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3 Development and Cardiovascular Disease C hapter 2 reviewed the extent and nature of the burden of cardiovas- cular disease (CVD) and focused primarily on classically defined in- dividual risk factors that contribute to the global burden of disease. To build on this epidemiological information, it is equally important to understand the relationship of CVD to economic growth and development, including related systemic drivers that contribute to the global burden of CVD, such as demographic change, urbanization, globalization, techno- logical development, and social and cultural norms. This chapter presents conclusions from available evidence and analysis to help further understand the nature and consequences of the problem in low and middle income countries from this broad perspective. This chapter first offers a discussion of the available evidence on the relationship between stage of economic development and CVD across coun- tries. This is then expanded to a general overview of broad systemic drivers of health that affect trends in CVD and are closely related to economic growth and development—Chapter 5 will describe the drivers with the strongest rationale and evidence for targeted intervention approaches in more detail. The chapter then concludes with a review of the evidence documenting economic impacts of CVD in low and middle income coun- tries, both for countries and for households, highlighting the finding that the burden falls disproportionately on the poor. ECONOMIC DEVELOPMENT AND CARDIOVASCULAR DISEASE Unfortunately, the economics of CVD in low and middle income coun- tries is not heavily studied and methods and data are not uniform; as a 

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD result, there is a scattering of estimates that are not comparable. Although more work is needed to truly understand the economics of this pressing global health issue, the totality of the existing evidence makes it clear that now, and increasingly over time, the economic consequences of CVD are significant. It is widely accepted that health and income are interdependent, but the magnitude of the interaction is more difficult to discern. This is probably because each country has its own unique circumstances that determine how much health it can buy for a given expenditure. The point at which poor health slows economic growth sufficiently to impede development depends on the specific economic conditions. It is therefore difficult to derive gen- eral rules. In theory, the health–wealth relationship should be improved if health promotion and disease prevention policies and programs are able to start earlier in a country’s development trajectory. The relationship between health and economic development was carefully reexamined by the Com- mission on Growth and Development (World Bank Commission on Growth and Development, 2008), which concluded that despite considerable efforts through historical research, cross-sectional analysis, and innovative ways of integrating household factors into cross-country studies that have pushed the methodological envelope, the effects of health investments on economic performance remain inconclusive. The commission also concluded that chronic illness undermines current productivity and is likely to lead to fu- ture losses in economic output; however, it did not indicate the magnitude of that economic loss. Thus, not only will economic development alone be insufficient to improve chronic disease outcomes in developing countries, but also the widespread appearance of chronic disease also threatens to deter the economic growth needed in many low income countries. Historical experience in and across countries illustrates how increased wealth and development can be expected to affect cardiovascular health. Two conclusions emerge from the empirical analysis. First, there is no single pattern that characterizes the relationship between economic development and CVD. Indeed, as described in Chapter 2, there is wide variation in age-standardized mortality rates from CVD even among countries in the same income category (WHOSIS, 2009). Second, despite the variability, a general pattern does emerge in which the prevalence of CVD and its risk factors appear to increase and then to decline as countries progress through phases of development. Cross-country evidence suggests that CVD and other chronic disease incidence rises as countries move from lowest income to low-middle income, driven by exposure to lifestyle risks and low access to health services. As countries move further up the income scale to upper- middle and high income status, risks and prevalence decline (Ezzati et al., 2005). As described in Chapter 2, these declines stem from both behavioral changes and better health care. Figure 3.1 shows that with increasing gross

