Burden of Disease
CVD is the leading cause of death in all World Bank regions with the exception of Sub-Saharan Africa (figure 33.1), where HIV/AIDS has emerged as the leading cause of mortality (Mathers and others 2006). Between 1990 and 2020, IHD is anticipated to increase by 120 percent for women and 137 percent for men in developing countries, compared with age-related increases of 30 to 60 percent in developed countries (Leeder and others 2004). Even though 80 percent of CVD deaths occur in low- and middle-income countries, the death rates for most regions are still below the rate for high-income countries, which is 320 per 100,000 population annually. The marked exception is Europe and Central Asia, which has a rate of 690 CVD deaths per 100,000 population.
[Figure
33.1]
Regional Burdens
The majority of the burden occurs in East Asia and the Pacific, Europe and Central Asia, and South Asia because a large proportion of the world's population lives in East Asia and the Pacific and South Asia and the incidence of IHD is high in Europe and Central Asia.
East Asia and the Pacific
The status and character of the epidemiological transition across the region reflects the diversity of economic circumstances in East Asia and the Pacific. Since the 1950s, life expectancy in China has nearly doubled from 37 years to 71 years (WHO 2003b). Approximately 60 percent of the population still lives outside urban centers, and as is the case in most developing countries, rates of IHD, stroke, and hypertension are higher in urban centers. China appears to be straddling the second and third stages of a Japanese-style epidemiological transition, with CVD rates higher than 35 percent, though dominated by stroke, not IHD. However, in urban China, the death rate from IHD rose by 53 percent from 1988 to 1996.
Europe and Central Asia
The emerging market economies, which consist of the former socialist states of Europe, are largely in the third phase of the epidemiological transition. As a group, they have the highest rates of CVD mortality in the world, similar to those seen in the United States in the 1960s when CVD was at its peak. Belarus, Croatia, Kazakhstan, Romania, and Ukraine have seen significant increases in IHD death rates (figure 33.2). In the Russian Federation, life expectancy for men has dropped precipitously since 1986 from 71.6 years to about 59 years in 2004, in large part because of CVD. In the Czech Republic, Hungary, Poland, and Slovenia, age-adjusted CVD rates have been declining. Nevertheless, CVD rates generally remain higher than in Western Europe.
[Figure
33.2]
Latin America and the Caribbean
In 2001, CVD accounted for about 31 percent of all deaths in Latin America and the Caribbean, but that figure is expected to rise to 38 percent by 2020 (Murray and Lopez 1996). In recent decades, average life expectancy in Latin America and the Caribbean has risen from 51 to 71 years, and the quality of nutrition has improved steadily. At the same time, the region has seen a switch from vegetables as a source of protein to animal protein and an increase in fat intake as a percentage of energy. As a whole, the region seems to be in the third phase, but in South America, some areas are still in the first phase of the transition.
Middle East and North Africa
Increasing economic wealth in the Middle East and North Africa has been characteristically accompanied by urbanization. The rate of CVD has been increasing rapidly and is now the leading cause of death, accounting for 25 to 45 percent of total deaths. Over the past few decades, daily per capita fat consumption has increased in most countries in the region, ranging from a 13.6 percent increase in Sudan to a 143.3 percent increase in Saudi Arabia (Musaiger 2002). IHD is the predominant cause of CVD, with about three IHD deaths for every stroke death. RHD remains a major cause of morbidity and mortality, but the number of hospitalizations for RHD is declining rapidly.
South Asia
Some regions of India appear to be in the first phase of the transition, whereas others are in the second or even the third phase. Nonetheless, India is experiencing an alarming increase in heart disease, which seems to be linked to changes in lifestyle and diet, rapid urbanization, and possibly an underlying genetic component. Diabetes is also a major health issue. India has 31.6 million diabetics, and the number is expected to reach 57.2 million by 2025 (Ghaffar, Reddy, and Singhi 2004). The World Health Organization estimates that, by 2010, 60 percent of the world's cardiac patients will be in India. About 50 percent of CVD-related deaths occur among people younger than 70, compared with about 22 percent in the West. Between 2000 and 2030, about 35 percent of all CVD deaths in India will occur among those age 35 to 64, compared with only 12 percent in the United States and 22 percent in China (Leeder and others 2004).
Sub-Saharan Africa
In Sub-Saharan Africa, deaths attributable to CVD are projected to more than double in between the years 1990 and 2020. Although HIV/AIDS is the leading overall cause of death in this region, CVD is the second-leading killer and is the first among those over the age of 30. Stroke is the dominant form, in keeping with patterns characteristic of earlier phases of the epidemiological transition. With increasing urbanization, levels of average daily physical activity are falling and smoking rates are increasing. Hypertension has emerged as a major public health concern, and hypertensive disease accounts for the dominance of stroke (Bertrand 1999). RHD and cardiomyopathies, the latter caused mostly by malnutrition, various viral illnesses, and parasitic organisms, are also important causes of CVD mortality and morbidity.
Social and Economic Impact
Leeder and others' (2004) report highlights the economic impact of cardiovascular diseases in developing economies, which arises largely because working-age adults account for a high proportion of the CVD burden. Conservative estimates in Brazil, China, India, Mexico, and South Africa indicate that each year at least 21 million years of future productive life are lost because of CVD. In South Africa, for example, costs for the direct treatment of CVD were equivalent to 2 to 3 percent of gross domestic product, or roughly 25 percent of all health care expenditures (Pestana and others 1996).
Current expenditures in developed countries are indicators of possible future expenditure in developing countries. For example, Hodgson and others (2001) estimated that in 2003 the direct and indirect costs of CVD in the United States would amount to US$350 billion. They also estimated that in 1998 Americans spent US$109 billion on hypertension, equivalent to about 13 percent of the health care budget. Studies are limited but suggest that obesity-related diseases are responsible for 2 to 8 percent of all health care expenditures in developed countries.
