There are three points I wish to raise in response to the statement by Lenfant (1). The first is that cardiovascular diseases (CVD) are already leading causes of mortality and morbidity in many low-income and middle-income countries. For lack of action, the situation is getting worse in these countries and the level of cardiovascular risk factors is now high. Today, more than 80% of smokers live in poorer countries, partly because of inadequate tobacco control initiatives (2). While tobacco consumption is falling in most industrialized countries, it is increasing in developing ones by about 3.4% per annum. Overall, smoking prevalence among men in developing countries is about 48%. In terms of other cardiovascular risk factors, studies also clearly show that high blood pressure and glucose intolerance are at least as prevalent in poorer populations as they are in richer ones. Action to prevent these diseases and their determinants is therefore long overdue.
The second point is about the strategies for CVD prevention in low-income and middle-income countries. Lenfant rightly states that since the risk factors for CVD are the same in different populations, reducing them can be expected to slow down the rise of CVD. There is no controversy over the importance of tackling risk factors. As stated in the global strategy for the prevention and control of noncommunicable diseases, which was endorsed by the World Health Assembly in 2000, health promotion and disease prevention are the most important components of reducing the burden of premature mortality and disability due to CVD. This is seen as the most feasible approach, particularly in low-income populations experiencing a rise in risk factors due to the epidemiological transition (3).
I agree that there is no reason to doubt that strategies for CVD prevention which have worked in established economies would work in developing ones too. However, the main challenge is in implementing these strategies through community-based action and health system interventions. It is not enough to recognize the need and increase the commitment of policy-makers. Considerable constraints have to be overcome before the successful work of developed countries can be fully translatable. It is because of these constraints that many countries in which CVD is a leading cause of premature death have failed to take comprehensive action or establish effective prevention programmes.
Health care systems are unable or ill-prepared to provide the services needed to prevent CVD. In many developing countries, there is no clear strategy for health or appropriate approach to delivering health services in the context of limited resources. …