Editorials
Editorials Developing a global agenda for action on cardiovascular diseases Australian health policy can and should address, as a core aim, cardiovascular health in less economically advanced nations
C
ardiovascular diseases have snatched the mantle of top-priority global health problem from infectious diseases including tuberculosis, malaria and HIV/ AIDS. This is because of the deaths attributable to cardioMedical Journal of Australia, vascular diseases, the years of life lost, and the longer-term Sydney, NSW. disability from heart failure and stroke.1 While deaths due [email protected] to cardiovascular diseases among people younger than 65 years have fallen dramatically in the past 50 years in doi: 10.5694/mja13.10911 Australia, in less economically advanced communities one-third of these deaths occur among people younger than 65 years.2 Cardiovascular diseases are potent widow- and orphanmakers. Particularly in developing communities, they can precipitate poverty. The cost of care in communities lacking affordable health insurance and effective primary care can be catastrophic. The effect on a nation’s lost productivity and growth is no less disastrous. Every 10% rise in chronic noncommunicable diseases is estimated to bring a 0.5% decrease in economic growth.3 It has also been estimated that deaths in developing countries attributable to chronic disease will grow from 46% of all deaths in 2002 to 59% of all deaths in 2030, or to more than 37 million lives lost per year.3 Why the delayed recognition? These circumstances have been many decades in the making. Three principal reasons for global inaction over those years stand out. First, in many countries maternal and infant mortality rates are high, visible, tragic and immediate, and a natural priority for scarce health care resources. Such countries that now also face the cardiovascular crisis are war-weary from fighting infant and maternal mortality, tuberculosis, malaria and HIV/AIDS. But great gains have been made in these conditions, and it is now imperative that we encourage and support those nations to address chronic diseases. Second, perception of cardiovascular diseases, in relation to human behaviour, differs radically from that of infectious diseases. As with type 2 diabetes, obesity and The Medical Journal of lung Australia ISSN: 0025chronic disease, cardiovascular diseases occur princi729X 5 August pally 2013 199 3 145-146 among older people, in social conditions of fast ©The Medical Journal of Australia 2013 economic development and generally favourable, povertywww.mja.com.au reducing urban development. They depend on human behaviour — smoking tobacco, overeating fats and sugars, Editorial abandoning traditional (usually healthier) nutrition, and underexercising. Potential donors who wish to improve international health consider cardiovascular diseases off Stephen R Leeder MD, PhD, FRACP, Editor-in-Chief
limits for funding, since these diseases are “the sufferers’ fault” or diseases of old age. It is hard to convince major donors that such adverse individual health behaviour is largely determined by domestic, community, work and economic environments and that older people matter. Preventive strategies for chronic disease that respond to the individual and the social environment behind these disorders appear soft and diffuse. They are complex compared with, say, an immunisation program with its clean start, jab and finish. Interest groups that profit from an environment that promotes chronic diseases, especially cardiovascular diseases, resist efforts that encourage change.4 But these detached, judgemental and indolent attitudes are changing, stimulated by a 2011 United Nations meeting on the global chronic diseases crisis.5 The UN meeting resulted from years of advocacy by a few governments, including Australia’s, and non-government agencies concerned about cardiovascular diseases, diabetes, cancer and chronic respiratory disease — the NCD Alliance. The Lancet has shown admirable academic leadership in noncommunicable diseases research by creating an action group, publishing special issues and providing support for international meetings. Often the recognition of a crisis jolts us to take the matter seriously, and so it is with cardiovascular diseases. A political declaration from the UN meeting articulated goals and strategies for preventing and controlling noncommunicable diseases over the following 5 years. This has pushed international agencies such as the World Health Organization to act. The WHO is responding with global strategies: enhancing tobacco control, addressing dietary salt reduction, nominating essential medicines (including antihypertensives), and advocating for fuller and more stable primary care services everywhere. In addition, chronic diseases are being reconceptualised, and are now frequently perceived as an impediment to social development, thus adding them to the agenda for discussion concerning the next steps to be taken after the Millennium Development Goals conclude in 2015.6 The third factor behind our relative inaction, despite indisputable progress, has been those massive holes, only now beginning to close, in knowledge about what to do, and how to implement the knowledge we have. Although we have had the major risk factors for cardiovascular diseases nailed for the past 50 years, and can use
