As the cardiovascular disease epidemic adds to existing burdens in developing countries, the challenges are great, but a multitude of opportunities also are available to stem this tide, starting with population level interventions. Fortunately, current knowledge about the causes of cardiovascular disease can direct public health interventions. Although genetic variability exists among different ethnic groups, common environmental risk factors such as obesity, high saturated fats diets, and smoking play major roles in the development of cardiovascular disease. Public health efforts aimed at minor changes in behaviors such as smoking cessation, lifestyle and diet modifications, and exercise can lead to significant reductions in cardiovascular morbidity and mortality. In primary prevention, the strategy is often on a population level, seeking to reduce the burden of disease in the community as a whole, frequently resulting in only smaller benefits to individuals. In secondary prevention, the strategy is to treat high-risk patients, providing larger benefits, but to fewer individuals.[15] In both cases, limited resources unfortunately hinder treatments and accessibility to primary and specialty care providers.

In seeking solutions to this problem, one must first identify the public health intervention challenges, and then, the opportunities. For many years, population control, infant survival, and infectious diseases have been the focus of global health resources. Many countries must deal with a multitude of barriers to the provision of high-quality health care, such as lack of education, health care provider shortages, and limited access to medications. Currently, few investments and fewer resources are directed toward preventing chronic disease compared with the resources directed at infectious diseases. In addition, political strife, migration (forced or otherwise), rebellions and war, and the inability to achieve cooperation among leaders have been major obstacles to creating sustainable long-term solutions.  Public policy efforts in cardiovascular health need to become a government priority to create the appropriate environment for reducing this disease burden.

The development of a health care infrastructure, such as having a trained health care workforce, pharmaceutical distribution networks, and community clinics and hospitals, must be established to allow community leaders and health care workers to administer basic services and education programs.

Fortunately, in many countries, an infrastructure exists for the treatment of infectious diseases such as HIV/AIDS and tuberculosis. Developing countries can build on the infrastructure for these infectious diseases by providing additional cardiovascular training for health care workers, utilizing similar drug procurement programs to obtain antihypertensive and lipid-lowering agents, and creating policies that facilitate the screening and treatment of cardiovascular disease at the same clinics and outreach programs that currently focus on infectious diseases.

In 2001, the WHO called for the creation of national commissions on macroeconomics and on health with the health effort focusing mostly on poverty, HIV, and infectious disease in the developing countries.[16] The purpose of the commissions was to help the world’s poorest countries allocate appropriate resources, train personnel, and make public health a vital national issue. These same programs could be applied to cardiovascular disease. For example, the Global Fund to Fight AIDS, Tuberculosis, and Malaria is an international financing institution that invests billions of dollars in 140 countries to support large-scale prevention, treatment, and care programs against the three diseases.[17] This type of program can be applied toward setting up funds to provide resources to combat the rapidly emerging cardiovascular epidemic.

Effective and inexpensive interventions to combat cardiovascular disease are needed. First, worldwide, it is important to focus on the promotion and education of healthy lifestyles, such as have been widely applied in Western Hemisphere countries. In much of the developed world, health fairs in schools, workplaces, and the community are common. In contrast, in the developing world, resources are minimally allocated toward health education. Moreover, there is a dearth of resources directed at health care research. The limited research publications consist mostly of case reports and case series, rather than randomized controlled trials, and most of the research continues to focus on infectious diseases rather than on cardiovascular health.[1]

CIGARETTE SMOKING
Cigarette smoking is a major cause of death and an important risk factor for cardiovascular disease. According to the WHO, about one-third of the adult male population smokes and, in the developing world, tobacco consumption is rising by 3.4 percent per year. The WHO estimates that by 2020, tobacco is expected to be the single greatest cause of death and disability worldwide, accounting for about 10 million deaths per year.[18] Globally, China, with its population of more than 1 billion, is the world’s largest producer and consumer of tobacco. A prospective cohort study of 169,871 Chinese patients showed a dose-response association between packyears smoked and all-cause mortality in both men and women.[19] This study and others have led to further recognition of the need for government-regulated programs for tobacco control and cessation. In 2003, the WHO Framework Convention on Tobacco Control called for countries to adopt such initiatives as tobacco price and tax increases, advertising bans, and warning labels for packages.[20]

In the United States, cigarette manufacturers are mandated to place warning labels on cigarette packets and tobacco advertisements geared toward children are regulated. Increasing numbers of public service announcements focus on the deleterious consequences of tobacco as well as bans on smoking inside most buildings, restaurants, and public areas. More recently, in 2009, Congress passed a bill empowering the Food and Drug Administration to regulate, though not outlaw, tobacco. A New York State smoking ban resulted in an 8 percent decrease in admissions for acute myocardial infarction with a savings in direct health care costs of $56 million in 2004.[21] Internationally, in 2004, Ireland became the first country to enact a nationwide comprehensive smoking ban in all workplaces, restaurants, and bars. These smoking bans are effective. Other countries across Europe and North America have followed suit and have mandated smoking bans in public areas. If these initiatives are applied worldwide, they could do much to reduce the global burden of smoking-related morbidity and mortality. Individually and collectively, these efforts represent both effective and potentially cost-saving ways to promote cardiovascular health.