use and preven-

tion policies; • protect people from tobacco smoke; • offer help to quit tobacco use; • warn about the dangers of tobacco; • enforce bans on tobacco advertis-

ing, promotion and sponsorship; and • raise taxes on tobacco.

According to the WHO report on the global tobacco epidemic 2013 (16), more than 2.3 billion people – one-third of the world’s population – are now protected by at least one of the MPOWER measures. Nearly one billion people are protected by two or more measures. The report also claims that an additional three bil-lion people are covered by national mass media campaigns (16).

G1K. World Health Assembly resolution on the global strategy to reduce the harmful use of alcoholIn May 2010, the World Health Assem-

bly adopted the global strategy to reduce the harmful use of alcohol in its declara-tion. The declaration urges the Member States to adopt and implement the glob-al strategy to reduce the harmful use of alcohol as appropriate in order to com-plement and support public health poli-cies in member states and to mobilise political will and financial resources for that purpose (17).

G2. Group and regional initiativesG2A. European Parliament declarationThe European Parliament in a declara-tion (18) on the eve of the UN High-level Meeting on NCDs, called on the EU and its Member States to endorse the following five key commitments and in-clude them in the political statement to be issued at the UN High-level Meeting on NCDs: • Reduction of preventable NCD mor-

tality by 25% by 2025, as proposed by the WHO.

• Implementation of cost-effective and cost- saving interventions.

• Monitoring of trends in NCD mor-tality and the common risk factors for NCDs.

• Development of global and national accountability mechanisms for all key stakeholders involved.

• Establishment of a high-level part-nership in 2012, to foster the im-plementation of the recommenda-tions and the organisation in 2014 of High-level Meeting to review the degree to which commitments have been honoured.

G2B. The Parma Declaration on


Environment and Health The Parma Declaration was adopted by the 53 Member States of the WHO Eu-ropean Region in March 2010 (19). The declaration recognised the burden of NCDs, and in particular the extent that it can be reduced through adequate poli-cies in areas such as urban development, transport, food safety and nutrition, and living and working environments.

G2C. CARICOM Summit Declaration – 2011Deep concern was raised about the im-pact of NCDs in the community at the meeting of the Heads of Government of the Caribbean Community (CARICOM) during their 2011 meeting in Port-of-Spain (20). The meeting welcomed the adoption of the Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-Communicable Diseases, held in New York in September 2011, and em-phasise the need to strengthen action and partnerships aimed at realising the commitments contained therein.

In this regard, the meeting reaf-firmed the commitment to addressing four diseases – diabetes, CVD, chronic respiratory illnesses and cancer; four risk factors – tobacco, diet, physical in-activity and inappropriate alcohol use; and four strategic approaches – risk factor reduction, health system re-form, equitable access to effective af-fordable medications and improving surveillance, and program monitoring and evaluation.

In an earlier summit in 2007, a 14-point Action Plan on Non-Com-

municable Diseases was adopted by the meeting of the CARICOM dur-ing their 2007 September Summit on Non-Communicable Diseases at Port-of-Spain (21).

The declaration documented com-mitment from the heads of government to give full support for the initiatives and mechanisms aimed at strengthen-ing regional health institutions; immedi-ate pursuance of a legislative agenda for passage of the legal provisions related to the International Framework Convention on Tobacco Control; and development of public education programs on lifestyle management. The declaration also stat-ed that the public revenue derived from tobacco, alcohol or other such products would be employed for preventing NCDs thereby promoting health and support-ing the work of the commissions.

Additionally, the declaration called for mandatory re-introduction of physi-cal education in schools, providing in-centives and resources to effect this policy and ensuring that the education sectors promote programs aimed at pro-viding healthy school meals and promot-ing healthy eating (21).

G2D. Commonwealth initiatives The Commonwealth Heads of States and Governments, which represents one-third of the world’s population, met in Port-of-Spain in November 2009 and issued a statement on Commonwealth action to combat NCDs. The meeting resolved to work towards reducing the incidence of NCDs by fostering multi-sectoral policies and community-based initiatives to discourage tobacco use and

unhealthy diets and to promote physical activity (22).

G2E. NHLBI international research initiatives in non-communicable diseasesFunded (US$34 million over 4 years) by the National Heart, Lung and Blood Institute (NHLBI) of the US National Institutes of Health and UnitedHealth Group, 11 collaborating centres of ex-cellence were supported to conduct re-search into NCDs commencing in 2009. The centres are located in Argentina, Bangladesh, China, Guatemala, India-Bangalore, India-New Delhi, Kenya, Peru, South Africa, Tunisia and along the border of the US and Mexico (23). The success of this venture is yet to be es-tablished, and global financial instability is a threat to its future.