MJA 199 (3) · 5 August 2013
145
Editorials them to explain most of the variance in cardiovascular disease frequency, more basic and clinical research is required alongside health services research to translate these insights into effective policy, population interventions and individual behaviour change. Fruitful fields of inquiry include events in early life capable of setting the later epigenetic, physiological and behavioural trajectories for chronic disease.7 Australia has generally done well with cardiovascular disease control, although onset and mortality occur a decade earlier in our Indigenous communities than in the rest of the population.8 Overall, rates of deaths due to coronary heart disease in Australia fell by 83% between 1968 and 2000, as newer medical and surgical interventions have exerted a spectacular positive influence on individuals, and lifestyle changes have contributed positively at the individual and population levels.9 Tobacco smoking is now less common in Australia than in most other economically advanced nations. Our efforts, although incomplete, in cardiovascular disease prevention and management in urban and rural Indigenous communities might apply to other communities. In a spirit of mutual learning, we should share our experience with these efforts. We know well the battles over entrenched behaviour, practices and social structures that nourish risk factors. The tobacco war is by no means over, and the food and alcohol wars are just beginning here and elsewhere. In the United Kingdom, the government has recently suspended the push for tobacco plain packaging legislation,10 and the same is likely to happen to a minimum alcohol pricing policy.11 In Africa, rapid modernisation will, by the middle of this century, potentially not only lead to food self-sufficiency but also surplus food to export.12 Although this will alleviate starvation, it will spell disaster for rapidly urbanising populations where, if the previous experience of developed societies is any model, cardiovascular disease rates will increase quickly.
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MJA 199 (3) · 5 August 2013
Translating knowledge and science into resource-poor (or even just less-developed) settings is culturally, politically and logistically difficult. But as a good and progressive global citizen, Australia can still advocate for access to essential medications, meaningful aid and public health support. Such strategies have worked to combat infectious diseases globally, but now they must address noncommunicable diseases. Australia has much expertise and experience to share in international efforts to prevent and control cardiovascular and other chronic diseases. If this challenge is embraced by both major parties in the upcoming federal election, it would be pleasing indeed. Competing interests: No relevant disclosures. Provenance: Commissioned; not externally peer reviewed. 1 Institute for Health Metrics and Evaluation, University of Washington. GBD
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2010 change in leading causes and risks between 1990 and 2010. http:// www.healthmetricsandevaluation.org/gbd/visualizations/gbd-2010-changeleading-causes-and-risks-between-1990-and-2010 (accessed Jul 2013). A race against time: the challenge of cardiovascular disease in developing economies. University of Sydney, The Earth Institute and Mailman School of Public Health, 2004. http://www.earth.columbia.edu/news/2004/images/ raceagainsttime_FINAL_051104.pdf (accessed Jul 2013). Stuckler D. Population causes and consequences of leading chronic diseases: a comparative analysis of prevailing explanations. Milbank Q 2008; 86: 273-326. Stuckler D, Basu S, McKee M. Commentary: UN high level meeting on noncommunicable diseases: an opportunity for whom? BMJ 2011; 343: d5336. Moodie AR. A slow-motion disaster that is breaking the bank. Med J Aust 2011; 195: 508-509. United Nations Economic and Social Council. Millennium Development Goals and post-2015 development agenda. http://www.un.org/en/ecosoc/about/ mdg.shtml (accessed Jul 2013). Gluckman PD, Hanson MA, Cooper C, Thornburg KL. Mechanisms of disease. Effect of in utero and early-life conditions on adult health and disease. N Engl J Med 2008; 359: 61-73. Penm E. Cardiovascular disease and its associated risk factors in Aboriginal and Torres Strait Islander peoples 2004–05. Canberra: AIHW, 2008. (AIHW Cat. No. CVD 41; Cardiovascular Disease Series No. 29.) Taylor R, Dobson A, Mirzaei M. Contribution of changes in risk factors to the decline of coronary heart disease mortality in Australia over three decades. Eur J Cardiovasc Prev Rehabil 2006; 13: 760-768. Government rejects Labour’s cigarette ‘U-turn’ claim. BBC News 2013; 12 Jul. http://www.bbc.co.uk/news/health-23281804 (accessed Jul 2013). Minimum alcohol pricing plan ‘to be dropped’. BBC News 2013; 12 Jul. http://www.bbc.co.uk/news/health-23283821 (accessed Jul 2013). World Bank. Growing Africa: unlocking the potential of agribusiness. http://siteresources.worldbank.org/INTAFRICA/Resources/africaagribusiness-report-2013.pdf (accessed Jul 2013). ❏
