5th International Heart Health Conference (2004)Reflection on the 5th International Heart Health Conference in Milan (June 13-16, 2004) I am writing this letter to the subscribers of ProCOR to share my feelings (mixed), after attending the recent International Heart Health Conference in Milan. About 300 physicians, scientists, researchers and community health workers attended it. I am writing this letter with the intention of getting a healthy, constructive dialogue from the readers. But for a notice in the ProCOR, I would have missed this meeting. Thanks for the public platform ProCOR has provided us, for discussing the issues related to non-communicable diseases (NCDs). Scientists, physicians and clinicians have done a marvelous job of conducting epidemiological investigations, organizing community studies, conducting clinical trials and arranging international workshops and conferences in Italy on NCDs. Italy has lowest incidence of Coronary artery disease in the CINDI group, yet has been doing so much to promote the prevention of these diseases. I salute the efforts of these various active groups in Italy. According to WHO, significant disease burden in the future will be in the developing countries. Over 75% of the CVD deaths occur in the resource poor countries of the world. If we are talking about global disease burden, those are the places where immediate action is needed. Yet, when we look at the representation of delegates from these countries in any major conference discussing issues related global health, it is bare minimum. This conference was no exception. India with the highest NCD burden had no representatives. Main reason for such conspicuous absence of delegates from these developing nations is lack or resources. That brings us the question of whether are not such important conferences should be held in less developed world. On the same lines, sometimes I think, that if WHO head quarters are located in less developed country, it may better serve the needs of these countries. I may be wrong on both the counts, but I welcome response from the readers. Speaking in general terms, developing countries, which face this tremendous disease burden, have the least resources, to combat the ever increasing NCDs. There is a great need to think through, develop appropriate action plan for these countries, to address the issues related to the prevention of NCDs During a session on "Tobacco Initiative" a young energetic cardiologist from American University Beirut (Dr. Sameer Jabour?) expressed his disappointment with what was happening in terms of preventive programs. He said it is time to get angry and put some teeth in this problem. May be, majority of the delegates did not like the tone and the passion that he showed. Some of us, who were equally disappointed, did not have the guts or conviction to stand up and express our feelings. I congratulate this young committed cardiologist, for raising issues with this panel on tobacco initiative. We need to get angry at what is happening in the area of global health programs. We should take a very active role in promoting the global health. Just organizing conferences and passing declarations (Victoria1992,--- Milan, 2004) will not solve the serious issues related to NCDs in the resource poor countries. What is applicable for the "Market Economies" is not applicable to these countries. Therefore, new action plans have to be developed and ways and means to implement such plan should be seriously considered. I am sorry; I missed the session on Benefits of Professional Education for Cardiovascular Disease Prevention. I sure would like to know more about the Canadian project Teaching the Teacher, which has trained health care workers in methods of patient education for hypertension. I for one would like to know more about this project in India. Canadian Heart Health Initiative (CHHI) has done marvelous job in the areas of prevention and management of CVDs. It is a great model for the developing countries. I cannot understand, why South Asian Countries (India, Pakistan, Bangladesh and Sri Lanka), who are members of the British Commonwealth, have not taken advantage of the rich experiences of CHHI. In the session on Regional Networks and Global Forum Dr. Glasunov of Russian Federation presented an impressive list of international collaboration (WHO/CDC, NHLBI, CHHI and Karolinska Institute). It is high time, that India with the highest diabetes disease burden should enlist such international collaboration and develop appropriate action plan, for the prevention and management of NCDs. In a session entitled National Plans for Heart Disease and Stroke Prevention Dr Sania Nishtar, President of Heartfile, Pakistan, described the process by which Pakistan developed its newly released National Action Plan, a collaboration among Pakistan's Ministry of Health, the WHO Pakistan office, and Heartfile (an NGO). In summary the plan included reviewing available epidemiological data, exploring best practices, examining existing projects and developing priorities for implementation and identifying the resources. It incorporated networking with various agencies involved in health care delivery. It included use of television as a media for providing health promotion information to the public. I was pleasantly