Control of Cardiovascular Diseases in Developing Countries

Research, Development, and Institutional Strengthening

Committee on Research, Development, and Institutional Strengthening for Control of Cardiovascular Diseases in Developing Countries

Board on International Health

INSTITUTE OF MEDICINE

Christopher P. Howson, K. Srinath Reddy, Thomas J. Ryan, and Judith R. Bale, Editors

NATIONAL ACADEMY PRESS
Washington, D.C.
1998



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Control of Cardiovascular Diseases in Developing Countries Research, Development, and Institutional Strengthening Committee on Research, Development, and Institutional Strengthening for Control of Cardiovascular Diseases in Developing Countries Board on International Health INSTITUTE OF MEDICINE Christopher P. Howson, K. Srinath Reddy, Thomas J. Ryan, and Judith R. Bale, Editors NATIONAL ACADEMY PRESS Washington, D.C. 1998

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NATIONAL ACADEMY PRESS 2101 Constitution Avenue, N.W. Washington, D.C. 20418 NOTICE: The project that is the subject of this report was approved by the Governing Board of the National Research Council, whose members are drawn from the councils of the National Academy of Sciences, the National Academy of Engineering, and the Institute of Medicine. The members of the committee responsible for the report were chosen for their special competences and with regard for appropriate balance. The Institute of Medicine was chartered in 1970 by the National Academy of Sciences to enlist distinguished members of the appropriate professions in the examination of policy matters pertaining to the health of the public. In this, the Institute acts under both the Academy's 1863 congressional charter responsibility to be an adviser to the federal government and its own initiative in identifying issues of medical care, research, and education. Dr. Kenneth I. Shine is president of the Institute of Medicine. This study was supported by the World Health Organization. The views presented in this report are those of the Institute of Medicine Committee on Research, Development, and Institutional Strengthening for Control of Cardiovascular Diseases in Developing Countries and are not necessarily those of the funding organization. International Standard Book No. 0-309-06137-7 Additional copies of this report are available for sale from the National Academy Press, Box 285, 2101 Constitution Avenue, N.W., Washington, DC 20055. Call (800) 624-6242 or (202) 334-3313 (in the Washington metropolitan area), or visit the NAP's on-line bookstore at: www.nap.edu. The full text of this report is available on line at: www.nap.edu/readingroom. For more information about the Institute of Medicine, visit the IOM home page at: www2.nas.edu/iom. Copyright 1998 by the National Academy of Sciences. All rights reserved. Printed in the United States of America. The serpent has been a symbol of long life, healing, and knowledge among almost all cultures and religions since the beginning of recorded history. The image adopted as a logotype by the Institute of Medicine is based on a relief carving from ancient Greece, now held by the Staatliche Museen in Berlin.

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BOARD ON INTERNATIONAL HEALTH BARRY R. BLOOM* (Cochair), Howard Hughes Medical Institute, Albert Einstein College of Medicine HARVEY V. FINEBERG* (Cochair), Harvard University JACQUELYN CAMPBELL, The Johns Hopkins University School of Nursing JULIO FRENK,* Fundación Mexicana para la Salud, San Jerónimo DEAN JAMISON,* University of California, Los Angeles EILEEN T. KENNEDY, Research, Education, and Economics, United States Department of Agriculture ARTHUR KLEINMAN,* Harvard Medical School BERNARD LIESE, The World Bank WILLIAM E. PAUL,* National Institute of Allergy and Infectious Diseases and Office of AIDS Research, National Institutes of Health ALLAN ROSENFIELD,* Columbia University School of Public Health PATRICIA L. ROSENFIELD, The Carnegie Corporation of New York THOMAS J. RYAN, Boston University School of Medicine and Boston University Medical Center JOHN H. BRYANT* (Ex Officio), Moscow, Vermont WILLIAM H. FOEGE* (Ex Officio), Carter Center, Emory University JUNE E. OSBORN (Institute of Medicine Liaison),* Josiah Macy, Jr., Foundation DAVID P. RALL* (Institute of Medicine Foreign Secretary), Director Emeritus, National Institute of Environmental Health Sciences Staff CHRISTOPHER P. HOWSON, Director, Board on International Health (until February 1998) JUDITH R. BALE, Director, Board on International Health (after February 1998) HEATHER CALLAHAN, Administrative/Research Assistant (until February 1998) STACEY KNOBLER, Administrative/Research Assistant (after April 1998) SHARON GALLOWAY, Financial Associate *   Member, Institute of medicine