Editorials Developing a global agenda for action on cardiovascular diseases Australian health policy can and should address, as a core aim, cardiovascular health in less economically advanced nations
C
ardiovascular diseases have snatched the mantle of top-priority global health problem from infectious diseases including tuberculosis, malaria and HIV/ AIDS. This is because of the deaths attributable to cardioMedical Journal of Australia, vascular diseases, the years of life lost, and the longer-term Sydney, NSW. disability from heart failure and stroke.1 While deaths due [email protected] to cardiovascular diseases among people younger than 65 years have fallen dramatically in the past 50 years in doi: 10.5694/mja13.10911 Australia, in less economically advanced communities one-third of these deaths occur among people younger than 65 years.2 Cardiovascular diseases are potent widow- and orphanmakers. Particularly in developing communities, they can precipitate poverty. The cost of care in communities lacking affordable health insurance and effective primary care can be catastrophic. The effect on a nation’s lost productivity and growth is no less disastrous. Every 10% rise in chronic noncommunicable diseases is estimated to bring a 0.5% decrease in economic growth.3 It has also been estimated that deaths in developing countries attributable to chronic disease will grow from 46% of all deaths in 2002 to 59% of all deaths in 2030, or to more than 37 million lives lost per year.3 Why the delayed recognition? These circumstances have been many decades in the making. Three principal reasons for global inaction over those years stand out. First, in many countries maternal and infant mortality rates are high, visible, tragic and immediate, and a natural priority for scarce health care resources. Such countries that now also face the cardiovascular crisis are war-weary from fighting infant and maternal mortality, tuberculosis, malaria and HIV/AIDS. But great gains have been made in these conditions, and it is now imperative that we encourage and support those nations to address chronic diseases. Second, perception of cardiovascular diseases, in relation to human behaviour, differs radically from that of infectious diseases. As with type 2 diabetes, obesity and The Medical Journal of lung Australia ISSN: 0025chronic disease, cardiovascular diseases occur princi729X 5 August pally 2013 199 3 145-146 among older people, in social conditions of fast ©The Medical Journal of Australia 2013 economic development and generally favourable, povertywww.mja.com.au reducing urban development. They depend on human behaviour — smoking tobacco, overeating fats and sugars, Editorial abandoning traditional (usually healthier) nutrition, and underexercising. Potential donors who wish to improve international health consider cardiovascular diseases off Stephen R Leeder MD, PhD, FRACP, Editor-in-Chief
limits for funding, since these diseases are “the sufferers’ fault” or diseases of old age. It is hard to convince major donors that such adverse individual health behaviour is largely determined by domestic, community, work and economic environments and that older people matter. Preventive strategies for chronic disease that respond to the individual and the social environment behind these disorders appear soft and diffuse. They are complex compared with, say, an immunisation program with its clean start, jab and finish. Interest groups that profit from an environment that promotes chronic diseases, especially cardiovascular diseases, resist efforts that encourage change.4 But these detached, judgemental and indolent attitudes are changing, stimulated by a 2011 United Nations meeting on the global chronic diseases crisis.5 The UN meeting resulted from years of advocacy by a few governments, including Australia’s, and non-government agencies concerned about cardiovascular diseases, diabetes, cancer and chronic respiratory disease — the NCD Alliance. The Lancet has shown admirable academic leadership in noncommunicable diseases research by creating an action group, publishing special issues and providing support for international meetings. Often the recognition of a crisis jolts us to take the matter seriously, and so it is with cardiovascular diseases. A political declaration from the UN meeting articulated goals and strategies for preventing and controlling noncommunicable diseases over the following 5 years. This has pushed international agencies such as the World Health Organization to act. The WHO is responding with global strategies: enhancing tobacco control, addressing dietary salt reduction, nominating essential medicines (including antihypertensives), and advocating for fuller and more stable primary care services everywhere. In addition, chronic diseases are being reconceptualised, and are now frequently perceived as an impediment to social development, thus adding them to the agenda for discussion concerning the next steps to be taken after the Millennium Development Goals conclude in 2015.6 The third factor behind our relative inaction, despite indisputable progress, has been those massive holes, only now beginning to close, in knowledge about what to do, and how to implement the knowledge we have. Although we have had the major risk factors for cardiovascular diseases nailed for the past 50 years, and can use