G3. Country-specific initiativesIt is reassuring that many countries with a large burden of NCD have recognised the magnitude of the problem, and have responded with programs to com-bat NCDs. In the following section we summarise NCD prevention initiatives in the five study countries described in our report.

G3A. BrazilHealth care reforms in Brazil began in 1988 as part of a broader sociopolitical movement after nearly 20 years of mili-tary rule. The new constitution, which was guided by principles of political de-centralisation and community partici-pation, laid the foundation for the Sis-tema Único de Saúde, or Unified Health

System. This marked the beginning of a nationwide shift from tertiary centre-based health care to comprehensive primary health care (24,25).

The Family Health Program, which was initiated in 1994, is the main pro-gram relevant to the control of CVD and other chronic diseases. Through it, com-munity health workers identify prob-lems in chronic disease management and medication adherence. They sup-port healthy lifestyle choices through home-based health promotion and edu-cation, provide continuously updated population registers and ensure disease surveillance. Finally, they also identify simple acute health problems that can be dealt with in the home (24,25).

The Brazilian Center for Chronic Dis-ease Control (CDC), Brazil’s Ministry of Health (MOH), and the World Bank initiated the VIGISUS (Disease Surveil-lance and Control Project) which seeks to improve and strengthen the national disease surveillance and control system to reduce mortality and morbidity. This is a systematic process (VIGISUS I,II and III) that will help develop public health infrastructure for NCD prevention in Brazil.

In 2006, the National Health Promo-tion Policy was published and a com-prehensive chronic disease risk factor surveillance system (VIGITEL – Surveil-lance of Risk and Protective Factors for Chronic Diseases Telephone Survey) was created with technical support from the University of São Paulo School of Public Health and the Brazilian CDC (26).

Strong legislation and a government-led nation-wide decentralised program


with support percolating down from the different levels of the government re-sulted in a successful anti-tobacco pro-gram in Brazil (27). Available evidence indicates that a significant decline (50%) in smoking (28) and total cigarette con-sumption per adult has occurred in the past 20 years since the early 1990s (29).

Brazil started a CVD prevention pro-gram in São Paulo, where the prevalence of CVD was high. The Agita São Paulo was based on community organisa-tion initiated by Victor Matsudo. The program was aimed at spreading the information on the benefits of physical activity and thus getting the populace moving. When the program was shown to be successful, it was extended to oth-er areas of Brazil as the Agita Brazil.

In 2001, Brazil initiated a nation-wide population screening program for diabetes where citizens aged 40 years or older were invited to participate. This demonstrated the feasibility of a screen-ing program, within the context of an organised national health care system, for chronic diseases (30) although as with most screening programs a posi-tive therapeutic outcome is yet to be demonstrated. Another program called the National Survey on NCD Risk Fac-tors was implemented in 27 states in 2003 (31). The results of this program are also unknown.

In 2000, the Agency for Food and Drug Administration in Brazil (ANVISA) began to implement its National Policy on Food and Nutrition. Food labelling was made mandatory and is similar to that in the US. The rule was formulated to mandate inclusion of nutritional In-

formation to be set by portion of food expressed by its respective “household measurement”, for example, cup, table-spoon, teaspoon etc (31).

Realising the higher prevalence and incidence of CVD among men, the Brazilian Ministry of Health, with the support of several medical so-cieties, including the Brazilian Soci-ety of Cardiology, implemented the National Policy of Primary Attention to Men’s Health (PNAISH) in 2008. This policy has the objective of promoting the health and decreasing the premature death of male individuals which includes cardiovascular diseases (32). The basic principle of PNAISH is the guidance of health actions and services for men aged between 20 and 59 years through health promotion acting through the primary health system (33).

Another initiative is the GUIA project (Guide for Useful Interven-tions for Physical Activity in Brazil and Latin America). It was reported that participation in the community physical activity promotion programs was associ-ated with meeting recommended levels of physical activity in leisure time (34).

These programs in Brazil have been accompanied, from 1996 to 2007, by a 20% fall in NCD mortality mainly due to a 31% reduction in CVD mortality (35). Smoking prevalence also decreased dra-matically by 51% from 34.8% in 1989 to 17.2% in 2009 (35,36). In 5 years, hospi-tal admissions due to diabetes or stroke decreased by 25%.

