The World Health Organization’s 2002 World Health Report showed that more than three-quarters of all cardiovascular disease is attributable to a few reversible risk factors, such as high blood pressure, high cholesterol and cigarette smoking. While these factors have traditionally been thought of as “Western risks”, it is clear that their greatest impact is now on the populations of the developing world. For example, about two-thirds of all blood pressure-related disease affects individuals from low- or middle-income countries.

A large number of studies have shown that the benefits of controlling the major risks accrue rapidly. For example, a few years of lowering cholesterol or blood pressure appears to be enough to largely reverse the risks associated with decades of exposure to high cholesterol or high blood pressure levels. Reducing the same risk factors has also been shown to rapidly reduce risks of the cardiovascular complications of diabetes. Similarly, within just a few years of quitting, ex-smokers have about the same risk of heart attack as never-smokers; however, the earlier smoking is ceased, the greater the health benefits achieved. What is required now is evidence about how best to deliver effective prevention programs in a manner that is affordable, equitable and appropriate for a range of low- and middle-income countries. At present, the only established models of preventive care are those developed for high-income countries such as the US. The development and evaluation of programs designed for use in resource-poor settings is a priority.

The recent report of the Commission on Macroeconomics and Health demonstrated that premature mortality is a barrier to economic development. As indicated above, cardiovascular disease and diabetes are now leading causes of premature death in many low- and middle-income countries. Reduction of this burden by cost effective means can therefore be expected to have important consequences for economic and social development. The Commission suggested that interventions costing less than two to three times gross domestic product (GDP) per capita for each healthy life year gained represented good value for money. Many simple primary health care-based strategies for the prevention of cardiovascular disease and the control of diabetes meet this definition. For example, highly effective and safe off-patent medications to lower blood pressure or cholesterol are now available for only a few dollars per person per year. Aspirin is also a cheap and effective means of preventing heart attack in high-risk individuals. Moreover, there are low-cost risk assessment strategies with which it is possible to identify the few percent of individuals who suffer almost half the entire cardiovascular disease burden. However, there is still a pressing need for more comprehensive assessments of the cost-effectiveness of prevention programs designed for delivery through community health services in low- and middle-income countries.

View major causes of lost healthy life years (DALYs) in developing countries