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Concern about increasing rates of death and dis-
ability due to cardiovascular disease in non-West-
ern countries is often met with skepticism: Do they
really constitute a serious public health problem?
With justifiable alarm about the spread of human
immunodeficiency virus and AIDS and with old foes
such as malaria and tuberculosis still posing for-
midable challenges in many developing countries,
it is understandable that epidemics of cardiovas-
cular disease have insidiously established them-
selves without attracting global attention or local
action. The fact that 80 percent of deaths from car-
diovascular disease worldwide and 87 percent of
related disability currently occur in low-income and
middle-income countries, however, indicates the
magnitude of the problem. Cardiovascular disease
has become the leading cause of death in many de-
veloping countries and will soon attain that status
in several others.
The high burden of mortality from cardiovas-
cular causes in developing countries (estimated at
9 million in 1990 and expected to increase to 19 mil-
lion by 2020

1

) is only partially explained by their
large populations (see Figure 1). The projected in-
crease in the proportion of all deaths that are due to
cardiovascular causes, from about 25 percent in
1990 to more than 40 percent in 2020, signals the
advance of the epidemics. China has witnessed a
doubling of the number of deaths attributed to cir-
culatory diseases during the past two decades, with
the most marked increase among persons 35 to
54 years of age. Over the past 40 years, the preva-
lence of coronary heart disease in urban India has
increased by a factor of six to eight, to about 10 per-
cent among persons 35 to 64 years of age. Stroke is
now the dominant type of cardiovascular disease
in China, Southeast Asia, and sub-Saharan Africa,
whereas coronary heart disease predominates in
Latin America, the Middle East, and urban India. As
the so-called health transition in these countries
progresses, hemorrhagic stroke is being replaced
by thrombotic stroke and coronary heart disease as
the leading form of cardiovascular disease.
In non-Western countries, deaths due to cardio-
vascular disease tend to occur a decade or two ear-
lier than they do in Western countries; nearly half
occur before 70 years of age, whereas only one fifth
occur so early in the West a difference attribut-
able to both the earlier occurrence of cardiovas-
cular events and the lower level of clinical care
available.

2

The rate of death due to stroke among
persons 15 to 59 years of age is three to eight times
as high in Tanzania as in England and Wales. Death
and disability occurring in midlife have disastrous
consequences for families who lose wage earners,
and the resulting loss in productivity adversely af-
fects national development. Of the 24 million peo-
ple expected to die of cardiovascular disease in
2020, about 9.3 million will be between 30 and 69
years of age; most of them will be in non-Western
countries.
These epidemics are driven by social and eco-
nomic changes that have profound effects on living
habits. Although sharp shifts in demographic pat-
terns and lifestyle have resulted from urbanization
and industrialization, the globalization that consti-
tuted the tailwind of the 20th century propelled de-
veloping countries into the worldwide epidemic
of cardiovascular disease. The change reflects both
a demographic shift toward increasing life expect-
ancy and a shift in nutrition: people who live long-
er have greater exposure to cardiovascular risk
factors, and Westernized diets and patterns of phys-
ical inactivity result in elevations in blood pressure,
body weight, blood sugar levels, and lipid concen-
trations. A huge increase in the prevalence of dia-
betes will further increase the burden of cardiovas-
cular disease; India, where nearly 20 million people
had diabetes in 1995, will see at least a tripling of
that number by 2025. Moreover, the global expan-
sion of the tobacco trade has led to large increases
in the rate of smoking.
The levels of these risk factors have increased
steeply in most non-Western countries over the past
two decades. Although there are some differences
among ethnic groups in the interactions between
genes and the environment, the available evidence
indicates that the main risk factors for cardiovas-
cular disease are relevant to all populations and that
most of the risk is environmentally determined.
Cardiovascular Disease in Non-Western Countries
K. Srinath Reddy, D.M.

Cardiovascular Disease in Non-Western Countries

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Thus, these trends portend an explosion of athero-
thrombotic cardiovascular diseases in developing
countries. Given the rate at which the distributions
of body-mass index and blood cholesterol levels
have changed in the Chinese population (see Fig-
ure 2), possibly in association with a sharp increase
in fat consumption, it is clear that countries like
China will see a rapid escalation of the rate of coro-
nary heart disease.
The epidemics of cardiovascular disease struck
the more affluent sections of developing countries
first, but as the epidemics mature, the social gradi-
ent is reversing, with socioeconomically disadvan-
taged groups becoming increasingly vulnerable.
The poor and the less educated everywhere now
use tobacco with greater frequency than the rich
and the better educated do. In Brazil, women in low-
er-income groups have had increasing rates of over-
weight and obesity since 1989, in contrast to the sig-
nificant decrease observed in high-income groups.
Studies conducted in Indian cities in the past dec-
ade have shown that the poor have a higher risk of
heart attack than the rich. The poor also have less
access to health care; their risk factors are not rec-
ognized in a timely fashion; and they often do not
receive effective treatment, since public health care
is generally restricted to the treatment of infectious
diseases. Neglect of the epidemics of cardiovascu-
lar disease will heap greater injustice on the poor-
est of countries and the poorest of people.
Although these developments mirror in many
ways the path of the epidemics of cardiovascular
disease in Western countries, there are important
differences. Whereas the epidemics in the West
flowed and ebbed over the course of a century, the
health transition in developing countries has been
compressed into a few decades. Urbanization is
occurring in places with uncorrected poverty and
increasing disparities in income, causing the poor
to be especially vulnerable, while resource-con-
strained national health systems are ill equipped
to cope with the double burden of infectious and
chronic diseases. Globalization accelerates the
change, as Western products and models of behav-
ior are increasingly exported to non-Western coun-
tries. However, globalization also offers opportu-
nities to facilitate the prevention of cardiovascular
disease, through the application of knowledge
generated in Western countries: the understand-
ing of risk factors, evidence regarding effective in-
terventions, tools and technology for reducing risk,
and new models of healthy behavior that can be
promoted through the mass media. Thus, there is
an opportunity to alter the pattern of health transi-
tion in developing countries by implementing ef-
fective measures for prevention and control before
the epidemics peak ideally, permitting a rapid
shift to a state in which cardiovascular events oc-
cur only or primarily after 70 years of age.
A concerted public health response must inte-
grate population-based prevention strategies and
cost-effective clinical care, since the health systems
of developing countries can ill afford the demands
of technology-intensive treatments. The popula-
tion approach is more rewarding and sustainable
in the medium and long term, since even small re-
ductions in each risk factor can add up to huge re-
ductions in the rate of cardiovascular events. And if
healthy behavior is established as a desirable norm
in a society, it can have a multigenerational effect.
There are differences of opinion, however, re-
garding whether population-level interventions
should rely principally on behavioral change gov-
erned by the personal choices of well-informed
people or should operate through policy interven-
tions that modify behavior through social and
economic determinants. Western countries gen-
erally favor the personal-choice approach, but this
approach assumes that healthy choices are widely
available and affordable and that it is easy to edu-
cate consumers about the merits and demerits of
each option. The North Karelia project in Finland
provides a successful model of behavioral change
through community health education combined