The above statistics and facts show that Brazil has adopted a cost-effective, large scale primary health care program

that addresses the public health prob-lems typical of low income countries and those undergoing the epidemio-logical transition (24,25,37). The high rate of economic growth of Brazil in the same period also might have contrib-uted to the effect. Other countries that face the same problems should look into this Brazilian model of primary care for inspiration (38).

G3B. ChinaThe National Centre for Chronic and Non-Communicable Disease Control and Prevention (NCNCD) was estab-lished in 2002, under the leadership of the Chinese Centre for Disease Preven-tion and Control, which is the technical counterpart of the Ministry of Health. The NCNCD is the institution for chron-ic disease prevention and control at the national level, and is responsible for sur-veillance and population-based inter-ventions (39).

Data regarding the incidence and prevalence of CVD have been collected from different parts of China (40-42). Following the framework of the WHO STEPs Surveillance system, the first Na-tional Risk Factor Surveillance Survey was conducted in August, 2004.

The China Cholesterol Education Program started as a national survey ap-proved by the Ministry of Health of Chi-na in 2004, as one of the Top 100 Pro-grams in the Future Decades. It aimed at investigating dyslipidaemia and to pub-licise therapy aimed at reducing choles-terol levels in China (43).

China signed the WHO FCTC in 2004, signalling a change of atti-

tude of Government toward tobacco control (44). In December 2012, the first tobacco master plan for Chi-na, the Tobacco Control Program 2012–15, was initiated by the Chinese government. It includes an ambitious target of reducing the adult smoking rate from 28.1% in 2010, to 25% in 2015, a relative reduction of approxi-mately 10% (45).

Despite these positive developments, we should recognise the China National Tobacco Corporation is the world’s larg-est single producer of tobacco products, producing 40% of the world’s cigarettes, and that it is protected by the govern-ment. There are also no smoking bans in public places except for few locations in Beijing and Shanghai. Tobacco taxes in China are among the world’s lowest.

The National Initiative of Healthy Lifestyle for All program, is a gov-ernment-initiated program imple-mented through the China Centre for Disease Control network country-wide. It commenced in 2007 to promote healthy lifestyles among the Chinese population. The relevant health promo-tion activities are implemented in most Chinese provinces (46). For example, salt reduction is a primary theme for the next 2 years in this program (47).

In addition, several innovative and novel approaches are being evaluated by academic, private and not-for-profit organisations. For example, the NHLBI-funded China Centre of Excellence is evaluating two novel intervention pro-grams through the China Rural Health Initiative. The programs are detailed be-low. (48).


The Healthcare Provider Program is a primary care-based program seeking to enhance the identification and the need for medical management of individuals at high cardiovascular risk. Part of this plan will be the temporary assignment of doctors to the countryside. The gov-ernment will provide most of the fund-ing, with some small contributions from the public, so that the goal of universal health coverage can be achieved.

The Community Education Program aims to reduce salt consumption in the population. The program is developing strategies that include working with vil-lage doctors, store owners and people in the community. The education com-ponent of the program is focusing on healthy habits, behavioural change and alternatives, such as the use of salt sub-stitutes (48).

The Chinese government has launched a China National Plan for NCD Prevention and Treatment (2012–2015) (49).

The Healthy Cities Initiative, led by local Governments and collaborating ef-forts from various other governmental departments, is spreading from major cities to minor cities needs mention. An example is the Healthy Beijing Action Plan (2009–2018). Under this initiative a series of goals, such as 10% reduction in NCD mortality and a 25% reduction in smoking prevalence, have been set.

Even though some of the unpub-lished reports claim to have very good success with these programs, we have to wait for hard data to be reported (39).

G3C. India

The Indian Government initiated pro-grams in the late 1980s aimed at NCD control, which were limited due to lack of funds. An example is the National Diabe-tes Control Programme that was started on a pilot basis in 1987 in districts in three states. Due to paucity of funds in subsequent years this program could not be expanded (50).