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 DEVELOPMENT AND CARDIOVASCULAR DISEASE domestic product (GDP) there is an increase and then a decline in the major biological risks for CVD for both men and women. Economic development is a major factor driving the epidemiological transition. For example, differences in GDP per capita explain almost two- thirds of the differences in female obesity among 37 developing countries (Monteiro et al., 2004). Within countries, CVD is also closely related to income level. CVD and its risks are concentrated among the lowest socio- economic groups of the more developed (upper-middle and high income) countries, and among middle and high income populations of low-middle income countries (McLaren, 2007; Monteiro et al., 2004). However, even in some countries that have seen little economic progress, a transition to chronic disease can be observed. In part of rural Bangladesh, for example, estimated chronic disease-related mortality went from 8 to 68 percent, while estimated communicable disease mortality dropped from 52 to 11 percent (Ahsan Karar et al., 2009). Because CVD is rising in low and middle income countries and among the lowest socioeconomic groups in high income countries while falling among the wealthy, CVD is one of the few diseases that increases global health inequalities (Becker et al., 2005). Indeed, CVD and its related risks are gradually becoming diseases of the poor, and these divergences are pushing life expectancy in opposite direc- tions in high income and low and middle income countries. Not only can economic development influence trends in CVD risk, but also CVD can affect economic development. High CVD prevalence has likely depressed economic growth in high income countries in the past. This effect has lessened with recent declines in CVD in high income countries (Becker et al., 2005). CVD and other chronic diseases already have an eco- nomic impact in low and middle income countries, as described later in this chapter. The potential to result in a brake on economic growth may emerge as CVD risk rises (Suhrcke and Urban, 2006). Therefore, serious economic concerns remain for developing countries; however, the diminishing nega- tive economic effects of CVD with decreasing prevalence in high income countries suggests that there is potential for risk and disease prevention to protect those countries from more serious economic ramifications. Conclusion 3.1: In general, CVD risks are rising among low income countries, are highest for middle income developing countries, and then fall off for countries at a more advanced stage of development. This pattern reflects a complex interaction among average per capita income in a country, trends in lifestyle, and other risk factors, and health sys- tems capacity to control CVD. Thus, the challenge facing low income developing countries is to continue to bring down prevalence of infec- tious diseases while avoiding an overwhelming rise in CVD, especially under conditions of resource limitations. This will require balancing

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD Males 30 7.0 BMI Cholesterol Mean cholesterol (mmol/L) SBP 28 6.5 Mean BMI (kg/m2 ) 26 SBP: 135 mmHg 6.0 24 5.5 SBP: 125 mmHg 22 5.0 20 4.5 18 4.0 0 5000 10000 15000 20000 25000 30000 GDP (Int $) Females 30 7.0 BMI Cholesterol Mean cholesterol (mmol/L) SBP 28 6.5 Mean BMI (kg/m2 ) 26 SBP: 135 mmHg 6.0 24 5.5 SBP: 125 mmHg 22 5.0 20 4.5 18 4.0 0 5000 10000 15000 20000 25000 30000 GDP (Int $) FIGURE 3.1 CVD risks in relation to national income. NOTE: SBP = systolic blood pressure. SOURCE: Ezzati et al., 2005. Figure 3-1 R01642

