Prevention better than cure…

Tackling cardiovascular disease in the Seychelles

Von Pascal Bovet

Cardiovascular disease is becoming a leading cause of morbidity and mortality in developing countries while they go through the ‘epidemiologic transition’. An intervention program in the Seychelles (Indian Ocean) is presented as an illustration. Prevention and health promotion should be initiated promptly in developing countries to impede the up-surging epidemic and avoid the future burden of disease in young and middle age adults.

Emergence of cardiovascular disease

The rapid raise of cardiovascular disease (CVD) in developing countries is becoming a main challenge for public health and socio-economic development. It is often not realized, possibly due to concurrent dramatic and important other problems, that the global burden of CVD is already larger in developing than developed countries (1). The combined morbidity and mortality burdens (expressed as disability-adjusted years of life lost) due to ischemic heart disease and cerebrovascular disease in developing countries are anticipated to rank 1st and 4th in 2020, compared to 6th and 7th in 1999. For example, the probability of stroke death is several folds higher, at all ages, in Tanzania than in the UK (2). CVD have a large impact on the health of economically active adults, on whom young and old members of the population are often dependent.

The epidemiological transition

The raise of CVD in developing countries results from the ‘epidemiologic transition’, which provides the framework linking changes in disease patterns with demographic and social changes (3). The first engine of the epidemiological transition is the rapidly ageing population thanks to improved sanitation and nutrition and better infectious diseases control. Prolonged survival allows for longer exposure to CVD risk factors and results in larger numbers of diseased persons. Industrialization and urbanization favor sedentary habits, tobacco use and unfavorable dietary patterns. These lifestyle changes are detrimental to heart health, by promoting risk factors such as hypertension, overweight and blood lipid disorders. The shift from early transition diseases (infections and malnutrition) to late transition diseases (CVD and other chronic diseases) is rapid, large and consistent among most developing countries.

Mixed effects of the globalization

Globalization, which can be characterized by intensified social, political, economic, and environmental interactions, is closely linked to CVD. Liberalization of trade favors tobacco use and the adoption of several unhealthy dietary patterns (e.g. increased consumption of fatty foods and carbonated drinks -‘coca-colanization’). On the other hand, improved economic growth benefits health, including among the poor (4). Liberalization of trade can result in improved dietary patterns, e.g. consumption of less animal products and more fresh fruit and vegetables in Hungary after markets became liberalized in the early 1990s (5). Global political public health tools can be created to counter transnational political or economical influences. The Framework Convention for Tobacco Control, which is currently being drafted by the member states of the World Health Organization, is an example. By calling for strengthened tobacco control measures and legislations in signatory states, this international legally binding treaty will help decrease tobacco use worldwide.

The situation on the Seychelles

The Republic of Seychelles in the Indian Ocean has developed rapidly over the last 30 years, partly due to a booming tourism industry. GDP per capita increased in real terms from $2927 in 1980 to $5731 in 1999. In that time, infectious diseases have been tamed and infant mortality has dropped from 50 to 10 per 1000 live births. As a result, the absolute number of people in their 30s and 40s has doubled over the last 20 years and lifestyles and consumption patterns have dramatically changed. Data from the local vital statistics showed that CVD accounted already for as much as 30-40% of all deaths in the late 1980s. Baseline surveys in 1989 and 1994 showed that the prevalence of high blood pressure, obesity (women), smoking (men) and raised blood cholesterol levels were at least as high as in Western countries.

The prevention and promotion program

Recognizing the need to curb the increasing incidence of CVD, the Ministry of Health established a primary prevention program in the early 1990s, in collaboration with the University Institute of Preventive Medicine of Lausanne, Switzerland. A dual approach was considered: screening and treatment in high-risk individuals while fostering population-wide preventive activities, starting in childhood, to reduce risk factor levels in the entire population.

Population approach and health promotion components include:

  • Sustained mass media campaigns, largely through the radio and one channel national television. Healthy lifestyles are promoted, including the need to abstain from smoking, to adopt healthy dietary patterns and to practice physical activity regularly. In this tropical small island state, the campaign also largely stresses the benefits of locally available products such as fish and tropical fruits and vegetables.
  • High profile events are organized every year for World No Tobacco Day, Diabetes Day and Heart Day. These internationally sponsored events are favorably received by the mass media, which permits to produce a wide range of health education programs inexpensively.
  • A national committee on tobacco control has been set up and is working towards the development of a national tobacco control program including appropriate legislation.
  • National policies for healthy nutrition and for physical activity for all are being developed.
  • Training programs aim at updating health professionals on the need and means for CVD prevention and health promotion.