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COMMITTEE ON RESEARCH, DEVELOPMENT, AND INSTITUTIONAL STRENGTHENING FOR CONTROL OF CARDIOVASCULAR DISEASES IN DEVELOPING COUNTRIES THOMAS J. RYAN (Cochair), Boston University School of Medicine K. SRINATH REDDY (Cochair), All India Institute of Medical Sciences, New Delhi, India ANDREW G. BODNAR, Bristol-Meyers Squibb Company, New York City KATHLEEN A. DRACUP, University of California School of Nursing, Los Angeles ALFREDO DUENAS, Cuban Institute of Cardiology, Havana, Cuba LIU LISHENG, Cardiovascular Institute and Fu Wai Hospital, Beijing, People's Republic of China WALINJOM F.T. MUNA, The General Hospital of Yaounde, Cameroon AULIKKI NISSINEN, University of Kuopio, Finland ELIZABETH O. OFILI, Morehouse School of Medicine, Atlanta, Georgia THOMAS A. PEARSON, University of Rochester School of Medicine, New York RICHARD PETO, University of Oxford, England IL SUH, Yonsei University College of Medicine, Seoul, Republic of Korea MAGDI H. YACOUB, National Heart and Lung Institute, Middlesex, England Liaisons ARUN CHOCKALINGAM, Canadian Coalition for High Blood Pressure Prevention and Control, Orleans, Ontario, Canada WILLIAM HARLAN, National Institutes of Health, Bethesda, Maryland DEAN JAMISON, University of California at Los Angeles PRABHAT JHA, The World Bank, Washington, D.C. DARWIN LABARTHE, University of Texas-Houston School of Public Health JIM MARKS, Centers for Disease Control and Prevention, Atlanta, Georgia INGRID MARTIN, World Health Organization, Geneva, Switzerland FREDERICK PACCAUD, Institut Universitaire de Médecine Sociale et Préventive, School of Medicine, Lausanne, Switzerland SYLVIE STACHENKO, Health Canada, Ottawa, Ontario, Canada RODMAN STARKE, American Heart Association, Dallas, Texas MARK TSECHKOVSKI, World Health Organization, Geneva, Switzerland Staff CHRISTOPHER P. HOWSON, Director, Board on International Health (until February 1998) JUDITH R. BALE, Director, Board on International Health (after February 1998)

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HEATHER CALLAHAN, Administrative/Research Assistant (until February 1998) STACEY KNOBLER, Administrative/Research Assistant (after April 1998) SHARON GALLOWAY, Financial Associate

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Preface Cardiovascular diseases (CVDs) are increasing in epidemic proportions in developing countries. Of the 52 million deaths reported worldwide in 1990, 15 million were attributable to CVD (World Bank, 1993). CVD already accounts for almost 10 percent of the total global burden of disease and most likely became the developing world's leading cause of death in the mid-1990s. There is reason for hope, however, given that huge potential exists for applying R&D to prevention or control of the emerging epidemic. It is frequently noted that half of all the gains in human life expectancy of the past several thousand years have occurred in this century. As the report of the Ad Hoc Committee on Health Research points out, although some of these gains have resulted directly from improvements in economic and educational standards, another important factor is the advance in scientific knowledge and its application both in creating powerful new interventions such as vaccines and dietary supplements and in guiding behavior (Ad Hoc Committee, 1996). If one assumes that growth in scientific knowledge will continue to be of fundamental importance, investments in health research will help prevent, and control health problems and protect the health benefits that result from socioeconomic development. This can vastly improve health and economic productivity, particularly for CVDs which are so amenable to intervention. In addition, a considerable body of evidence suggests that current programs for CVD risk factor prevention and low-cost case management offer feasible, cost-effective ways to reduce CVD mortality and disability in developing country populations (Pearson et al., 1993). In most developing countries, however, implementation of these programs is hampered by the lack of awareness of these options. The view that investments in CVD detract from investments in communicable disease control and childhood, maternal, and reproductive health reflects