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 DEVELOPMENT AND CARDIOVASCULAR DISEASE competing population-level health demands while maintaining relatively low overall health expenditures. Investments in health will also need to be balanced with pressing needs to invest in other social needs and industrial development to produce a positive health–wealth trajectory. The challenge facing middle income developing countries is to reverse or slow the rise in CVD in an affordable and cost-effective manner. DEVELOPMENT AND SYSTEMIC DRIVERS OF HEALTH Most of the countries that are now considered developed went through an economic transformation in the early to mid-20th century that was ac- companied by major advances in health and longer life expectancy. The catalysts for advances in economic production included the expansion of public sanitation systems, new medical technology, and improved nutrition. Today, however, the relationship between health and economic develop- ment is more complex. Key historic indicators of development progress—a relative decline in agrarian society and rise in urban lifestyles, a dominance of manufacturing and service-sector employment, and greater diversity in food and agriculture—also pose risks that threaten to undermine or thwart economic development and negatively affect health, including shifts that increase chronic disease risk. Therefore, related to the strong role that economic development and economic conditions exert on CVD, key systemic drivers—both distal and proximate—have emerged. Systemic drivers here refer to broad processes that ultimately have an effect on classically defined individual risk factors. Distal drivers have long-term impacts across many populations and can be thought of as underlying causes; while proximate drivers are closely tied to specific conditions and periods. Both are influenced by country-specific social, political, and economic factors; yet they may present opportunities to modify the factors leading to increased CVD incidence. These opportuni- ties are discussed in Chapter 5. The broad distal drivers that influence CVD include dynamic demographic conditions such as population aging and urbanization; shifts in agriculture; technology development and adoption; education; cultural and social norms; and the multifarious influences of glo- balization and increasingly open world markets. These are accompanied by more proximate drivers such as health financing structures, the built envi- ronment, and ideology diffusion. This section briefly describes the expected relationship between these drivers and CVD, summarized in Figure 3.2. The drivers with the strongest rationale and evidence for targeted intervention approaches are described in more detail in Chapter 5. The relationships between CVD and other economic conditions—such as inequality and poverty—are described in greater detail later in this chapter.

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0 Globalization and Development Information and Foreign direct Health Knowledge and Ur banization investment ; Communications Technology Scienc e Trade policies Technology Industrializatio n Ur ban designs eliminate Communication about ac tivity from work and risk, behavior change, daily living ac cess to health care Commercial Policies Lifest yle Changes and Prac tices Pressure on time ; Ef ficient Marketing women in workplac e; agriculture; Pricing demand for processe d Taste convenience foods food Availabili ty Consumption Patterns Activity Patterns Health Service Availability and Use Foods Work Detection and treatment of risk Calories School Fats /oils Leisure Hospital care for CVD events Salt Tobacco Blood pressure Morbidity Blood cholesterol Incidence Mortalit y Obesit y Blood glucose FIGURE 3.2 Systemic drivers of global CVD. Figure 3-2 rev.eps landscape

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 DEVELOPMENT AND CARDIOVASCULAR DISEASE Dynamic Demographic Conditions Population Aging A younger population is generally at lower risk of CVD, and most developing countries have younger populations than developed countries. However, the population median age in developing countries is catching up to that of developed countries. The number of persons worldwide aged 65 years or older is projected to reach more than 690 million by 2012, with 460 million in developing countries (Reddy, 2009). The decline in infec- tious diseases and nutritional disorders contributes to this transition and enhances the proportional burden of CVD (Reddy and Yusuf, 1998). Although it is often assumed that age is a risk factor for CVD, in reality, this may be overstated. As discussed in Chapter 2, with age comes cumu- lative exposure to specific CVD risks as well as to the impact of negative social, educational, and economic factors. For example, the relationship between increasing risk and age with respect to blood pressure has been well described in various populations as they move from low-salt and low- stress environments to cities (Danaei et al., 2009; He and MacGregor, 2009; Iqbal et al., 2008). It may be the accumulation of these risks over time that contributes to increases in CVD rather than age per se (Darnton-Hill et al., 2004).This suggests that aging need not necessarily lead to a greater burden of ill health in the future but rather that by preventing and removing the risks, a significant part of the relationship between CVD and aging may be reduced. In fact, work done by Fries (2005) shows convincingly that in the United States there is evidence that lifelong prevention can yield lower age-specific disease and disability rates. Urbanization While many countries still lack those basic amenities that contribute to a large proportion of the infectious disease burden, such as clean water and sanitation, many more people also inhabit urban environments that inhibit human-propelled movement or punish it with soaring rates of road traffic accidents, expose people to highly polluted air, and introduce severe limita- tions on access to healthy food choices, especially for the poor. The nature of economic production has also changed with the rise of technology-based and other forms of employment that accelerate the transition from rural lifestyles. Occupational health risks—including sedentariness—add to a shift toward chronic disease risk exposures. Urbanization is perhaps the second most powerful demographic change underway worldwide, second only to population aging in terms of its impact on CVD. The world has recently passed the point where there are more people living in the urban environment than in rural areas

