"Our Greatest Challenge": Tackling CVD in Developing World

December 03, 2008

December 3, 2008 (Sydney, Australia) — A new report is highlighting once again the danger of a cardiovascular disease (CVD) epidemic in many low- and middle-income countries, with the prediction that 85% of cardiovascular deaths worldwide will occur in such nations by 2030 [1]. The article demonstrates the widening gap between rich and poorer countries and the "irrepressible" rise of risk factors, the lack of primary-care facilities for chronic disease, and the unaffordable costs of treatment in low- and middle-income countries.

Dr Rohina Joshi (George Institute for International Health, University of Sydney, Australia) and colleagues publish their findings in the December 2, 2008 issue of the Journal of the American College of Cardiology. They are particularly critical of the lack of resources currently directed toward solving the problems arising from CVD in low- and middle-income countries, stating that the key players who determine priorities for international health investment have not heard their previous calls. Chronic disease attracts only 5% of the entire WHO budget, they note, and major health development funds, the World Bank, regional development banks, and bilateral aid programs have neglected funding for major CVD prevention and control. The Bill and Melinda Gates Foundation also excludes CVD from its list of priority diseases and conditions, the researchers add.

We know what treatments work, and what we need is to find out is which model of care works best in these settings.

But Joshi et al stress that it is not too late to intervene, and there still exists "a window of opportunity" to prevent the epidemic from reaching its full potential and magnitude. To achieve this, the rapid deployment of strategies already proven to be effective in high-income countries is required, and such strategies need to be tailored for low- and middle-income countries for them to be affordable, effective, and accessible to all, they say. In their paper, they use the example of rural China to illustrate many of the problems facing low- and middle-income countries in their management of cardiovascular disease and to suggest ways in which these issues could be tackled.

When asked by heartwire what is the one thing that would make the most difference, Joshi said: "Galvanizing political will at all levels--including international agencies, national governments, local-level healthcare providers, and members of the community themselves--to make changes happen. We know what treatments work, and what we need is to find out is which model of care works best in these settings. Hence, translational research is needed to determine how to bridge the evidence-practice gap."

The Key to Tacking CVD Is to Improve Primary-Care Systems

Although it is now well-recognized that CVD is a major and growing health problem for low- and middle-income countries, what is less well-known is the fact that it is also a major cause of the widening inequity in the health status of the rich and poor within these counties, say Joshi et al. CVD can no longer just be considered a disease of affluence in these nations.

Fueling the increasing mortality rates from CVD in low- and middle-income countries are upward trends in the prevalence of obesity, high blood pressure, tobacco smoking, and diabetes. In China, for example, obesity has increased fourfold in the past two decades. And "the most striking feature" of the cardiovascular disease burden in low- and middle-income countries is the fact that this disease occurs at relatively young ages in these countries, they say.

A critical feature of any strategy for prevention and treatment of CVD will be to reorient primary-care systems to more effectively deliver the care required for chronic disease management, the researchers note.

Primary-care systems in many low- and middle-income countries have evolved to cater to infectious diseases, injuries, and childbirth, so that they often provide episodic rather than continuing care, with a failure to maintain medical records. Primary care needs to be geared toward using absolute risk to identify individuals who would benefit most from medical intervention, they note, which involves assessing risk on the basis of multiple risk factors and CVD history. Various risk-prediction tools--such as Framingham--need to be recalibrated and validated using data from low- and middle-income countries.

And although safe and effective preventive treatments are available at low cost and have been successfully employed in richer nations, resulting in a decline in cardiovascular mortality in these countries, a range of issues currently prevents the same interventions from being successfully deployed in low- and middle-income countries, the researchers say.

Reasons for Treatment Gaps Are Complex

"The reasons for these treatment gaps are complex," Joshi et al observe. Many essential preventive medicines, such as genetic diuretics, ACE inhibitors, and statins are not readily available through the public sector in many developing countries. They are more often available through the private sector, but with a generally several-fold higher cost. And there is enormous variability worldwide in the costs of medicines, they add. For example, a one-month course of combination therapy for secondary prevention varies in cost from 1.5 days' wages in Sri Lanka to 18 days' wages in Malawi.

In this respect, the concept of the CVD "polypill" for disease prevention is attractive, they note. Other cost-effective strategies include nicotine-replacement therapy for smoking cessation and fixed-dose blood-pressure–lowering therapy for those with moderate to severe hypertension.

Using the example of rural China, they illustrate many of the other problems that contribute to this treatment gap. Healthcare providers there are paid according to the services provided, with commissions from the sale of medicines being a significant component. This "discourages prevention and encourages the overuse of high-technology diagnostic tests, prescription of expensive drugs, and prolongation of hospital admissions."

Treatment choices become more about the price. . . . This has corroded people's confidence in the system.

Coauthor Dr Yangfeng Wu (George Institute China, Beijing) explains: "Treatment choices become more about the price of the treatment and the amount of income to be paid to the health worker, rather than the effectiveness of the treatment for the patient's illness. Over time, this has corroded people's confidence in the system."

Also essential to progress will be innovative approaches to personal healthcare financing, say the researchers, given that most healthcare expenditures are out-of-pocket in low- and middle-income countries, and it "is unlikely that the public-health systems of most developing countries will pay for primary CVD care in the foreseeable future." Hence, systems of prepayment or community insurance need to be developed and deployed, they note.

Solutions Exist

But Joshi told heartwire she is hopeful about the future: "There are solutions [as outlined above] that can prevent this disease and manage the current situation."

"We work with [nongovernmental organizations] NGOs and conduct workshops to disseminate our findings. We also make an effort to meet the relevant ministries of these countries to present our findings. For example, our work in India has been published and discussed at several levels, including discussion with the minister of health of India."

Nevertheless, she stresses, "More field studies are needed to demonstrate to policy makers the effectiveness and cost-effectiveness of such interventions in various settings."

  1. Joshi R, Jan S, Wu Y, et al. Global inequalities in access to cardiovascular healthcare. Our greatest challenge. J Am Coll Cardiol 2008; 52:1817-1825. Abstract



face="Verdana" size="1">The complete contents of Heartwire , a professional news service of WebMD, can be found at www.theheart.org, a Web site for cardiovascular healthcare professionals.

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