Preventing heart diseases

Interview with Dr. Arun Chockalingam.

Heart disease will become a major cause of death and disability in the new millennium. The World Health Organisation (WHO) says that cardiovascular diseases (CVDs) already claim some 15 million lives every year, 10 million of them in developing countries . According to Dr. Arun Chockalingam, Adviser to the Canadian Ministry of Health, the prevention of cardiovascular diseases acquires great importance in a situation in which most developing countries have an annual health-care budget of not more t han $25, (about Rs.1,050) per person.

The abysmal health-care infrastructure in developing countries, which have few programmes for the control and prevention of CVDs, was highlighted by a World Heart Federation (WHF) report, "Impending Pandemic of Cardiovascular Diseases - Challenges and Op portunities for the Prevention and Control of the Disease in Developing Countries and Economies in Transition." Dr. Chockalingam is the chief editor of the report. According to the report, inadequate legislation on such issues as tobacco sales and food l abelling, which are crucial to the prevention of CVDs, has caused a CVD pandemic in these countries and that warrants urgent attention.

A member of the Geneva-based WHF, an international body of cardiology societies and heart foundations, Dr. Chockalingam was elected a Fellow of the American College of Cardiology this year. His epidemiological surveys and patient awareness programmes, wh ich bring together professional associations and voluntary agencies, have led to a pragmatic approach to preventive medicine.

Several Canadian and international research groups have sought the expertise of Dr. Chockalingam, who combines in him an engineer (he is an M.S. in biomedical engineering from the Indian Institute of Technology, Chennai) and a doctor (he has a Ph.D. in c ardiac physiology and pharmacology from the Memorial University of Newfoundland, Canada).

Dr. Chockalingam is special adviser to the Executive Committee of the World Hypertension group; chairman of the Patient Educating Project in Canada, and co-director of the WHO Centre for Research and Training on stroke prevention, epidemiology and survei llance in Saskatoon, Canada. He is on the advisory committee of several journals; he was the editor-in-chief of Hypertension Control from 1991 to 1994. Dr. Chockalingam has to his credit over 150 papers published in international journals. He has written some chapters of three textbooks on cardiology.

Recently in Chennai to deliver the second E.S. Krishnamoorthy Endowment Lecture, Dr. Chockalingam spoke to Asha Krishnakumar on the WHF report, the risk factors of heart diseases, their occurence, and the ways to prevent CVDs. Excerpts from the in terview:

What is the purpose of the recent report brought out by the World Heart Federation?

One of the major initiatives from a global perspective is the anticipated and growing incidence of heart diseases, particularly in developing countries. In fact, the magnitude of the problem is such that we do not call it an epidemic, but a pandemic. No single agency or government can tackle it. The problem is global and the solution has to be global. So, to initiate a process, the WHF surveyed 143 developing countries and economies-in-transition.

Basically, the report says that heart diseases are on the rise in developing countries, particularly in India and China. The West suffered from this problem for 40 years but now it is on the decline there.

What causes these cycles - the rise and fall in CVDs?

Many developing countries are going through an economic transition, which is accompanied by an epidemiological transition. People moving from rural to urban areas compete for space, water and other infrastructure. In multi-storeyed buildings, where there used to be just one family, between 25 and 30 families live now. In India, for instance, the infrastructure - the sewage system, hygiene and health care facilities - was planned for 50 years ago. But even as the economy grew and people shifted from rura l to urban areas, the issue of infrastructure was not addressed. All these led to the re-emergence of infectious diseases.

So, a country like India faces a double burden - death and disability due to infectious diseases and a new wave of non-communicable diseases, particularly cardiovascular. Unless we address the fundamental problem and arrest the progress of these diseases in the next 20 years, India will face problems of unmanageable proportions.

What are the reasons for the rise in the incidence of non-communicable diseases?

There are many reasons. First, urbanisation and the rat race. There is no time to eat a proper meal, to exercise. Food habits change and one ends up eating less nutritious food. The lack of physical activity leads to obesity. For humans, the energy intak e should equal the energy output. If there is no such balance, the excess energy will accumulate in the body as fat. This increases the risk of CVDs.

What other issues does the report address?

Since CVDs are assuming pandemic proportions globally, the major issues we try to document are the resources, infrastructure and systems available in developing countries and the economies-in-transition of Eastern Europe, where CVDs are going to be a maj or problem in the next 20 years.

The book also pins down the responsibility of various international and national agencies. It spells out the role of the government, the judiciary, the bureaucracy, healthcare professionals, non-governmental organisations (NGOs), the society and the indi vidual in dealing with the pandemic. It also suggests strategies to deal with the impending problem at the global level. It puts on developed countries the responsibility to help developing nations deal with the problem.

What was the response of developing countries to the survey?