Years of advocacy, largely by phy-sicians interested in CVD prevention (51,52), led to the initiation of a national program for the prevention and control of diabetes, cardiovascular diseases, and stroke. The CVD prevention program was entitled the National Programme for Prevention and Control of Diabetes, CVD and Stroke (NPDCS) commenced in 2008 as a pilot study in 10 states in 10 districts. It is managed through the National Rural Health Mission (NRHM), a division of the Health Ministry (53). The crucial strategies under NRHM have been the integration of Family Welfare and National Disease Control Programs under an umbrella that seeks to optimise resources and manpower, strengthen outreach services by incorporation of a minimally trained village health worker, and strengthen and upgrade the public health infrastructure to Indian Public Health Standards (54).

The focus of the NPDCS is health promotion and prevention, strengthen-ing of infrastructure including human resources, early diagnosis and manage-ment and integration with the primary health care system through NCD cells at different levels for optimal opera-tional synergies (55). The strategies of NPDCS are aimed at three areas in so-

ciety: schools; community; and work-place. Rainbow Ribbon clubs – health clubs that increase awareness among children about CVD and its risk factors are established in each school. In work-place and community, activities revolve around conducting medical camps that will screen patients to rule out CVD and its risk factors and for imparting health education.

The main objectives of the Indian NPDCS are:• Promotion of healthy lifestyle

through massive health education and mass media efforts at country level, opportunistic screening of persons above the age of 30 years.

• Establishment of NCD clinics at community health centre and dis-trict level, development of trained workforce and strengthening of ter-tiary level health facilities.

• Screening of over 70 million adult population (30 years and above) for diabetes and hypertension, early di-agnosis of NCDs and treatment at early stages.

• To fill the gap in the health deliv-ery system, to train about 32,000 health personnel at various levels to provide opportunistic and targeted screening, diagnosis and manage-ment of NCDs (56).

The pilot project was completed successfully (successful in establish-ing certain systems in CVD control, although we don’t have any outcome measures) in October 2010, which led the government to extend it to more regions in the country. Subsequently, the program was extended to selected

districts in major states in India. An outlay of US$2.8 billion was allocated for the period from 2010 to 2012. The new program, which includes cancer, is renamed the National Programme on Prevention and Control of Cancer, Dia-betes, CVD and Stroke (NPCDCS) and is currently being implemented in 20,000 sub-centres and 700 community health centres in 100 districts across 15 states (53). Under the program, 8.7 million adults were screened until 2012. Of these, 6.7% were found to have diabe-tes and 7.7% had hypertension (57). The outcome of those screened and their follow-up is the key issue, for which we have to wait and see.

In April 2013, the Indian Health Min-istry announced plans to extend the NCPCDS program to all districts in the country from the current 100 districts during the ongoing 12th Five Year Plan (2012–2017) (57). Also, the success-ful program of providing free generic drugs which was implemented in certain states will be extended to the whole country.

Based on the success of the NRHM, the National Urban Health Mission (NUHM) was initiated on 1 May 2013 (58). This is expected to address the pri-mary health care needs of nearly 40% of the urban population living in slums and other poor areas, who are one of the important primary targets of CVD prevention. The NUHM is expected to cover all cities that have a population of more than 100,000 (59). In the Un-ion Budget of 2013, it was proposed to integrate both NRHM and NUHM into a single initiative – the National Health


Mission – incorporating all the programs envisaged under NRHM and NUHM.

India, which is second only to China in global tobacco consumption, is waging a battle against tobacco. The Supreme Court of India ratified an order banning smoking in public places in 2001. India ratified and signed the FCTC in 2003.

The National Tobacco Control Program (NTCP) was started as a pi-lot program in the state of Assam in 2007. Subsequently it was extended in 2007–08 to 18 districts of nine states and in 2008–09, 12 new states cover-ing 24 districts were added to the pro-gram. Even though the budget alloca-tion for the NTCP was made in 2007, the cabinet approval for the NTCP was given only in January 2010. Ulti-mately, the NTCP is expected to cover the entire country.

G3D. RussiaContributed by Nana Pogosova, MD, Pro-fessor, Head, Federal Health Center and Department of Internal Diseases Preven-tion, National Research Center for Pre-ventive Medicine, Moscow, Russia.Russia has one of the world’s highest rates of CVD mortality, as we have dis-cussed. The prevalence of risk factors is also very high and it has not fallen in the past 40 years, especially the prevalence of smoking.