Cardiovascular Disease in Non-Western Countries

Figure 1. Deaths from Cardiovascular Causes,
Worldwide, in 1990 and Estimated for 2020.

Data are from Murray and Lopez.

1
M
i
l
l
i
o
n
s

o
f

D
e
a
t
h
s
f
r
o
m

C
a
r
d
i
o
v
a
s
c
u
l
a
r

C
a
u
s
e
s
30
10
20
25
5
15
0
1990 2020
5
9
6
19
Non-Western (developing)
countries
Western countries

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PERSPECTI VE

with industry-level interventions for providing
healthful food choices. Such programs, however,
may be less effective in non-Western societies, where
personal choice is limited by lack of awareness
and highly restricted options.
Policy-level interventions have proved effec-
tive in bringing about population-wide behavioral
change and risk reduction even in the short term. In
Mauritius, governmental action to substitute soy-
bean oil for palm oil as the subsidized, rationed oil
resulted in a remarkable reduction in cholesterol
levels. Changes in economic policy that increased
the availability of fresh fruits and vegetables and
helped to substitute vegetable fats for animal fats
led to a sharp decline in mortality from cardiovas-
cular causes in Poland. Non-Western countries must
implement policies that will help to reduce the con-
sumption of tobacco, salt, and unhealthful fats
and increase the consumption of fruits and vege-
tables, through production and pricing mecha-
nisms that increase options and influence consum-
er choice. But policy interventions will have limited
success if the community is unwilling to accept
them. Hence, the top-down approach of enabling
legislation and regulation must be complemented
by a bottom-up approach of community mobiliza-
tion through health education. Measures taken in
Western countries to protect nonsmokers from ex-
posure to environmental tobacco smoke illustrate
such a combined approach.
At the same time, people with a high risk of car-
diovascular disease or clinical manifestations of
disease need protection from premature death and
prolonged disability. Evidence-based, context-spe-
cific, and resource-sensitive interventions must be
cost-effectively integrated into all levels of health
care, to strengthen both primary and secondary
prevention of cardiovascular disease. The exten-
sive use of aspirin in primary care settings for the
treatment of suspected myocardial infarction can
save millions of lives at low cost (about $3 per life
saved, in India). Blood-pressurelowering thera-
pies reduce overall cardiovascular risk and have a
substantial effect on mortality from coronary heart
disease and stroke, and smoking cessation effec-
tively reduces cardiovascular risk. Operational re-
search is required to ensure the effective integration
of such therapies and community-based preven-
tive strategies into the health care systems of non-
Western countries. The Initiative for Cardiovascu-
lar Health Research in the Developing Countries is
a multi-institutional, international program that
works to stimulate, support, and strengthen such
research.
Epidemics of cardiovascular disease in non-
Western countries present complex challenges but
also great opportunities. Seldom in the history of
human health have we been endowed with such
foresight about our destiny and forearmed with
such power to change it. It is a challenge to human
intellect and enterprise to apply our knowledge cre-
atively and cost-effectively to minimize the burden
of cardiovascular disease throughout the world.

From the All India Institute of Medical Sciences, New Delhi.

1.

Murray CJL, Lopez AD. The global burden of disease: a com-
prehensive assessment of mortality and disability from diseases,
injuries, and risk factors in 1990 and projected to 2020. Cam-
bridge, Mass.: Harvard University Press, 1996.

2.

Reddy KS. Cardiovascular diseases in the developing coun-
tries: dimensions, determinants, dynamics and directions for
public health action. Public Health Nutr 2002;5:231-7.

3.

The world health report 2002: reducing risks, promoting
healthy life. Geneva: World Health Organization, 2002.

Cardiovascular Disease in Non-Western Countries

Figure 2. Trends in Mean Total Cholesterol Levels
among Persons 25 to 64 Years of Age in Beijing, China.

Data are from the Monitoring Cardiovascular Disease
(MONICA) study of the World Health Organization.

3

To convert values for cholesterol to milligrams per decili-
ter, divide by 0.02586.
M
e
a
n

T
o
t
a
l

C
h
o
l
e
s
t
e
r
o
l

C
o
n
c
e
n
t
r
a
t
i
o
n
(
m
m
o
l
/
l
i
t
e
r
)
5.0
4.6
4.8
4.9
4.5
4.7
4.3
4.2
4.1
4.0
4.4
0
Women
Men
1984 1988 1993 1996 1999