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an unfortunate competition among opportunities for improving health. Clearly, the latter remain a high priority, but each investment needs to be evaluated according to its costs and benefits. Although control of communicable, childhood, and maternal diseases has benefited from several decades of international efforts in epidemiology, clinical care, policy, and implementation, such large-scale efforts for CVD are lacking and have left both governments and individuals to make choices about health and health care services without adequate information on the costs and benefits of the alternatives. There remains, therefore, an increasing need to promote policy dialogue on CVD and to base this dialogue on informed knowledge of R&D opportunities in CVD that offer effective, affordable, and widely applicable responses in developing countries. PROJECT CHARGE This project was designed to provide such a basis for the work of the Global Forum for Health Research, a newly formed international organization of governments of low- and middle-income countries, major traditional "donors," and health researchers. The task of the Forum, which met for the first time in June 1997, is to assess R&D opportunities for solving health problems in developing countries and to identify the flow of resources to meet these needs. The Forum also convinces governments and other investors of the benefits of health research in improving health and enhancing economic development among the poorest populations. To function effectively, the Forum requires access to (1) high-quality data on disease burden; (2) reasons for the persistence of this burden; (3) measurements of the cost-effectiveness of potential interventions; (4) estimates of current patterns of spending on R&D; and (5) assessments of national health systems. It thus requested that the Institute of Medicine (IOM) of the U.S. National Academy of Sciences prepare a report with appropriate data for CVD. To accomplish this task, the IOM constituted an international committee of 13 members representing broad expertise in clinical cardiology; epidemiology and research methods, including clinical trials; international health and R&D policy; health economics; traditional medicine; and nutrition as they relate to CVD prevention and control. Special attention was given to obtaining the input of developing countries, through committee membership, consultations with expert groups, and developing country experts on the Academy panel that provided independent peer review of the committee's report. In addition, 11 liaison members with appropriate expertise and institutional affiliations assisted the committee by providing information at initial deliberations and by commenting on preliminary reports. Although liaison members provided important information and perspective, the report findings and recommendations are those of the primary committee alone.

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An initial three-hour meeting of the committee was held in conjunction with the Fourth International Conference on Preventive Cardiology in Montreal. Members in attendance agreed on the key issues to be addressed, an outline for the report, and author assignments for first drafts of chapters. A number of committee members, liaisons, and staff also participated in a symposium on June 30, 1997, organized by Arun Chockalingam of the Canadian Coalition for High Blood Pressure Prevention and Control and Prabhat Jha of the World Bank, and cochaired by Darwin Labarthe of the University of Texas-Houston School of Public Health and Fred Paccaud of the Institut Universitaire de Médicine Sociale et Préventive of Lausanne. The symposium provided an important starting point for the part of the committee's report dealing with institutional arrangements in support of CVD R&D. The full committee then met on November 13-14, 1997, to review the report draft and identify needs for revision. The committee's report underwent independent peer review in February-May 1998. ORGANIZATION OF THE REPORT This report contains six chapters, an epilogue, and two appendixes in addition to the summary chapter. Chapters 1 and 2 describe the current and future burden of CVD in developing countries. Chapter 3 describes current practices in CVD prevention and care in developing countries, and Chapter 4 reports the findings of a committee survey to determine the levels and types of R&D that currently support CVD prevention and treatment in developing countries. Chapter 5 summarizes the needs, opportunities, and priorities for global R&D. Chapter 6 outlines recommended institutional arrangements under which these activities can best be facilitated and enhanced, and the Epilogue comments on the question: Why should countries in the developed world care about the emerging epidemic of CVD in developing countries? Appendix A presents the rationale for the committee's recommendations according to the five-step procedure for setting priorities in health research proposed in the Ad Hoc Committee's report. Appendix B provides a glossary of terms. The committee offers this report to help educate funders, health policymakers, and the medical community about the emerging epidemic of CVD in developing countries and the threat it poses to countries least able to afford it. More importantly, this report recommends R&D opportunities and priorities to reduce CVD in developing countries. It is hoped that these can assist the Forum and other funders to direct funding to the support of scientifically robust, coherent R&D that complements other public health initiatives. K. Srinath Reddy and Thomas J. Ryan, Cochairs