We sent out a questionnaire to all developing countries and economies-in-transition in mid-1998, but the response was not good. The questions were simple, such as: 'Have you done any health survey in the last five years?'; 'Do you have data on cause-spec ific mortality rates?'; 'Do you have any guidelines to deal with hypertension?'; 'Is there any legislation against tobacco?' and so on. They had to just answer 'yes', 'no' or 'don't know'. Yet, only 10 per cent of the countries responded. This most likel y meant that the rest did not have the data but did not want to admit it.

We sent a letter again to these countries telling them to say 'no' if they did not have the data, and that it was equally important. After much persuasion, the response rate went up from 10 per cent to 45 per cent. Most of them either said 'no' or a 'par tial yes'. We were then able to make some inferences.

How long did the survey take?About 12 months beginning mid-1998.

Apart from getting information on preventive measures, did the survey deal with clinical information?

Yes. We asked the countries details about the number of doctors and cardiologists they had, the number of procedures such as open heart surgery and angiograms they did, the number of nurses they had for every 1,000 people, and so on. For this, the respon se was better, with 60 per cent of the countries replying. We got some meaningful information on the clinical resources of the countries.

This is our first attempt at documenting the health resources of developing countries and we hope to do a similar one a few years later. We plan to make the countries aware of their relative conditions and hope that on seeing the comparative picture, the countries that have poor health resources will start doing something about it.

Why did you deal only with developing countries?

First, health data are poor in these countries. Second, the population growth is going to be enormous. We already have evidence that out of a population of five billion in the world, 15 million deaths occur every year owing to heart diseases, 10 million of which are in developing countries. We may be fooled when we take percentages. For instance, if we say that the death rate of people with heart diseases is 17 per cent, it appears low. But in absolute numbers, it translates to about three million peopl e. They include people who die young, indicating the loss of valuable productivity time. This need not happen. Cardiovascular diseases, in particular, can be controlled and even prevented. If the disease is identified in time, one can be saved the bother of expensive procedures as well as the pain.

How can we prevent or control cardiovascular diseases?

There are six fundamental risk factors: Smoking, hypertension, hyperlipidemia (high cholesterol), sedentary lifestyle, diabetes and obesity. These can be modified and controlled. Other risk factors, which are not modifiable, include genetics, sex and age . Thus, if we try to modify the risk factors that are controllable, we can avoid the disease and prevent premature death.

Does the book outline ways of tackling the problem nationally and globally?

That is the last part of the book. If we do not act now to control the disease, all the statistics and analyses that are put out will be mere garbage. We have thus provided a strategy. As the problem is global, the solution has to be global. The develope d and developing countries have to work together. Though the problem is in developing countries, it is in the interest of the developed nations to help the former avoid the problem.

How can developed countries help developing nations in tackling the problem?

In several ways. One, financially. Two, by providing the technology and imparting knowledge about the preventive measures they practised when they faced the ordeal between the 1930s and the 1980s. The lessons learnt by developed countries in bringing dow n mortality due to cardiovascular diseases - from 60 per cent to 30 per cent - can be imparted to developing nations, which can adapt them to suit their cultural, economic and local needs. The risk factors and problems arising from them are the same eve rywhere. Only such factors as genetics may differ. To that extent the strategies can be modified and applied in developing countries.

But unless you know what the problem is, you cannot tackle it. So, baseline data are a must. And they are lacking in many countries, including India.

Are there no epidemiological data on cardiovascular diseases in India?

There is no coordinated national level data in India. There are some pieces of information in some pockets. But as the methodology is not similar, they are not even comparable. The data are not difficult to get. It requires the right mindset and the coop eration of the people. Prof. K. Srinath Reddy of AIIMS (All India Institute of Medical Sciences), Delhi, is doing excellent work in this area. But this needs to be replicated throughout the country.

Apart from global partnerships, what needs to be done within a country?

Internal consistencies are important. Various groups must work together - the policymakers and bureaucrats need to be sensitised, the public must be made aware, professionals should be willing to work together. The patient must be made aware of the probl em. It is the responsibility of physicians to tell their patients what the numbers mean. It is important to come out with a committed policy. This needs partnerships at various levels.

Even within a government, various departments, such as health, agriculture, industry and environment, need to work together. For example, if the Industries Department gives subsidy and support to the tobacco companies while the Health Department works to wards banning smoking, then they are working at cross purposes.

Recently, in New Delhi, a move was made to forge a global partnership when Dr. Srinath Reddy got together some of the best doctors in the world to share their experiences so that the developing world can learn from them.

Coming back to the issue of controlling modifiable risk factors, how does one do this?

First, people who smoke need to be persuaded to quit smoing or at least reduce smoking.

Second, owing to economic development there is a section of the urban population that has a sedentary lifestyle and is prone to heart diseases. The projections for the year 2025 are that half of India's population would be living in the urban areas. So, those exposed to heart diseases will also increase. Thus it is important to encourage physical activity.

Third, check your blood pressure regularly. If it cannot be controlled by physical activity, plenty of medicines are available.