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD (UNFPA, 2007). The pace of urbanization in the developing world will not slow for decades, and will be concentrated in the poorest—currently the most rural—regions (UNDESA, 2008; Yusuf et al., 2001a). Indeed, it is estimated that developing country populations will be largely urban by 2050 (UNDESA, 2008). In China, for example, the pace of urbanization has been staggering, with more than 170 cities with a population greater than 1 million people and more than 920 million people expected to be living in cities by 2025 (Agence-France Presse, 2008). The consequences of urban living for health in general and CVD more specifically demand far greater attention. A very simplistic summary of the trends shows that urbanization is generally associated with an increase in tobacco use, obesity, some aspects of an unhealthy diet, and a decline in physical activity (Gajalakshmi et al., 2003; Goyal and Yusuf, 2006; Steyn, 2006; Yang et al., 2008; Yusuf et al., 2001a). These relationships have profound implications for CVD risk. However, concomitant with increased risks come greater access to health care and education—both factors that are associated with reduced CVD risk. On the whole, urban populations are both healthier and wealthier than rural populations. Latin America may be the best example of these dual trends as it has almost completed the journey through the demographic and epidemiological transitions as a consequence of economic growth and urbanization, but displays increasing inequalities in both income and level of education, with adverse impacts on lifestyle and nutritional risks (PAHO, 2007). As will be discussed in Chapter 5, there are potential opportunities to avoid the negative impacts of urbanization, and possibly to use the growing investment in new city development for health gains, including gains for CVD. However, these opportunities need to be fully grasped, which requires urban designers to be more aware of the need to consider and incorporate CVD prevention and to be more willing to plan accordingly. In this context, recent proposals by Collins and Koplan (2009) about the value of health impact assessments prior to urban development initiatives being undertaken deserves attention. There are examples in the United States and Europe where this approach has been done successfully. Immigration and Acculturation Part of demographic change is population migration and acculturation into new social and cultural contexts. Since the 1970s evidence has grown that immigrants to western countries have higher rates of coronary heart disease (CHD) than the rates found in their country of origin. Early studies found that Japanese immigrants to the United States had higher rates of CHD and higher prevalence of several risk factors including dyslipidemia

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 DEVELOPMENT AND CARDIOVASCULAR DISEASE and hypertension (Kato et al., 1973; Marmot et al., 1975). Subsequent research has found similar increases in CHD compared to that of the popu- lation of origin among immigrants from China and South Asia to western countries as well as among migrants who move from rural to urban settings within countries and adopt more “western” lifestyles (Yusuf et al., 2001a, 2001b). Research on indigenous populations within western countries has also found significant increases in rates of CVD and its associated risk factors when they abandon their traditional diets and ways of life (Yusuf et al., 2001b). When compared to the general population in their new country, re- search has found that some immigrant groups exhibit higher rates of CVD, while other groups experience lower rates. For example, South Asian im- migrants in the United Kingdom and Canada have higher rates of CHD compared to other ethnic groups; however, Chinese immigrants in Canada have markedly lower rates (Yusuf et al., 2001b). In general, research on immigration and acculturation supports the conclusion that the same risk factors are the main drivers of CVD across populations and countries and that it is differences in the exposure to these risks factors that influence rates of CVD in immigrant groups. Shifts in Agriculture In the past century, people were just beginning to move off the farms and away from small-scale food production. People were cognizant of what they were eating: if they hadn’t grown it themselves, they knew where it came from. Now, food is a globalized commodity—food exports accounted for 7.1 percent of all merchandise exports globally in 2008 (World Trade Organization, 2009). Food production and consumption have become sepa- rated, and governments exert greater influence over what is produced and what it costs, driven in part by a strong agricultural lobby. Consumers in developing as well as developed countries have far greater food choices along some dimensions, but far fewer along others. Food is more often prepared and eaten outside the home. As discussed in Chapter 2, high in- come country patterns of eating are increasingly available everywhere in the world to those who can afford it. However, developing country populations experience these dietary patterns without the educational levels, medical care, and public health systems that, in developed countries, can somewhat mitigate the risks they pose. Technology Development and Adoption Sparked by the discovery of penicillin, which quickly and cheaply cured many of the infectious diseases that formerly led to death at a young age,

