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Global Cardiovascular Disease and the Academic Public Health Curriculum Henry Greenberg⁎ Department of Epidemiology, Columbia University Mailman School of Public Health, New York, NY Department of Medicine and Institute of Human Nutrition, Columbia University, New York, NY Division of Cardiology, St. Luke’s and Roosevelt Hospitals, New York, NY




The epidemic of cardiac risk factors and cardiovascular disease in developing regions has


reached sub-Sahara Africa. This global reality needs to energize the academic public health

Non-communicable diseases

establishment to incorporate this phenomenon in its curriculum. The focus for control of

Sub-Sahara Africa

these risk factors and illnesses will need to be on their cultural, political, and economic

Public health curriculum

upstream drivers. The schools of public health will need to collaborate with a broad array of university disciplines to craft a focused and appropriate curriculum with which to train the next generation of global health professionals. © 2013 Elsevier Inc. All rights reserved.

Two recent papers introduce an epidemiologic vignette that both reveal the magnitude of the cardiovascular disease (CVD) impact in sub-Sahara Africa (SSA) and initiate a logical trail back to the need for change in the curriculum of schools of public health. In 2010, Walker et al1 reported that the age adjusted stroke rate in Dar es Salaam, Tanzania was higher than in Harlem, a black enclave in New York City long considered to have the highest stroke rate in the U.S. However, from age 45 on, the rate in this urban African locale exceeded that in Harlem. A few years earlier Edwards et al2 reported that the percentage of hypertensive patients treated to goal in Tanzania was about 0.5%. More recently studies from Ghana3 and Cameroon4 reported levels of BP control at 6% and 10% respectively. At that time the rate in the U.S was 31%5 and by 2010, it was 53%.6 Hypertension prevalence was 2–3% in rural Tanzania in the 1960s and 1970s2 but had increased to 31% in the late 1990s and today it is 39%.7 While the treatment-to-goal rate is likely higher today than in 2000, it is unlikely to exceed 10%.3,4

What drives the hypertensive epidemic in Tanzania? How can it be managed? The answer to these questions takes us far upstream, and does so quickly. The narrative of this vignette follows a journey from a young patient at risk for a premature stroke to new models of global health assistance and then to the curriculum changes that are needed at schools of public health. This view of public health recognizes that cultural, political, and economic factors are major contributors to the creation of the risk factor profile for hypertension and other risk factors for CVD and diabetes. These societal characteristics often have long, well established and strongly embedded histories and are not readily changed. The barriers to change, then, are diverse and cross into arenas not usually associated with public health interventions. The dominant “active” factor today is urbanization. (There are others such as the demographic transition, democratization, and globalization but the overarching impact of urbanization is more than sufficient to support the argument of this

Statement of conflict of Interest: see page 324. ⁎ Address reprint requests to Henry Greenberg, MD, Division of Cardiology, St. Luke’s and Roosevelt Hospitals, Room 3B-30, 1000 10th Ave., New York, NY 10019. E-mail address: [email protected]. 0033-0620/$ – see front matter © 2013 Elsevier Inc. All rights reserved.

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Abbreviations and Acronyms

essay.) While urbanization is in full force CVD = cardiovascular disease around the globe, it NCD = non-communicable has most recently bediseases come a transforming phenomenon in SSA. SSA = sub-Sahara Africa Rapid urbanization creates as much cultural disequilibrium as any phenomenon other than war or famine. It changes nearly everything. A partial list includes diet, physical activity, the role of women, the availability of disposable income, intergenerational relationships, exposure to contemporary marketing by global multinational corporations and their local imitators, and television and Internet access to new and transforming information. It also brings children and their parents closer to medical and traditional preventive care (vaccination, acute illness management), educational opportunities, and income-producing employment. Children, often with better education and early childhood health metrics than their parents such as vaccines and benefits that emanate from access to clinics, nonetheless develop more obesity, engage in less physical activity, smoke more, consume excessive salt, and hence develop diabetes, hypertension, and hyperlipidemia, and are on a trajectory for premature CVD and end-organ effects of diabetes. Interrupting these cycles is extraordinarily difficult, especially when confronting the impact of mass marketing of fast food and tobacco, an increase in the female work force with women less willing or able to be the epicenter of the family meals and diet, and the globalization and corporatization of trade and agriculture. Current health systems are not designed to identify, manage, or treat asymptomatic chronic disease. The clinic is where fevers, rashes, coughs, injuries, and wasting are treated. There is minimal capacity for advice on diet, physical activity, or smoking. There is limited ability to follow longitudinally asymptomatic disease nor are there campaigns to inform a healthy population on the need to prevent them. These two complementary forces – the siren lure of risk-promoting behavior and the unpreparedness of the health care delivery system to even identify let alone manage asymptomatic noncommunicable disease (NCD) risk factors – represent the power urbanization has had on the health of new nations. Successful management requires new and complex systems, and a range of potential interventions including many that are not part of traditional preventive health. Our journey takes us not only far upstream, but far afield. Examples of non-health arenas in which assistance expertise will be required include agricultural subsidies in faraway lands and World Trade Organization agreements, unfettered marketing by food and tobacco industries, the lack of urban planning, school curricula that do not include a health component, as well as a health system locked into an acute care model because of need and demand. Reversing the trend of CVD risk factor acceleration requires new visions of public health, the embrace of health by nearly all cabinet ministries as part of a newly defined, economic-driven mandate, new models of assistance on the part of the donor communities, the enlistment of new


