International Journal of Epidemiology 2001;30:1495-1496
© International Epidemiological Association 2001
Letter to the Editor |
University of Aukland and WHO, Geneva.
Sirs—I welcome your timely and perceptive views on the prevention and control of the increasing burden of cardiovascular disease in developing countries.1 Though your comments are particularly addressed to the problems facing developing countries, they are also relevant for wealthy countries. Despite the limited successes in controlling the CVD epidemics in countries such as Australia, the USA, New Zealand and western Europe, these epidemics are completely uncontrolled in many Eastern European countries and CVD are still among the leading causes of premature death in most wealthy countries.
It is timely to encourage the development of surveillance systems for the major CVD and especially their risk factors. Estimates of the global burden of disease will be improved by these data. The surveillance data are also needed to help countries develop, implement and evaluate their prevention and control programmes. Several carefully chosen sentinal sites are required in each region. Ideally these surveillance sites should be based on public health training institutions. In most parts of the world these institutions are vulnerable and need long-term external support, especially for developing career pathways and research experience of the junior faculty. Surveillance projects could usefully connect these institutions to the communities they serve and to the ministry of health. Critical decisions need to be made about the choice of risk factors to be measured and when to include disease endpoints. There is a danger in overloading new systems and above all the utility of data to policy and action needs to be demonstrated.2
In terms of programmes and policies, there can be no serious argument with the need to focus on the population approach to primary prevention. In an ideal world, with unlimited resources, covering the full spectrum of preventive strategies would be useful. But nowhere do we have more than pitiful resources for prevention. It behoves us to make the best use of these resources. Working towards environmental change is the logical place to start. It is difficult to convince our professional clinical colleagues of the importance of this strategy and our lay constituency needs to be actively involved in debates on the use of limited resources.
The primary goal is to shift the risk factor distributions towards the left. Fortunately, we have evidence that this is possible and likely to be highly effective in reducing the burden of CVD.3 Furthermore, we know that the major risk factors are qualitatively the same in all regions of the world4 and, that where the epidemics are fully developed, these risk factors explain the vast majority of new events of CVD.5
I trust that your editorial encourages a greater attention to applying the knowledge gained from decades of careful and productive public health sciences.6 I also hope that the IJE will devote more of its pages to explorations of the policies and programmes needed to implement the population approach to primary prevention.7
References
1
Ebrahim S, Davey Smith G. Exporting failure? Coronary heart disease and stroke in developing countries. Int J Epidemiol 2001;30:201–05.
2 Bonita R, Winkelmann R, Douglas K. The WHO STEP wise approach to NCD risk factor surveillance. In: McQueen and Puska P (eds.). Global Behavioural Risk Factor Surveillance. Cordrecht: Kluwer (In press), 2001.
3 Rodgers A, Lawes C, MacMahon S. Reducing the global burden of blood pressure-related cardiovascular disease. J Hypertens 2000;18 (Suppl):S3–6.
4 Eastern Stroke and Coronary Heart Disease Collaborative Research Group. Blood pressure, cholesterol, and stroke in Eastern Asia. Lancet 1998;352:1801–07.[Web of Science][Medline]
5
Stamler J, Stamler R, Neaton JD et al. Low risk-factor profile and long-term cardiovascular and non-cardiovascular mortality and life expectancy. Findings for 5 large cohorts of young adult and middle-aged men and women. JAMA 1999;282:2012–18.
6 Beaglehole R. Global cardiovascular disease prevention; time to get serious. Lancet 2001;358:661–63.[Web of Science][Medline]
7 Rose G. The Strategy of Preventive Medicine. Oxford: Oxford University Press, 1992.
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