CORRESPONDENCE
COMMENTARY
CORRESPONDENCE e-mail submissions to
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Global cardiovascular disease prevention Sir—Robert Beaglehole (Aug 25, p 661)1 argues that a population approach to the primary prevention of cardiovascular disease, rather than an approach based on high risk, should be the major thrust of a strategy to combat this disease. The restriction of programmes to the population approach is not a new idea; such programmes have been effective in part. The successful implementation of available knowledge for the prevention of cardiovascular disease worldwide is more complex. In attempting to argue his case, Beaglehole criticises World Heart Day, an initiative run by the World Heart Federation (WHF). He asserts that this day encourages an individualistic message. He is incorrect and his comments are misleading. World Heart Day is aimed at increasing public awareness of heart disease and, by informing the public, influencing governments to develop appropriate policies. The top five tips put forward for a healthy heart were exercise, diet, weight, smoking, and stress, which Beaglehole advocates. The tips he cites—blood pressure, diabetes, and cholesterol—came later and do carry additional costs that need to be taken into account in low-income or middle-income countries. The WHF is a non-governmental organisation dedicated to the prevention and control of heart disease and stroke around the world, with a focus on lowincome and middle-income countries. It is comprised of 140 member national societies of cardiology (specialists) and heart foundations (the public) from 95 countries, and continental members covering the Asian Pacific, European, American, and African regions. It works in partnership with WHO and UNESCO. As part of an overall strategy, WHF has created the World Heart Forum for Global Cardiovascular Disease Prevention to bring together experts and partner organisations sharing a common interest in disease prevention. This forum includes societies, heart foundations, non-
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governmental organisations, industry, international organisations, and governments or health ministries. International strategies and national implementation programmes are being defined, including tobacco control, global principles for nutrition and physical exercise, public-health advocacy platforms, medical professional education programmes, and research into risk factors, capacity building and surveillance in less-developed countries. The general population are unaware that cardiovascular disease accounts for 17 million deaths per year or one of every three deaths worldwide. Decision-makers are commonly surprised to learn that 80% of those deaths occur in low-income and middle-income countries. Women are unaware of the risks. Awareness is a first step in the promotion of implementation of knowledge about prevention of coronary heart disease. The second World Heart Day, on Sept 30, 2001, which had wide media coverage, encouraged healthy lifestyles through increased physical activity and risk reduction through smoke-free living, healthy nutrition, and weight control. Additionally we recommend, if possible, health checks for blood pressure, cholesterol, and diabetes. The WHF believes that population-based and individual approaches should not be seen as separate strategies. Implementation of current knowledge is unlikely to be achieved solely by government command or medical edict, but needs the active support of the public. World Heart Day is a crucial step forward. As such, it should be supported by the medical profession and partner organisations. *Mario Maranhão, Tak-Fu Tse, Philip Poole-Wilson, Antonio Bayes de Luna World Heart Federation, CH-1205 Geneva, Switzerland (e-mail:
[email protected]) 1
Beaglehole R. Global cardiovascular disease prevention: time to get serious. Lancet 2001; 358: 661–63.
Author’s reply Sir—I am pleased that Mario Maranhão and colleagues agree on the need to increase global efforts to prevent cardiovascular disease. My point is that we are not applying available knowledge on the importance of the population-wide approach to prevention, the only strategy with the potential to control the cardiovascular disease epidemics. Too much of our limited resources are directed towards the individualistic approach, which can be useful in certain circumstances, but is inappropriate for the less-developed world where the burden is greatest. Maranhão and colleagues suggest that my comments on the individualistic focus of World Heart Day are wrong, but provide no arguments to support their claim. They seem to believe that encouraging people to be “aware of just how extraordinary their heart really is” will somehow lead to sound prevention and control policies. It seems naïve to suggest that encouraging people in lessdeveloped countries, for example, to walk briskly for 30 min every day will do anything to inform the public, through which governments can be influenced to develop appropriate policies. And what is the evidence that if people in less-developed countries “smile on life when you can and try to be as relaxed as possible” it will make any difference to their risk, let alone the population risk, of cardiovascular disease? Do Maranhão and colleagues have evidence to support the link between messages to the individual and appropriate policies in poorer countries? I remain sceptical about this causal chain. However, I am hopeful that the newly created World Heart Forum for Global Cardiovascular Disease Prevention will provide strong leadership, based on what we know, for the prevention of global cardiovascular disease. Robert Beaglehole University of Auckland, Private Bag 92019, Auckland 1020, New Zealand
THE LANCET • Vol 358 • November 10, 2001
For personal use. Only reproduce with permission from The Lancet Publishing Group.