technologies, perhaps the most important of which is telemedicine, and an acceptance of a generational time frame for change. All of this presages an exciting era for global prevention of CVD and other major chronic diseases. The range of skills needed to be brought to bear on the issues is immense and should engage not just the existing global health assistance communities, currently ill-equipped to do it well, but the schools of public health that train leaders for the future demands of the field. Academic public health needs to embrace chronic disease with far greater vigor going forward than it has done in the past. This engagement will require far more complex changes in curriculum than adding new courses. The faculty of the Mailman School of Public Health at Columbia8 and we9 have argued, that public health must refocus on intervention at the population level and diminish its reliance on the biomedical paradigm. It must go upstream, and far upstream, to confront the societal drivers of CVD and chronic disease risk factor behavior. Any broadly effective universal health care system will be expensive everywhere, and the health budget cannot be viewed simply as an isolated ministerial line item in a national budget. The argument here is that every ministry needs to have a health-related portfolio as part of its overall mandate. This concept has been accorded a formal title, Health in all Policies, and put forth prominently in the report from the 8th Global Conference on Health Promotion in Helsinki in 2013.10 As health costs, including lost opportunity costs, exceed even the military budget everywhere there is a comprehensive health care system, public health needs and must push for a seat at the “big table”. In their global track, schools of public health in the Unites States focus on the triad of HIV/AIDS, TB and malaria, with HIV/AIDS holding an overriding dominance. In large part this is due to the “soft money” structure of these schools with faculty support being highly dependent upon external grants. HIV/AIDS attracts more than 60% of all U.S. global health funds and the triad gets upwards of 75%.11 Chronic disease draws off little more than a rounding figure buried in approximately 1% categorized as “other”. Faculty teach to their strength, and their current roles are endorsed by the support they receive from the leading funding organizations. These three diseases are surely important problems and will be so for years to come; however, their preeminent status is going to be challenged, and quite vigorously so, by the emerging epidemic of NCDs now prefaced by an increasing prevalence of traditional risk factors. As the Tanzanian population ages, the impact of stroke, other CVDs, diabetes, lung disease and cancer will wreak havoc, robbing the economy of its experienced, productive work force and families of their middle aged parents. However, the health care system in today's Tanzania, including its external assistance, is not focused on our hypertensive patient at risk. As incubators of the public health work force of the future, schools of public health need to have a long term vision and be willing to anticipate change. If HIV/AIDS continues on the trajectory outlined by UNAIDS 201212 and if NCDs, especially CVD and diabetes, continue what appears to be an inexorable ascendency, the academic public health community needs to