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Acknowledgments The committee is grateful to the many individuals who contributed to this report. In particular, it thanks Prabhat Jha for providing substantive background for the study; Arun Chockalingam, Kathleen Dracup, William Harlan, Christopher Howson, Prabhat Jha, Thomas Pearson, and Srinath Reddy for their chapter drafts; and Liu Lisheng, Walinjom Muna, II Suh, and Magdi Yacoub for their substantive contributions to the committee deliberations. The committee expresses its appreciation to Fred Paccaud for organizing an initial meeting of implementers around the committee's charge and for his input to the next stages of the project. The committee thanks its liaison members for their essential contributions to the project and the following reviewers for their substantive input into the report: Ximena Berrios, WHO-Inter-health Project, Santiago; A.O. Falase, University of Ibadan Teaching Hospital, Ibadan, II Soon Kim, Yonsei University College of Medicine, Seoul; Jean Claude Mbanya, University of Yaoundé I, Yaoundé; Rafael G. Oganov, Cardiology Research Center, Moscow; Munro H. Proctor, Boston University School of Medicine, Boston; and Cheira Suporrsilaphachai, Ministry of Public Health, Bangkok. The committee is grateful to the following institutions for providing information on current and projected CVD funding flows: Australian Agency for International Development, Australia; Victorian Health Promotion Foundation, Australia; Federal Chancellery, Austria; Secrétaire d'Etat à la Coopération adjoint au Premier Ministre, Belgium; Canadian International Development Agency, Canada; Ministry of Foreign Affairs, Denmark; European Commission, Belgium; Ministry of Foreign Affairs, Finland; Ministre délégué de la Coopération et du Développement, France; Bundesministerium für Wirtschaftliche Zusammenarbeit und Entwicklung, Germany; Department of Foreign Affairs, Ireland; Ministry of Foreign Affairs, Italy; Ministry of Foreign Affairs, Japan;

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Secrétaire d'état pour les Affaires étrangères, Commerce extérieur et Coopération, Luxembourg; Ministry for Development Cooperation, Netherlands; Ministry of Foreign Affairs and Trade, New Zealand; Royal Ministry of Foreign Affairs, Norway; Instituto da Cooperaçao Portuguesa (I.C.P.), Portugal; Ministère des Affaires étrangères, France; Ministry of Foreign Affairs, Sweden; Département Fédéral des Affaires étrangères, Switzerland; Overseas Development Administration, United Kingdom; Agency for International Development, United States; Carnegie Corporation of New York, United States; Kaiser Family Foundation, United States; and the National Institutes of Health, United States. The committee thanks the IOM staff—Heather Callahan, Stacey Knobler, Sharon Galloway, Mike Edington, and Claudia Carl—for their essential roles in the project. The cochairs thank Judith Bale for her role in completing the final drafts and Christopher Howson for his effective leadership and strong commitment to CVD prevention and control in the developing world. Finally, the committee wishes to note the following special contributors: Dean Jamison for his vision for the project and persistence in securing support for the study, Prabhat Jha for his inestimable assistance with key sections of the report, Darwin Labarthe for his keen editorial eye and substantive contributions during report review, and Srinath Reddy and Thomas Ryan for their effective leadership of this fast-track project. This project was funded by the World Health Organization. The committee is deeply appreciative of its support and of the commitment and productive efforts of Tore Godal and Thomas Nchinda. This report has been reviewed by individuals chosen for their diverse perspectives and technical expertise, in accordance with procedures approved by the National Research Council's Report Review Committee. The purpose of this independent review is to provide candid and critical comments that will assist the authors and the IOM in making the published report as sound as possible and to ensure that the report meets institutional standards for objectivity, evidence, and responsiveness to the study charge. The content of the review comments and the draft manuscript remain confidential to protect the integrity of the deliberative process. We wish to thank the following individuals for their participation in the review process: Francois Abboud, University of Iowa College of Medicine; John Chalmers, Royal North Shore Hospital, St. Leonards, Australia; Chen Chunming, Chinese Academy of Preventive Medicine, Beijing; Shanta C. Emmanuel, Ministry of Health, Singapore; and A.D. Mbewu, South Africa Medical Research Council, Cape Town. Although the individuals acknowledged have provided valuable comments and suggestions, responsibility for the final content of this report rests solely with the authoring committee and the IOM.