This is a timely  and much needed initiative. 

 In  Pakistan ,  one in three middle aged persons has hypertension and obesity, the rates of  CAD and stroke are  curoiusly the same amongst men and women and the ages of those afflicted are a decade younger  than those in the West.  Having practised in both the regions ,  I am often surprised at the fact that the distrubution of atherosclerotic disease in affected vessels is different - there is very little carotid atherosclerosis in this population for instance.

It is important however to realize that there is a large body of good science - eg controlling blood pressure - that needs an  implementation science approach in our regions- at the very least - we in the developing world need to develop methods to demystify and apply the science that we know will work.

 The positive is that there is precedence for using an algorthmic , multidrug approach in the culture of  Asian and Lower income countries --  TB regimens are complex, require long term surveillance , and knowledge of interactions -- -- if that care can be provided through grass roots community efforts --- then we have hope for non communicable disease.

I am really happy  to see this global effort in action !

Thanks Jerry!

Am glad you highlighted the reality of the rising chronic diseases in the third world. I am sure you appreciate the difficulties in rural Africa where you may suspect ACS and not have an EKG machine leave alone treatment options or suspect a correctable Congenital heart disease and not have an echo machine. Poverty largely contributes to these limitations in my opinion. What practical advise would you have for the local physicians with these limitations.

Dear Pius,  Thanks for your comments.  

I share your concern about limitations of resources in rural regions of sub-Saharan Africa and I would extend that these difficulties are present in resource constrained regions of developed countries as well.  Where technology - and in some instances, even electricity - is less available, getting what most consider to be "routine" tests becomes difficult.  In my own experience, I have noticed that clinicians in these settings come to rely more on their clinical skills and tools that are not heavily technology-dependent.  In the case of estimating coronary artery disease risk, for example, non-laboratory based risk assessment tools based on height, weight, blood pressure and historical elements have been shown to be as effective as some laboratory based scoring systems.

I would say, though, that without some sort of access to the basic tools of modern cardiology, the situation is dire for cardiovascular patients and clinicians alike in resource constrained areas.  I have had patients who have traveled up to 6 hours to get an ECG or an echocardiogram because these services are not available where they live.  Donors (individual and agencies) often come to play a role.  While I do not have the answer to this systemic problem, I think that this is where establishing the local epidemiology of CVD and informing local administrators, community leaders and policy makers can impact healthcare spending decisions and ultimately, care.  

 As we figure out how to deliver excellent, cost-effective CVD care in resource constrained areas of the developing world, I would hope that these solutions could be transferred back East-to-West and South-to-North where our healthcare systems have suffered from escalating costs.

Thank you for your comments, Dr. Kamal.

The degree to which primary care services are strengthened will likely impact a region's ability to combat chronic diseases, including cardiovascular disease, as well as the "unfinished agenda" of nutritional and infectious diseases.  Such system strengthening will provide a stronger platform for innovative--and ideally simple--clinical interventions that can complement public health interventions (stronger tobacco taxation policies, salt reduction, e.g.) in both Pakistan and the US.

I am delighted to know that there is some interest in studying incidence of  global chronic diseases and their prevention. South Asians (India, Pakistan, Bangladesh, SriLanka) have the highest incidence of coronary aritery disease, compared to any other ethnic group in the world. India ranks number one in the list of countries with highest type-2 diabetes. To create awareness, develop educational, diagnostic and prevention programs, we started a society in Minnesota; South Asian Society on Atherosclerosis and Thrombosis (SASAT). We orgainze conference in India, every other year and have published 5 books on the subject (www.sasat.org).

Although India was one of the countries to suggest WHO, to start studies on coronary artery disease globaly, in the early days of its independence, it has not created any national platform to study these diseases. There are no action plans to study the incidence or prevention of these diseases. Since these diseases have already reached epidemic proportions, it is high time the decision makers in this part of the world consider seriously some joint initiative for this region. 

National Institutes of Health USA, CDC Atlanta, Health Canada and UK, do mention occasionally about Global health programs. Now a days even US Universities have programs called Global Health.  However, in reality, not much has been done to study these diseases in the resource poor countries or to prevent these chronic diseases, which pose a great health care burden.

Thank you for your comments and for the link to SASAT, Dr. Rao.  While chronic diseases have not received widespread attention until recently, the Goverment of India has launched the National Programme on the Prevention and Control of Diabetes, Cardiovascular Diseases, and Stroke in an attempt to provide support for this rising burden at the primary health center level.  In addition to this infrastructural support, the Public Health Foundation of India, as one of the 11 Global Centers of Excellence funded by United Health and NHLBI, will be studying the secular trends of cardiovascular disease and CV risk factors in Delhi, Chennai, and Karachi over the next 4 years to help provide contemporary baseline data for South Asia (as well as a surveillance model to expand throughout South Asia).  While these data will not provide incidence data per se, it is an effective way to understand trends in CVD and CV risk factors in a cost- and time-effective manner.  These data will complement previous data from the Indian Sentinel Surveillance Study in 10 industries throughout India (see Prabhakaran et al.  JACC 2009 for details, including a successful community-based multiple risk factor intervention program).  We at the Centre for Chronic Disease Control are also in the process of collaborating with Santosh Bhargava, HPS Sachdev, Caroline Fall, and others on a manuscript that details the incidence of CV risk factors in the New Delhi Birth Cohort, a cohort followed since 1969, which will help provide some of the first incidence data on CV risk factors in India.   While there is much work to be done, I think that efforts are underway and will hopefully provide a clearer understand of the breadth and depth of the problem in the near future.

Dear Huffman:

I am delighted to read your comments and the information you have provided on various activities going on in India and Pakistan. I am glad to know that your group at CDC are going to publish your findings on CV risk factors in the New Delhi Birth Cohort. Pioneering work at Mission Hospital, Mysore has collected the data on the new born children since 1930. Studies done by the UK/MRC, ICMR, India,  and other investigators have demonstrated clearly the ill effects of low birth weight. Even to this day according to  information available, 30% of all children born in India are of low birth weight. I have not seen any concerted effort by the Government to address this issue or the epidemic of heart disease, type-2 diabetes or stroke. I agree with you that there are some sporadic studies on the subject. But at the level of the Government there is no serious commitment. We do not have a National platform to address this issue. We do not have any action plan to prevent these chronic diseases. I have been in touch with most of the national and international organizations that have announced their willingness to address this issue. However, when it comes to the real implementation, it will be the responsibility of these countries to make commitment and take the suggestions and develop action plans. Our society is organizing the 10th international conference in Bangalore, during second week of November. If you are still in India do plan and participate in our activities. I spend 6 months a year in India working on various projects related to this subject. If you have time come and see us are keep in touch with us. I thank you for taking time to write the comments and for providing information on what is happening in India.