Alcoholism is a problem with a very high impact in Russia. The results of the analysis suggest that 41.1% of all deaths among men and 30.7% of deaths among women from ischaemic heart disease (IHD) in Russia could be attributed to alcohol (60). Even though

alcohol-related deaths have come down from 800 per 100,000 men in 1994 to 290 per 100,000 by 2002, this rate is still higher than nearly any other nation (61). The Russian government enacted a new law on regulation of the production and turnover of ethyl alcohol and alcohol-containing products, which was signed by President Putin on July 2005 (62). These measures are not very success-ful, and the Putin government has come out with tougher measures and a na-tiowide campaign against alcoholism in 2012. The Russian parliament Duma has banned internet alcohol advertisements, and raised the legal age of drinking from 18 to 21 years (63).

The Russian government has recog-nised the importance of the problem of CVD and has started the Priority State Project “Zdorovie” (“Health”) in 2006, including various programs to combat the problem of CVD. The State Law on Health Protection in citizens of the Rus-sian Federation, endorsed by the Parlia-ment in 2013, established the priority of NCDs prevention in Russian health care and its realisation through fed-eral and regional state programs on healthy lifestyle and risk factor con-trol with priority given to smoking and alcohol consumption.

The 13-country Global Adult To-bacco Survey (GATS), which monitored adult tobacco use and key tobacco-control indicators, provided the first evidence-based national data on to-bacco prevalence and other indicators from Russia. Results from 2009 from the GATS showed that 39.1% of Russians (43.9 million) were currently smoking

tobacco, of whom 60.2% were men and 21.7% were women (64). The Ministry of Health’s National Research Centre for Preventive Medicine estimates that 500,000 people die from illnesses relat-ed to tobacco each year, 80% of whom die in age below 60 years. About 40% of deaths from coronary heart disease among men are linked to smoking (65).

Russia joined the WHO’s FCTC in 2008, being one of the late signatories. Following this a law came into effect in 2010 that stated that at least 80% of the surface of a cigarette pack must contain information about tobacco harm. The Russian government increased health care funding, sixfold from 2001 to 2011, and programs designed to curb smoking and alcohol and to encourage healthy lifestyles have been launched. Recently, President Putin signed one of the most stringent laws in the world on smoking bans. According to this law, restrictions (e.g., smoking in medical and education-al institutions, airports and railway sta-tions), have started from 1 June 2013, A total ban on smoking in public places in Russia will come into force in 2015.

One of the first attempts in primary prevention of CVD in Russia is in the creation of 502 health centres for adult population and 193 health centres for children around the country, which were opened in 2009. People can attend these centres, free of charge. for basic health screening (including smoking sta-tus, obesity, blood pressure, blood glu-cose levels, cholesterol levels, electro-cardiogram [ECG]). Almost 5,000 doctors have been trained on healthy lifestyle counselling.

Promoting prevention and well-ness has been chosen as one of the key health priorities under the Bilateral Presidential Commission between the presidents of US and Russia, which was announced in July 2009, and chronic dis-ease prevention will be one of the key areas in this cooperation. The mortality trends for the period 2004–2010 show that there is decline in cardiovascu-lar disease mortality (66). Among men and women aged 45–64 years, reduc-tions in mortality from ischaemic heart disease contributed most to the rise in life expectancy; while at ages 65 years and older, reductions in mortality from cerebrovascular disease had the biggest impact. Since 2003 the cardiovascular mortality on the Russian Federation is decreasing, including a 21% decline in 2012 (66).

In spring 2013, the Ministry of Health of the Russian Federation started a large state-level program, called “dispanseri-zation”, which is a comprehensive health check aimed to evaluate non-commu-nicable, chronic diseases and their risk factors in adult population (above 21 years). The program has begun in out-patient clinics throughout all regions of the Russian Federation, and more than 23 million people will be involved.

G3E. South AfricaCause-of-death statistics indicate that overall mortality from NCDs has hardly changed in the past 10 years in South Africa (67), although reductions have been reported for certain risks, such as smoking (68,69).

The South African national health


and nutrition examination survey (SAN-HANES) is a national survey that is expect-ed to provide critical information to map the emerging epidemic of NCDs in South Africa. The survey is expected to bridge the gap of information about the current status of NCDs in the country. The first report (SANHANES-1) was released in August 2013 (70).

A national summit on NCDs was con-vened by the South African Ministry of Health in September 2011. The major outcome of the summit was that South Africa has set targets to radically reduce NCDs through a set of commitments and a strategic plan that addresses pre-vention, early detection, behavioural change and universal treatment. These targets were incorporated in the South African Declaration on the Prevention and Control of Non-Communicable Dis-eases, which was issued ahead of the UN Summit on Non-Communicable Diseases (67).