MJA 199 (3) · 5 August 2013
145
Editorials them to explain most of the variance in cardiovascular disease frequency, more basic and clinical research is required alongside health services research to translate these insights into effective policy, population interventions and individual behaviour change. Fruitful fields of inquiry include events in early life capable of setting the later epigenetic, physiological and behavioural trajectories for chronic disease.7 Australia has generally done well with cardiovascular disease control, although onset and mortality occur a decade earlier in our Indigenous communities than in the rest of the population.8 Overall, rates of deaths due to coronary heart disease in Australia fell by 83% between 1968 and 2000, as newer medical and surgical interventions have exerted a spectacular positive influence on individuals, and lifestyle changes have contributed positively at the individual and population levels.9 Tobacco smoking is now less common in Australia than in most other economically advanced nations. Our efforts, although incomplete, in cardiovascular disease prevention and management in urban and rural Indigenous communities might apply to other communities. In a spirit of mutual learning, we should share our experience with these efforts. We know well the battles over entrenched behaviour, practices and social structures that nourish risk factors. The tobacco war is by no means over, and the food and alcohol wars are just beginning here and elsewhere. In the United Kingdom, the government has recently suspended the push for tobacco plain packaging legislation,10 and the same is likely to happen to a minimum alcohol pricing policy.11 In Africa, rapid modernisation will, by the middle of this century, potentially not only lead to food self-sufficiency but also surplus food to export.12 Although this will alleviate starvation, it will spell disaster for rapidly urbanising populations where, if the previous experience of developed societies is any model, cardiovascular disease rates will increase quickly.
146
MJA 199 (3) · 5 August 2013
Translating knowledge and science into resource-poor (or even just less-developed) settings is culturally, politically and logistically difficult. But as a good and progressive global citizen, Australia can still advocate for access to essential medications, meaningful aid and public health support. Such strategies have worked to combat infectious diseases globally, but now they must address noncommunicable diseases. Australia has much expertise and experience to share in international efforts to prevent and control cardiovascular and other chronic diseases. If this challenge is embraced by both major parties in the upcoming federal election, it would be pleasing indeed. Competing interests: No relevant disclosures. Provenance: Commissioned; not externally peer reviewed. 1 Institute for Health Metrics and Evaluation, University of Washington. GBD
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3 4 5 6
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8
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10 11 12
2010 change in leading causes and risks between 1990 and 2010. http:// www.healthmetricsandevaluation.org/gbd/visualizations/gbd-2010-changeleading-causes-and-risks-between-1990-and-2010 (accessed Jul 2013). A race against time: the challenge of cardiovascular disease in developing economies. University of Sydney, The Earth Institute and Mailman School of Public Health, 2004. http://www.earth.columbia.edu/news/2004/images/ raceagainsttime_FINAL_051104.pdf (accessed Jul 2013). Stuckler D. Population causes and consequences of leading chronic diseases: a comparative analysis of prevailing explanations. Milbank Q 2008; 86: 273-326. Stuckler D, Basu S, McKee M. Commentary: UN high level meeting on noncommunicable diseases: an opportunity for whom? BMJ 2011; 343: d5336. Moodie AR. A slow-motion disaster that is breaking the bank. Med J Aust 2011; 195: 508-509. United Nations Economic and Social Council. Millennium Development Goals and post-2015 development agenda. http://www.un.org/en/ecosoc/about/ mdg.shtml (accessed Jul 2013). Gluckman PD, Hanson MA, Cooper C, Thornburg KL. Mechanisms of disease. Effect of in utero and early-life conditions on adult health and disease. N Engl J Med 2008; 359: 61-73. Penm E. Cardiovascular disease and its associated risk factors in Aboriginal and Torres Strait Islander peoples 2004–05. Canberra: AIHW, 2008. (AIHW Cat. No. CVD 41; Cardiovascular Disease Series No. 29.) Taylor R, Dobson A, Mirzaei M. Contribution of changes in risk factors to the decline of coronary heart disease mortality in Australia over three decades. Eur J Cardiovasc Prev Rehabil 2006; 13: 760-768. Government rejects Labour’s cigarette ‘U-turn’ claim. BBC News 2013; 12 Jul. http://www.bbc.co.uk/news/health-23281804 (accessed Jul 2013). Minimum alcohol pricing plan ‘to be dropped’. BBC News 2013; 12 Jul. http://www.bbc.co.uk/news/health-23283821 (accessed Jul 2013). World Bank. Growing Africa: unlocking the potential of agribusiness. http://siteresources.worldbank.org/INTAFRICA/Resources/africaagribusiness-report-2013.pdf (accessed Jul 2013). ❏
