South-East Asia Regional Conference on Epidemiology

168 | <strong>South</strong>-<strong>East</strong> <strong>Asia</strong> <strong>Regional</strong> <strong>Conference</strong> on Epidemiology
The rationale for focusing on the prevention and control of cardiovascular diseases are: a) the
burden is rising in low- and middle-income countries; b) they affect people at the peak of their
productive lives; c) an integrated health system is required for all health needs, not for specific
diseases; d) there are cost-effective interventions available that, if implemented, would save lives,
reduce suffering and poverty; and e) reducing CVD risk factors will reduce deaths due to infectious
diseases (16,17,18,19).
In following up their 2005 initiative, WHO published a further set of articles in Lancet in 2007 to
present a strategy for the prevention and control of chronic diseases, with a strong focus on CVDs.
These articles updated the burden estimates, including economic burdens (20), providing costeffectiveness
estimates for both population (21) and high-risk individual treatments (22). A call to
action was mounted claiming that “36 million deaths from chronic diseases could be postponed by
public health and primary care in the next 10 years at a cost of US$1.50 per person per year” (23).
Calls to action on specific interventions
Tobacco: Full implementation of the WHO Framework Convention on Tobacco Control (FCTC) (24)
is an essential component of reducing the CVD burden. Action on smoking and health is variable in
the region and little attention has been given to the issue of taxation levels on bidis (25) or tobacco
crop substitution programmes. In Pakistan, these hand-rolled cigarettes are among the cheapest in the
world (US$0.25 for a packet of 10 cigarettes) and are widely exported.
Salt: A second strategy promoted by WHO and others is reduction in dietary salt intake with
estimates of profound reductions in high blood pressure, stroke and ischaemic heart disease (21).
However, empirical evidence on the ability of people to reduce their salt intake long term is not
encouraging (26). Voluntary restrictions on hidden salt by food manufacturers is also being promoted,
but it remains rather difficult in this region as the market is dominated by very large numbers of
small, non-regulated producers. Estimates of the costs of tobacco and salt restriction policies appear
affordable.
Drugs: A combination of effective drugs is proposed - comprising aspirin, a statin and two blood
pressure-lowering drugs (22). This combination approach scores highly in reducing deaths and events
and has a low average cost of US$1 per person per year. Such drugs are now being evaluated in largescale
trials and should offer real benefits if coverage and adherence can be assured.
However, there are considerable uncertainties in implementing these prevention packages through
“calls to action” which have been discussed (27,28,29).
Are they really affordable? Reallocation of health budgets is rather difficult to achieve in countries
that are spending only 1%-3% of their gross national income on public health services. There is
seldom any space for new spending with resources fully committed to existing programmes.
Is it clinically relevant? Doctors and nurses in developing countries are already overwhelmed with
acute clinical problems. How to re-orientate their practice to changing disease patterns? The training
and reorientation of all levels of the health system workforce to respond to changing demography and
epidemiology is essential but has not yet been implemented.
We’re all going to die! The debate about CVD prevention has not taken notice of the fact that
competing causes of morbidity and mortality and co-morbidities will increase markedly when a greater
proportion of the population survives to older ages. Preventing a CVD death at age 50 may result
in survival to 70 but with complications and increased health care costs. Modelling the life-course
trajectories of prevention strategies will be an important means of providing evidence on relevance
(or otherwise) of this issue.