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD a new era in health care and medicine since the past century has focused on devising new treatments and technologies to reduce disease. Indeed, de- veloped countries have benefited relatively more than developing countries from reductions in mortality that required new technological developments, relatively costly change of habits, and expensive surgical interventions. In developing countries, it is transfers of previously available and less ex- pensive health technology and knowledge from developed to developing countries that have reduced mortality from infectious, respiratory, and digestive diseases, congenital anomalies, and perinatal period conditions and helped bring life expectancy closer to the developed country average (Becker et al., 2005). It is not clear to what extent new technologies and expensive interventions of the kind that have been responsible for declines in CVD mortality in rich countries will provide feasible solutions in devel- oping countries. Despite the technological advances being made and the market potential seen in many middle income countries, in many develop- ing country settings there are cost-prohibitive challenges across all types of treatment options, from diagnostic technologies to provision of medica- tion to advanced surgical interventions. It will be necessary to address the obstacles and opportunities associated with each aspect in order to ensure the continued development of affordable, sustainable solutions in low and middle income countries. Cultural and Social Norms Health is universally affected by cultural and social norms and be- haviors, with wide variation across countries. Cultural food preferences, societal norms for body shape, cultural practices around use of leisure time and physical activity, and gender norms can interact with other risk factors to contribute to high rates of obesity and CVD risk. In Mexico, for example, high levels of consumption of traditional fruit-based sugary drinks contribute to obesity as the population has shifted from rural to urban life- styles (Barquera et al., 2008). Cultural and social norms are embedded in society but not immutable. Greater globalization of the food supply, from agricultural production techniques to marketing, have altered consumer preferences and behaviors over a relatively brief period. Fiscal and other policies have also been used to rapidly change consumer choices for fats (Zatonski et al., 1998) and tobacco (Jha et al., 2006). Therefore, although CVD risk must be considered in view of cultural and social norms, it is not predetermined by them. Globalization and CVD Globalization has been associated with the spread of knowledge and science, telecommunications and other information technologies, and cul-

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 DEVELOPMENT AND CARDIOVASCULAR DISEASE tural and behavioral adaptations. Globalization is a broad term that some- times encompasses less regulated domestic and international markets; themselves associated with increased foreign direct investment, expansion of marketing, and wider and more homogeneous consumer choices. Al- though still a topic that arouses vigorous debate, globalization is generally accepted as having led to substantial improvement in quality of life for millions of people by advancing social and economic modernization. Yet, at the same time, there is legitimate concern and circumstantial evidence that globalization’s unintended consequences can fuel unhealthy consumption and lifestyle behaviors. Striking examples are presented by the spreading ubiquity of a “western” diet (Iqbal et al., 2008) and greater use of tobacco (Shafey et al., 2009), both of which are closely related to higher disposable incomes. While the latter phenomenon unambiguously contributes to CVD and should be addressed by aggressive public policies across agriculture, industrial, and consumer sectors, the former is more complicated. Global- ization of food not only provides greater consumer choice, but also it has improved diets for large numbers of previously undernourished people. Thus, in these and other ways, globalization and its related impacts both re- duce and create CVD risks. Policy action is required at the global level and through international channels such as trade discussions to, for example, address the expansion of transnational tobacco companies into low and middle income countries. Policy recommendations in international trade are generally beyond the Committee’s technical expertise and therefore, although acknowledged for their potential role in addressing the global epidemic of CVD, are not fully explored in the section on intersectoral policies in this report. In conclusion, the “healthy growth” of the past in which development was synonymous with better health is now not as easily achieved. Devel- opment brings the benefits of higher incomes including, in most countries, higher life expectancy as childhood infectious disease deaths fall. But the modern development process also confronts populations with serious and long-lasting health risks, challenging societies to find alternative organiza- tional, technological, and policy choices. Still-developing countries have the advantage that they have not fully adopted the behaviors and conditions that raise CVD risks, and countries all along the development spectrum have opportunities to use policy tools to create strong economic incentives to reverse the course that was established only very recently, and thereby implement healthier growth. Chapter 5 enumerates a wide range of policy actions that could lead to reduced CVD risks across multiple sectors and spells out health interventions that can achieve better CVD outcomes. How- ever, the effectiveness and cost-effectiveness evidence about the broader steps societies can take to achieve a health-promoting environment remains patchy.