South Africa has several programs aimed at CVD prevention and con-trol. The anti-tobacco campaign in South Africa is one example. In South Africa, the first Tobacco Products Control Act was signed in 1993, which initiated many steps towards effective tobacco control policies. The Tobacco P roducts Control Amendment Act of 1999, signed by President Nelson Mandela, created one of the most effective tobacco control policies in the world. There were many issues with the law which needed further amendments, which were enacted in 2007 to ensure optimal tobacco control in the country. SA endorsed the FCTC in June 2003 (71).

The impact of the tobacco control policies was dramatic. Among South Africans, 15 years and older, the smok-ing prevalence decreased from 32% in 1993 to 24% in 2003. The largest reduc-tion in smoking between 1993 and 2003 occurred in men, African and coloured people, as well as in those with limited education and a low income (68). Anoth-er study that compared smoking preva-lence in 1998 and 2003 found that the daily or occasional smoking prevalence among women remained unchanged at 10%–11%; it decreased among men from 42% in 1998 to 35% in 2003 (69).

The South African Ministry of Health has issued mandatory regulations passed in March 2013, to begin in 2016, which will affect the salt content of processed food (72). This is expected to reduce the mean population intake of salt from the present level of 8–10 g/day to less than 5 g/day by the year 2020. A reduction in salt by 0.85 g/person/day is expected to have significant reductions in CVD deaths and stroke, and to lead to health care cost savings (73).

Recently, the Diabetes Strategy for Africa was launched, which calls upon governments, non-government organisations and industry to imple-ment this integrated approach to reduce the burden of diabetes in Africa (74).

Key elements of the strategy in-clude supporting patients to follow a healthy lifestyle with physical activ-ity, a healthy diet and no smoking. The plans also include the provision of adequate, appropriate and afford-able medications and supplies for peo-

ple with diabetes; earlier detection, optimal quality care of diabetes; and the dissemination of information and education in order to improve self-care (74).

Hypertension is identified as a ma-jor CVD risk factor in South Africa (75). South Africa has a national program for the control of hypertension at the primary level – which includes primor-dial, primary and secondary prevention strategies. The CORIS study was con-ducted in three towns in the South-Western Cape in white communities (76). This study developed a model of active community-based interventions set on the principles mentioned above. This showed that the intervention towns managed to achieve better blood pres-sure control than the non-intervention towns after 4 years.

A national NCD plan is being de-veloped by the government of South Africa, and a pilot project has been set up to initiate integrated care in the facilities of three districts (67).

G4. Combating NCDs: where are we?Despite the above mentioned numerous initiatives and efforts at reducing NCDs there are several challenges. Broadly, the challenges stem from: (a) percep-tions; (b) inadequate implementation of program plans; and (c) the pushes and pulls of multiple stakeholders and their vested interests.

G4A. PerceptionsThe principal focus of health programs in developing countries remains infectious diseases, such as HIV/AIDS and tubercu-

losis, and under-nutrition, while NCDs are commonly viewed as something that can wait (77,78) until the infectious diseases have been “controlled”. There are arguments that shifting the focus to NCDs; for example, by having a universal free health service access, will channel resources more towards the rich than to the poor (78).

There is ample evidence to show that risk factors of CVD are preva-lent in low socioeconomic groups at least to the same level as high so-cioeconomic groups, if not higher (79). For example, the studies done in the post-liberalisation era in India indicate that while once CVD risk fac-tors were highly prevalent among the affluent, now they are principally pre-sent among the less well off as well (79). The Bill and Melinda Gates Foundation do not include chronic disease in their remit. Even the 2010 UN summit on the 2015 Millennium Development Goals that included the announcement of major new commitments for initiatives against poverty, hunger and disease, contained no plans to target NCDs (80).

There are no initiatives to combat CVD comparable to the Global Fund to fight AIDS, Tuberculosis and Malaria.

G4B. Inadequate implementation of program plansWhile many programs for NCD and CVD control have begun virtually worldwide, implementation remains weak and limited. For example, the first wave of the GATS after the FCTC (16 countries, three billion people) has shown persis-tent high rates of smoking in men, early


initiation of smoking in women, and low quit ratios (81). Eight years after the adoption of FCTC by the world commu-nity in 2003, only 10% of global popula-tion have comprehensive national bans on tobacco advertising, promotion and sponsorship. Just some 15% of the glob-al population have a national compre-hensive smoking cessation service as of 2013 (16). Only 14% of the global popu-lation meet the best practice for picto-rial warnings in local languages that cov-er at least half of the front and back of cigarette packs (16).