surprised about the affluence of Pakistan (According to Dr. Nishtar 95% of Pakistan's population has access to television). I wonder what percentage of people in India, Bangladesh and Sri Lanka has access to the TV? Anyway, we need such action plans in every developing country and resources to implement such projects. There were discussions about PREMISE project of WHO, in participating countries. When we are discussing about cost-effective intervention, we forget that 2/3rds the population in these countries, who live in rural areas have no access or minimum access to the public health projects. According to WHO, money spent on a week's supply of Statins (lipid lowering drugs) in developing countries can buy 25 kgs of rice. How many can afford such expensive therapeutic interventions? What is the solution for these problems? How do we address the problems associated with the global disease burden and as a result the economic burden? What we need is commitment and political will in these countries. We need committed volunteers, a network of NGOs and health care groups. We need to develop cost-effective diagnostic methods to detect the development of vascular dysfunction even before the classical CVD risk factors develop. We need to develop cost-effective intervention methods. We need cost-effective risk management programs. In general we need an action plan suitable for these countries and the resource and the will to implement these action plans. I was pleasantly surprised and quite impressed by the programs developed in Iran at the Isfahan Cardiovascular Research Center, a WHO Collaborative Center for Research and Training in Cardiovascular Disease Control, Prevention and Rehabilitation for Cardiac Patients. I was equally impressed by the director of this institute, Dr Nizal Sarraf-Zadegan, who has played a very active role in bringing the WHO collaboration and the participation of the Ministry of Health of Iran. We need such a National Platform in each of the developing countries to address the issues related to the prevention of NCDs. In a recent publication on Global Prevalence of Diabetes (Diabetes Care 27, 1047-53, 2004), India tops the list for the highest prevalence of diabetes. This trend will continue next three decades and by 2030 India will have 150% increase in the prevalence of diabetes. Conspicuous absence in this list of ten countries is Pakistan, Bangladesh and Pakistan. It is food for thought for researchers in this area to analyze this paradox. All these four countries (India, Pakistan, Bangladesh and Sri Lanka) have very high incidence (4 to 5 fold higher) of Coronary Artery Disease compared to any other ethnic group in the world. Yet, the incidence of diabetes in these countries seems to vary significantly. Is it the diet (high carbohydrate in India?), genetics, environment or better education that is responsible for this difference in the incidence of these diseases? Bangladesh with relatively low incidence of diabetes, compared to India has a WHO center for Diabetes. It is high time that India, as leader in the prevalence of diabetes, approach international collaborators (WHO, CDC, NHLBI, NIDD, CHHI) to address the issues related to these NCDs. Others and I have been trying to bring WHO collaboration to India with no success. There is an excellent platform for diabetes epidemiology and research in Chennai, India. It is high time the policy makers in India as well as at WHO should work together and initiate the development of a national platform to address the issues related to Diabetes. In conclusion, we need to change our thinking when addressing the global heart health. Much of the action should be where the action is needed. We will benefit better if we establish national platforms in the developing countries, so that they can develop appropriate action plans to suit specific requirements in the management of health care. International players such as WHO, NIH, CDC and CHHI should develop some flexible programs to address the needs of the developing countries on need basis. After all these diseases pose global health burden and drain the global economy. Time to sit and wait for the invitation from each developing country is over. It is high time; the international organizations should get involved in the development of appropriate plans, to combat this global health menace. We need more youngsters; who can stand and express their anger and frustration at the pace in which prevention programs are being developed and implemented. We need NGOs who can bring the respective health ministries and international collaborators to develop customized action plans. We need leaders to organize and run the National platforms in each of these countries. At the level of individual workers we need dedicated people like Shakuntala Chokkalingam who presented data on the community health project in the hometown of Karikudi, Tamil Nadu. With her commitment and dedication, she was able to establish a clinic to create awareness of CVD risk factors at a rural setting in Tamil Nadu, India. We need such clinics in every village in the developing countries. I hope when we meet again in three years, we will have a better representation from the developing countries. Gundu H. R. Rao, Ph.D
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