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be able to prepare a workforce that can assume a leadership role in that new public health environment. Looked at another way, these schools need to offer their students a pathway to a productive career; angry alumni 20 years hence ill-fitted to their jobs will not be generous. If the external global funding agencies were to redirect their attention to NCDs, academic public health would find itself embarrassingly unprepared. While many schools have global tracts, few if any, include substantive programs directed at NCDs. There are no NCD-fluent public health professionals emerging from this enterprise and hence no capacity for academic leadership to participate in the assault on these diseases. While the likelihood is low that the funders will pivot and redirect their resources in the immediate future, the lack of engagement will not be infinite. Both the 2011 United Nations General Assembly meeting devoted to NCDs and the 2012 release of the Global Burden of Disease data set13 offer intimations of coming change. As HIV/AIDS has evolved into a chronic disease, one quasi solution would be to refocus the HIV/AIDS work force on NCDs. However, the skill sets effective for HIV/AIDS management are more narrowly focused than those needed for CVD, diabetes, lung disease and cancer. The HIV/AIDS tool box includes skills for clinical management of a most complex disease both short term and long term, but as the NCD prevention focus will be on upstream drivers of both individual behavior and of a wide array of social, trade, and political policies, the experiential and educational preparation will be quite different. It will not be an easy transition for a mid-career professional. The upstream reach of chronic, often asymptomatic, NCDs requires a wide range of expertise so as to confront tax policy, trade policy, agricultural subsidies, urban planning, socioeconomic patterns of behavior, the impact of commercial advertising, as well as the complex issues that surround health care financing, patterns of universal health care delivery and determination of priorities. An HIV/AIDS worker may not be comfortable in this environment. The HIV/AIDS community has made powerful contributions in delivering drugs to patients and achieving high adherence rates and has shown that disease specific education in schools and selected populations can be effective.12 Reducing the impact of disease stigma is another arena of great success. Some have argued, quite persuasively, that AIDS has had a transforming impact on global health and global health assistance.14 The HIV/AIDS epidemic has united public health and clinical medicine tighter than ever before, elevated disease activism to a level of crucial necessity for clinical progress, and generated philanthropic support to unprecedented levels with economic and societal survival as the clearly defined long term outcome measures. But in spite of these glorious accomplishments, the HIV/AIDS work force is not well suited for the assault on NCDs. To train a work force for this role, schools of public health will need to go beyond their current confines and collaborate with many other university faculties, including medicine, business, law, international affairs, communication, urban planning, economics, sociology and anthropology. Hypertension control in Tanzania requires input from all of these experts, filtered through a new global health curriculum.

What can schools of public health do? Can they catch up? As soft money enterprises, few if any can fund major expansions or create new concentrations. Applicants still anticipate careers in HIV/AIDS and other even more traditional infectious diseases. But there are several paths to consider. One, the schools individually and collectively through their professional organizations need to approach the dominant funding organizations and make the case for the future. Two, the public health organizations can approach various national and international cardiac, cancer, and pulmonary societies for support of this effort; it is not inconceivable that these organizations themselves could initiate training grants and pilot studies for curriculum change. Three, curriculum initiatives can highlight the epidemic of chronic disease and begin to shift student interest toward these problems. Schools of public health are embedded in universities, all of which possess a broad array of disciplines that impinge on the drivers of risk factors of NCDs. These faculties can be recruited to participate in public health education at modest cost. Without abandoning a commitment to current problems, the schools can begin to assume a leadership role in creating a professional public health workforce committed to the future. Four, once an NCD curriculum is established, global assistance can replicate a Norwegian government funded program, established in the 1960s15 that educates public health leaders from emerging economies. Home grown masters and PhD public health professionals can then become research program directors, senior health ministry leaders and another nidus for inaugurating fundamental changes in national public health directions. As this symposium so amply demonstrates, there is an emerging excellence in NCD epidemiology and analysis in SSA, but it needs amplification and more robust funding. The message is clear. Our young asymptomatic Tanzanian hypertensive patient needs help. He, or she, is the harbinger of the future of the health portrait of the continent. While much of this help will come from local institutions and organizations, there will remain a large contributory role for academic public health. It is time to engage.

Statement of Conflict of Interest The author declares that there are no conflicts of interest.


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5. Hajjar I, Kitchen TA. Trends in prevalence, incidence, treatment and control of hypertension the United States, 1998–2000. JAMA. 2003;290:199-206. 6. Yoon SS, Bert V, Louis T, Carroll MD. Hypertension among adults in the United States, 2009–2010. NCHS Data Brief, No. 107; October 2012. (accessed 6/3/2013). 7. WHO, Country Profile: United Republic of Tanzania; Mortality and burden of Disease: Non-communicable Disease. (accessed 6/3/2013). 8. Fairchild AL, Rosner D, Colgrove J, Bayer R, Fried LP. The exodus of public health: what history can tell us about the future. Am J Pub Health. 2010;100:54-63. 9. Greenberg H, Raymond SU, Leeder SR. The prevention of global chronic disease: Academic public health’s new frontier. Am J Pub Health. 2011;101:1386-1391. 10. Organization World Health. 8th Global Conference on Health Promotion: Health in all Policies.

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Global cardiovascular disease and the academic public health curriculum.

The epidemic of cardiac risk factors and cardiovascular disease in developing regions has reached sub-Sahara Africa. This global reality needs to ener...
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