China’s endorsement of the FCTC in 2005 has made little difference in China’s tobacco control, and the coun-try lags behind many of the targets pre-scribed by the FCTC (82,83). Although India signed the FCTC in September 2003 and ratified it in February 2004, much remains to be done. Legislation in 1975 that made health warnings on cigarettes mandatory was largely inef-fective (84).

In 2003, the Indian Government passed the Cigarettes and Other Tobacco Products Act. The bill offered comprehen-sive legislation for all tobacco products, developed after expert consultants iden-tified tobacco as a “demerit commodity” in India (84). Although the bill called for graphic warnings on cigarette packets and other tobacco products, these were not implemented until 2009 after many delays, and finally the high court had to achieve implementation (84).

In India, 165 million adults use smokeless tobacco. As per the WHO report on the global tobacco epidemic, 2011, none of the South East Asian Re-

gion countries, including India, currently meets the best-practice level for health warnings on smokeless tobacco prod-ucts (85).

There are problems regarding aware-ness about existing anti-tobacco legisla-tion among the general public in India (86). Awareness does not translate into effective implementation due lack of administrative support, lack of interest among the stakeholders, fear of public opposition, and lack of financial and hu-man resources (87). Lack of clarity in the program protocols, relatively few front-line health workers, and few physicians working in or interested in public health mean that progress is slow.

The best way to implement NCD control programs, as discussed else-where, is through the primary health care system. But as we know in India, the primary health care system is already over-burdened with all the national pro-grams channelled through it. Unless the existing system is strengthened NCD programs are also unlikely to succeed.

G4C. Multiple stakeholders and their vested interestsThe implementation of NCD prevention program can be easily impeded by the presence of multiple stakeholders and their vested interests. NCD prevention programs will always require coordina-tion between different ministries and department (88). This can lead to con-flicts and that can affect the smooth functioning of the program. For example, there is scepticism about the implemen-tation of the ambitious Chinese Tobac-co Control Program (2012–15), which

aims to reduce smoking prevalence by 10% in 3 years. One of the seven gov-ernmental agencies implementing the program is the State Tobacco Monopoly Administration, ironically the aim of which is to strengthen and improve the tobacco industry (89).

There are rays of hope, but we have a long way to travel on the journey of NCD and CVD control. With stronger political commitment it is possible to envision a global future where NCDs are reduced so that personal, national and global tragedies that today are attribut-able to them lose their force.


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and treatment regimes, consultations with governments, professionals and private industry, macroeconomic and microeconomic initiatives, and powerful advocacy of greater clarity to change in-dividual, social, legislative and commer-cial behaviour to make affluence less toxic in the developing world.

H1. Putting CVD in the developing world on the international health and development agenda We, those who are concerned about these issues, and those responsible, need to invest additional effort to in-crease recognition of CVD as an epi-demic, including advocating for its fur-ther inclusion in the strategic priorities of international health, economic and aid agencies. To this end, we should continue to present our findings at in-ternational meetings, and to partici-pate in global development and health initiatives where possible. CVD and other NCDs should be given top prior-ity among focal diseases for attention and we should maintain the momentum gained out of the UN general assembly declaration on NCDs.

H2. Deeper documentation of the prevalence and costs of CVD Our study has examined CVD in five de-veloping countries, using available data (which are albeit sometimes hard to ob-tain, especially in the case of economic data). In order to put a persuasive case to governments concerning the need to act in relation to CVD, it is important that assessments that are more detailed be made of CVD prevalence and costs.

It is a good sign that such data are be-ing generated of late from many lower middle-income countries. Data genera-tion will require work in the countries by people committed to the task of sur-veillance, data extraction and ultimately building a robust health management information system.

H3. Developing partnerships at the macroeconomic level with national governments in key developing countries We can use these data as well as those provided in this report as entry points for advocacy in several developing countries. This work should aim first at putting CVD on those countries’ health and development agendas, and then on establishing working partnerships with representatives in the countries to pur-sue policy recommendations in relation to CVD management and prevention. This will include, where relevant, health system and health delivery initiatives, and work with government agencies in relation to taxes on tobacco products, subsidies for agricultural products, food labelling, guidelines for town planning and transportation systems etc. We pro-pose that this work may be initiated in four countries: Brazil, China, India and South Africa. Excellent work is occurring in this field through the efforts of the WHO and other groups that forms a basis for further action.