Various activities also focus on persons at high risk:

  • Screening programs in work places and public places permit to detect persons with high blood pressure and with diabetes. Proper counseling and health talks are subsequently administered to promote healthy lifestyles. This also provides opportunities to discuss with workplaces’ managements concrete options for improving the working environment and to enable workers to adopt healthier lifestyles.
  • Routine screening for overweight and high blood pressure among children provide credence and support to the integration of health education programs within the normal school curriculum.
  • A ‘Heart Health Club’ program is held regularly in many health centers throughout the country. These clubs gather a dozen of patients with hypertension and/or diabetes over an afternoon to provide them with in-depth information on CVD, the need to adopt healthy lifestyles and to comply with prescribed treatment.
  • Standards are being set for the clinical management of the main CVD, including the development of locally sound guidelines for the diagnosis and treatment of hypertension, diabetes and blood lipid disorders.

Impact of the program and future challenges

It is difficult to distinguish the specific impact of the program from the effects of external influences, such as the pressure to adopt a ”western” lifestyle (that brings about both favorable and unfavorable factors for heart health). A study has shown that knowledge about CVD among the population was good and that smoking prevalence had stabilized. However, several indicators, such as the high prevalence of overweight among children (6 and limited control of high blood pressure (8) and diabetes in many patients, show that there is much room for improvement.

Challenges are:

  • The adoption of new social norms that favor healthy lifestyles, including body weight control, no smoking habits, regular physical activity and a healthy diet.
  • Multisectoral interventions to provide an environment enabling the adoption of healthy lifestyles by the public, e.g. measures that increase the availability and affordability of healthy foods.
  • Fostering political will to prioritize prevention programs of non-communicable disease in the face of concurrent priorities, economic pressure and increasing demand for curative care.

More generally, it is urgent to recognize the up-surging CVD epidemic in low- and middle-income countries and the need to prevent this impending burden, which will add to a residual large burden of infectious diseases. The epidemic is still at its upswing and could largely be avoided if addressed at an early stage. Most developing countries will not be able to afford the considerable costs incurred by a control strategy that would rely predominantly on treatment –as this has been the case in western countries (8, 9). These different constraints are well illustrated by the annual expenditures for health that amount to ~$10 in Tanzania, ~$250 in Seychelles, and ~$3000 in some western countries or by the actual number of cardiac surgery: less than 30 interventions per 1 million people in Africa and Asia compared to around 1000 per 1 million people in the USA.

The question is not whether we can afford not to invest in cardiovascular disease prevention and related health promotion, but whether we can afford not to invest.

*Pascal Bovet, MD, MPH, senior lecturer at the Institute of Social and Preventive Medicine, Lausanne, Switzerland, works as a consultant for the Ministry of Health, Victoria, Seychelles. Contact: pascal.bovet@inst.hospvd.ch. Parts of this article were first published in ID21 Insights Health, March 2001.

References

1. Murray CJL, Lopez, eds. The global burden of disease: a comprehensive assessment of mortality and disability from diseases, injuries and risk factors in 1990 and projected in 2002. Cambridge, MA, Harvard School of Public Health, on behalf of the World Health Organization and the World Bank, 1996.

2. Walker RW, McLarty DG, Kitange HM, et al. Stroke mortality in urban and rural Tanzania. Lancet 2000;355:1684-7.

3. Omran AR. The epidemiological transition. A theory of the epidemiology of population change. Millbank Memorial Fund Quarerly 1971;4:509-38.

4. Feachem RGA. Globalisation is good for your health, mostly. Brit Med J 2001;323:504-506.

5. Zatonski WA, McMichael AJ, Powles JW. Ecological study of reasons for sharp decline in mortality from ischaemic heart disease in Poland since 1991. British Medical Journal 1998; 316: 1047-1051.

6. Stettler N, Bovet P, Shamlaye H, Zemel BS, Stallings VA, Paccaud F. Prevalence and risk factors for overweight and obesity in children from Seychelles, a country in rapid transition: the importance of early growth. International Journal of Obesity 2002;26:214-9.

7. Bovet P, Burnier M, Madeleine G, Waeber B, Paccaud P. Monitoring one-year compliance to antihypertension medication in the Seychelles. Bull WHO 2002;80:33-39.

8. Beaglehole R. Global cardiovascular disease prevention: time to get serious. Lancet 2001;358:661-63.

9. van der Sande MAB, Coleman RL, van der Loeff M, et al. A template for improved prevention and control of cardiovascular disease in Sub-Saharan Africa. Health Policy & Planning 2001;16:345-350.