Control of Cardiovascular Diseases in Developing Countries: Research, Development, and Institutional Strengthening (1998)

This report addresses the question recently raised by the Institute of Medicine in America's Vital Interest in Global Health (IOM, 1997) and "The Pursuit of Global Health: Relevance of Engagement for Developing Countries" (Howson et al., 1998): Why should countries in the developed world care about the emerging epidemic of cardiovascular disease (CVD) in developing countries? The benefits of engagement have to be recognized if there is to be sustained international attention to the CVD epidemic.

As the CVD epidemic emerges in developing countries, it has an increasingly severe impact on men and women in their productive middle years, as well as on those who are older. The growing middle class of many developing countries is experiencing the first phase of the CVD epidemic, which for many is disrupting family stability and family income. This has consequences for society as a whole. The cost of treatment can also have a serious impact on a country's health care expenditures and its economic development. For these reasons, development of effective approaches for CVD prevention and cost-effective management are urgent. Without effective prevention, the epidemic is predicted to expand, causing a profound impact on individuals and the country.

Developed countries were able to decrease mortality and morbidity from infectious diseases in the first half of the twentieth century because of the development of vaccines and other public health measures. They shared successful approaches and resources with developing countries through international assistance programs after World War II. There is a parallel opportunity for sharing knowledge on CVD prevention. Developed countries experienced an epidemic of CVD in the middle of this century and have since achieved a remarkable decline in cardiovascular mortality. Accomplishing this required major conceptual shifts in epidemiologic research (both observational and interventional), creation of a strong scientific database to guide policy and practice, and development of public information to discourage behaviors that predispose to CVD. As a similar epidemic of chronic diseases, especially CVD, emerges in developing countries, health professionals from developed countries are motivated to again share their experience of policies and approaches that have proven successful.

Worldwide immigration has created ethnic diversity in many countries such as the United States, Canada, Malaysia, and Singapore. Several studies from these countries indicate important differences in the incidence of CVD for recent immigrants now exposed to a new set of environmental risks. Some of these differences may be attributable to socioeconomic factors and culturally based patterns of diet, behavior, and activity, whereas others may be attributable to genetic factors. Studies of ethnically diverse groups in their original homeland and their newly adopted country continue to provide insights that improve understanding of the complexities and approaches for reducing the burden of CVD in the wider population.

Studies addressing the development, prevention, and management of CVD in developing countries can contribute significantly to the overall knowledge base of CVD worldwide. The Framingham Heart Study and other developed country longitudinal studies identified key risk factors. However, considerable unexplained risk remains, and the relative importance of risk factors may differ among ethnic or socioeconomic groups and may change over time. The opportunity to study a new epidemic in different populations with different genetic characteristics, different exposures, and different cultural patterns can provide information that is broadly applicable.

Success in reducing CVD mortality in developed countries has been attributed to a wide range of strategies for prevention and treatment, including management of acute events. The relative contribution of preventive strategies remains unclear. With limited resources for management of acute events, developing country programs may provide a clearer picture of the contribution of prevention alone, or of prevention and low-cost treatment, in lowering the CVD burden. This knowledge would contribute significantly to policy and planning for all countries.

Finally, the rapid spread of infectious diseases has emphasized the global nature of health risks. For CVD and other chronic diseases, policy changes in one country may have major effects on other countries. For example, tobacco regulations in the United States, Canada, and Australia have successfully decreased tobacco use in these countries. Tobacco manufacturing and promotion have intensified already in developing countries, While the burden of CVD is rapidly increasing, global surveillance and action are required to monitor changes in environmental and behavioral risks as CVD and other chronic diseases reach epidemic proportions. At the same time, health problems caused or exacerbated by tobacco use are likely to increase in developing countries as smoking becomes more prevalent there. As environmental and behavioral risks migrate internationally, they require global surveillance and action.