H4. “Train the trainer” initiatives in health education Low- and middle-income countries vary in the extent to which they have trained

In the US, since the 1960s, owing to the public awareness programs lead-

ing to individual behaviour change, to-gether with new therapeutic interven-tions and procedures, CVD mortality dropped by more than 55%. Countries facing the challenge of an emerging epi-demic of CVD might do as well in half the time because of current insights and therapies. Now, we have better drugs that are easier to take (once a day rather than more frequently), tobacco policies that are now widely accepted, consensus-driven dietary recommen-dations, and a recognition of the im-portance of physical exercise and the social origins of the CVD risk factors. There is also an understanding of the role of civil society and prudent incorporation of invasive medical and surgical proce-dures for those at grave risk where society can afford these.

This report poses a dramatic chal-lenge to the public health community, to governments and private enterprise.

It also challenges citizens in virtually every country. It suggests that without concerted, ongoing interventions to prevent the precursors and reverse the negative effects of CVD in developing countries, a global health crisis in the current workforces (and later among the elderly) of those countries will oc-cur – and sooner, rather than later. It is apparent in Russia and several other former Soviet republics, and is emerging in China, India and Brazil. This crisis hits not only individuals and their families but the economies of nations, as skilled workers die or become disabled in the prime of life, women are widowed and older people require expensive medi-cal interventions and social support for disability related to CVD.

Combating CVD requires action on a wide range of fronts. What follows is a statement of how we propose to move forward beyond this report. This will necessarily involve research, trial inter-ventions to assess alternative prevention

CONCLUSIONSH


health personnel capable of providing close-to-client primary care services. Often, educators will have trained these personnel primarily in the treatment of communicable diseases and in basic pub-lic health requirements. They may require additional training in the manage-ment of CVD. Specialist doctors and nurses will provide this training by do-nating their time to work with profes-sionals on the ground in the countries concerned. Training will also include the development of treatment protocols, complementing the WHO initiatives such as the WHO CVD-Risk Manage-ment Package for low- and medium-resource settings, but these have to be updated periodically as data is pouring in daily.

H5. Undertaking trial treatment and prevention interventions There are many possible points of entry for prevention and treatment of CVD and its precursor conditions. We propose several complementary strategies (iden-tifying an entry point, task-shifting and task-sharing and use of generic medica-tions). First, focusing on hypertension, we will seek cooperatively to develop treatment interventions in three or four countries. In India, we could use existing primary health centres and the multi-purpose health care workers employed under the National Health Mission. In South Africa, the establishment or re-activation of primary care facilities for the expanded programs of treatment of HIV/AIDS with antiretroviral drugs may provide a good opportunity for also treating CVD risk factors. With help

from existing governmental agencies, we expect good progress. In Brazil, with a government committed to expanding primary care, now may be a good time to investigate what is possible for wide-spread CVD treatment in its many com-munities.

Universal health coverage may be an important mechanism which can lead to the sustainable develop-ment goals, as we envisage. In all of these countries, it will be advisable to seek out industries (e.g., the pharma-ceutical industry in India, through ge-neric drugs) that might be interested in supporting these approaches. Phil-anthropic organisations such as the Melinda and Gates Foundation that is currently supporting the HIV/AIDS program can be approached to extend their reach to include NCDs also. This will require strong, evidence-based ad-vocacy, not only in relation to stress-ing how large the problems are, but also pointing to feasible, scalable inter-ventions that are likely to be effective, affordable and sustainable.

H6. Longer-term research and interventions A research base is essential for progress to be made in relation to the effective-ness of interventions and changes to the health systems that a CVD control program would demand. To demon-strate to governments the benefits of controlling CVD and its precursor con-ditions, ongoing research and evaluation in a range of countries are required. This involves working with existing bodies, such as the Center for Chronic Disease

Control and the Public Health Founda-tion in India, and developing a research capacity in countries where this is lack-ing. The intention would be twofold: to confirm that the preventive interven-tions in which they have invested are producing promised out-comes, and second, to learn from the experience, improving the quality and efficiency of local interven-tions, both preventive and therapeutic, in that country and elsewhere.


A WHO Collaborating Centre for Surveillance, Capacity Building and Translational Research in Cardio-Metabolic Diseases

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