Coronary heart disease and stroke in developing countries: time to act

Pekka Puska

Noncommunicable Disease Prevention and Health Promotion World Health Organization, Geneva, Switzerland.

Sirs—I was greatly confused by the article from Shah Ebrahim and George Davey Smith on ‘Exporting failure? Coronary heart disease and stroke in developing countries' in the Journal.1 What was the message?

In some respect it brought to my mind a similar editorial from the Journal 28 years ago; ‘Shot gun prevention?’ in 1973.2 That editorial started ‘Are we yet ready to attack coronary artery disease through prevention programmes in the community?’ The text was critical of the start of the North Karelia Project in Finland and stated that further research and development is needed, with reference to another Professor Smith.

In spite of the critics 30 years ago, the work was started in Finland: during the first five years in the Province of North Karelia as national pilot and work on national level was started after that.3 During the original 5 years (1972–1977), reductions in risk factors in North Karelia were significantly greater than in the original reference area. And in the 1970s the decline in coronary heart disease mortality (among the 30–64-year-old male population, age adjusted) was significantly greater in North Karelia than in all Finland or the reference area.3,4 After the national work was intensified, the national decline accelerated. By 1995 the (25 year) decline in male CHD mortality was 73% in North Karelia and 65% in all Finland.5 Tobacco-related cancers among men declined so that by 1995 the annual age-adjusted mortality was 71% less, and the decline was significantly greater than in the rest of the country. Thus in 25 years a dramatic change in CHD and NCD burden has taken place in accordance with the set objectives: a demonstration first in North Karelia and later on in all Finland.

The MONICA results have shown that most of the decline in CHD mortality in Eastern Finland has been due to changes in incidence, not case fatality.6 Furthermore, separate analyses have shown that most of the reduction in CHD mortality can be explained by the reduction in the population levels of the target risk factors.7 Thus there is strong evidence that prevention has worked in Finland. Ebrahim and Davey Smith should have made the effort to go through some of the main publications.

The message of Ebrahim and Davey Smith is remarkably similar to the mentioned editorial of 1973: critical of preventive action, and asking for more research. While it is easy to argue that more research is needed, that should not be presented as on alternative to necessary action. When we started work in North Karelia a journalist asked me a critical question ‘Is this going to be another academic study or is this project going to benefit the people?’. Although Ebrahim and Davey Smith are still critical, people in North Karelia and Finland are certainly happy with the results obtained.

Actually the contemporary critics remind me of the oft-repeated story in Finland: A town had both a regular fire brigade and voluntary one—with some rivalry. And the professionals already did not appreciate the amateurs. Once the voluntary fire brigade had arrived earlier and had extinguished the fire. When the regular fire brigade came, their captain gave a sour comment ‘Extinguished incorrectly!’. It seems like Ebrahim and Davey Smith think that CVD has been incorrectly prevented in Finland!

When comparing the critics of 1973 and 2001, one feels that little has changed. But the change in heart health in Finland has been great. And in addition to Finland, a number of other countries have started preventive work on various projects at local and national level. More and more countries agree: it is time to act. Of course there are questions on the components of the action, but the comprehensive preventive measures are cheap in comparison with the huge costs of treating CVD and its consequences. Furthermore, inbuilt surveillance and process evaluation guide the work.

Ebrahim and Davey Smith emphasize an important point about ‘the role of government in population approaches to prevention’. This is a key lesson from Finland and many other countries. The approach in Mauritius and other early approaches in many developing countries also follow this model: comprehensive national action.8

The real question is how to persuade governments to adopt needed preventive policies. My experience is that policy makers listen less to scientists, often seen to be in ivory towers, than to changes and activities actually taking place in their communities. Thus the community based programmes serve necessary political action by mobilizing people, by demonstrating the prevention possibilities and by providing training for personnel.

While I am sure Ebrahim and Davey Smith must have many valuable ideas and points, I am afraid that their message is again interpreted as justification for postponing actions that are necessary to fight the enormous cardiovascular epidemic. I cannot help making a reference to another recent article by the same authors and colleagues ‘Dietary fat intake and prevention of cardiovascular disease: a systematic review’.9 It was a strange review of very mixed small dietary intervention studies with short follow-up. Readers can conclude that dietary changes have little impact on cardiovascular rates, obviously a very harmful public health message.

Messages like that support the viewpoint, commonly supported by commercial interests, that prevention efforts are not worthwhile; instead we should concentrate on drug approaches and clinical treatment. Because the present article refers to the great burden and growing epidemic of cardiovascular diseases in the developing world, the message should be the opposite: While treatment and prevention are both important and should support each other, especially in the third world with great scarcity of resources, major public health achievements can take place only as a result of population based prevention.

The global problem is huge: Much firm evidence exists for prevention. It is time to act—with sound theoretical base and sufficient preventive dose—from demonstrations to national policy actions—not exporting, but working in global partnership—and also putting one's heart into the action!

References

1 Ebrahim S, Smith GD. Exporting failure? Coronary heart disease and stroke in developing countries. Int J Epidemiol 2001;30(2):201–05.[Free Full Text]

2 Editorial: Shot-gun prevention? Int J Epidemiol 1973;2(3):219–20.[ISI][Medline]

3 Puska P, Tuomilehto J, Nissinen A, Vartiainen E. The North Karelia Project 20 years results and experiences. Helsinki: National Public Health Institute, 1995.

4 Salonen JT, Puska P, Kottke TE, Tuomilehto J, Nissinen A. Decline in morality from coronary heart disease in Finland from 1969 to 1979. Br Med J 1983;286:57–60.

5 Puska P, Vartiainen E, Tuomilehto J, Salomaa V, Nissinn A. Changes in premature deaths in Finland: successful long-term prevention of cardiovascular diseases. Bull WHO 1998;76:419–25.[ISI][Medline]

6 Tunstall-Pedoe H, Vanuzzo D, Hobbs M et al. Estimation of contribution of changes in coronary care to improving survival event rates and coronary heart disease mortality across the WHO MONICA Project populations. Lancet 2000;355:688–700.[ISI][Medline]

7 Vartiainen E, Puska P, Pekkanen J, Tuomilehto J, Jousilahti P. Changes in risk factors explain changes in mortality from ischaemic heart disease in Finland. Br Med J 1994;309:23–27.[Abstract/Free Full Text]

8 Uusitalo U, Feskens EJ, Tuomilehto J et al. Fall in total cholesterol concentration over five years in association with changes in fatty acid composition of cooking oil in Mauritius: cross-sectional survey. Br Med J 1996;313:1044–46.[Abstract/Free Full Text]

9 Hooper L, Summerbell CD, Higgins JPT et al. Dietary fat intake and prevention of cardiovascular disease: systematic review. Br Med J 2001;322:757–63.[Abstract/Free Full Text]





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