Fourth, high cholesterol, or high fat content. If that is not reduced, the walls of the blood vessels will narrow and constrict the blood flow, which will cause hypertension. At some point the narrowing blood vessel is going to close, stopping the blood flow and leading to a heart attack. A heart attack means that the cells around that area are dead.

The most common risk factor is diabetes. Type Two diabetics are non-insulin-dependent. This is owing to increased sugar intake. This can be tackled easily by consuming less sugar and at the same time taking lots of fresh vegetables and fruits. This sugar crosses the blood barrier at a much slower rate than refined sugar, which increases sugar levels.

Blood pressure can also be controlled by reducing salt intake. Vegetarians get heart problems primarily because most often the food is over-cooked and leaves no nutrients. This requires education not of the patient alone but of the person who cooks.

Thus, there are several proven methods of controlling and avoiding heart diseases. And, as can be seen, it is a multi-factor, multi-partner effort even within society and a family. It is just not an issue of money from developed countries.

What is the effect of Dean Ornish's methods of yoga and meditation on heart diseases?

They play a very significant role. One of the factors that could increase blood pressure or the chance of a heart attack is what is commonly called tension.

What happens clinically when you have 'tension'?

The amount of hormones generated by the pituitary glands or hypothalamine (adrenalin) rises and they increase the activity of the heart by raising the blood pressure. By doing yoga, you can calm the mind and allow the enzymes to be released at normal rat es. We have studies that show that when one gets angry the blood pressure shoots up and when one is under constant pressure, it is always high, and the hormones activate the retention of fat in the blood stream. There are several such hypotheses. Yoga an d meditation are certainly helpful.

Developed countries confronted this problem in the 1930s. How did they tackle it, and what was their experience?

There was a clear correlation between the sale of tobacco and the rise in the number of people with hypertension. But by the 1970s, public awareness had become such that people started demanding smoke-free zones and many people started giving up smoking. All this was possible basically because of public awareness.

Who created this awareness among the people?

Non-governmental organisations and the medical community played a major role in generating awareness. In the United States and Canada there are associations for physicians against tobacco. A number of organisations work together to curb tobacco use. Ther e is also a lobby to fight with the government against giving subsidies to tobacco companies. These factors have led to a decline in tobacco sales. Multinational tobacco companies are now dumping tobacco in countries such as India and China. The governme nts of these countries are sacrificing the health of the people by letting in these multinational companies. It is a short-term gain for a long-term drain of the economy.

Also, with the advent of drugs and preventive measures for conditions like obesity, hypertension and hypolipidemia, there is an associated decline in the incidence of heart diseases.

Thus, the number of deaths due to heart diseases was brought down in the developed countries by a multi-factor strategy. India has to learn from their experience and act immediately before it drains its economy.

KRISHNAMOORTHY SRINIVAS

Health is the supreme foundation for the performance of one's duty (dharma), acquisition of wealth (artha), gratification of the (legitimate) pleasures of life (kama) and the achievement of salvation (moksha). Diseases are the destroyers of health, go od life and even life itself.

- Charakasamhita, Sutra 11:4,

as quoted in Dr. K.S. Sanjivi's book Only One Life.

PREVENTION was a dirty word at the turn of the 20th century. It gained respectability thanks to the pioneering efforts of Geoffrey Rose, an epidemiologist, and Sir Richard Doll, a Fellow of the Royal Society who did path-breaking work on the harmful effe cts of smoking. Sir Horace Smirk showed in a small country like New Zealand 50 years ago how preventive measures could bring down the risk of mortality in cases of coronary artery disease and stroke.

In the United States, the rate of mortality from stroke and, therefore, morbidity, has come down considerably owing to the control of hypertension. In the case of an individual with uncontrolled hypertension the risk of stroke is seven times higher than in the case of a normal individual of the same age.

Smoking does enormous damage. The awareness of this truth has increased tremendously in developed countries. India is one of the countries where the smoking habit, to say the least, is terrible.

Studies at Harvard and other institutions abroad have shown that moderate intake of alcohol protects the heart and the brain. But the question is: what is 'moderate'? In the Indian setting, no clear studies are available. Excess intake of alcohol is a ri sk factor for the brain and the heart.

Dr. K.S. Sanjivi, Professor of Medicine and the founder of the Voluntary Health Service, a Chennai-based institution, was clearly ahead of his time. In his book Only One Life, he advocates prevention and moderation.

M.C. Subramaniam, a Gandhian, founded the Public Health Centre at T. Nagar, Chennai. The very name of the institution suggests that prevention was one of his main goals.

Dr. Arun Chockalingam points out in his interview that prevention is not a substitute for cure. A lot of preventive work is necessary to deal with 'infections'. The watchword seems to be public education in the local language, through the media. It would appear that unless something is done urgently, India will be saddled with diseases that erupted in the early part of the 20th century and also newer diseases.