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD BOX 3.1 Interpreting Economic Data Economic results are obtained from both empirically measured studies and from • modeling exercises drawing on a variety of data sources. Both have strengths and weaknesses. Studies that measure actual economic costs are credible, but not always generalizable. They are also subject to data quality problems. Modeling or econometric studies rely on assumptions, which are usually made based on data sources such as systematic reviews of empirical research, and are valuable in cases where impacts are difficult or impossible to measure directly, such as projections or policy scenarios. Interpreting economic studies of CVD impact requires comparing results from both types of studies for logical consistency and understanding when differences in assumptions account for differences in outcomes. Measuring economic impact involves counting up the costs created by CVD. • Economists divide the costs of illness and death into three categories: direct costs, indirect costs, and welfare costs. These are generally measured at the individual and household level (and, hence, are microeconomic costs) and sometimes ag- gregated to the whole economy (becoming macroeconomic costs). Direct costs are expenditures on health services, nonmedical expenditures such as • transportation, and the value of lost work or earnings.The sum of these is called the “cost of illness,” and most economic studies of CVD and other diseases use this ap- proach. Cost-of-illness studies to measure the economic burden of CVD have been done for a broad range of developing countries; however, there is substantial varia- tion in which health endpoints are being measured and which costs are included. Thus there is little comparability. Indirect costs account for the time spent by family members and other caregivers • in caring for a CVD patient. In some studies lost work or earnings are considered indirect costs rather than direct costs. Other costs, sometimes mentioned but rarely measured, are the effects on indi- • vidual and national savings from reduced productivity and income, and the effects Social Welfare Measures of Macroeconomic Impacts Going beyond the effects of CVD on economic flows, the social wel- fare (or “full-income”) method includes an economic valuation for lives lost due to CVD. Studies using this method typically use a rule of thumb that values human life equivalent to 100 to 200 times average annual wages (Abegunde et al., 2007). This figure is intended to account for a person’s full worth, beyond simply one’s role as a worker. This method arrives at an economic cost of CVD of a larger magnitude than the studies described previously. One recent example (WHO, 2005) estimated 10-year cumulative GDP losses of $2.5 billion for Tanzania and $7.6 billion for Nigeria from major chronic diseases.

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 DEVELOPMENT AND CARDIOVASCULAR DISEASE on investments, both financial and human capital (such as education for children), caused by reduced income and earnings. Methods to measure or estimate these economic impacts from CVD come from economic growth models. They generally compare an estimate of GDP with CVD impacts to an estimate of GDP without CVD, and the difference is considered the “costs” of CVD or foregone economic output. The broadest economic studies of illness use social welfare (or social capital or • full-income) methods that impute a monetary value to a person’s life, much the same way that “years of life lost” and “disability-adjusted life years” (DALYs) mea- sure the human effects of a disease. This method estimates the economic costs of disease expansively by valuing human life at 100 to 200 times a person’s annual earnings. Such calculations imply economic losses in the billions from chronic dis- eases, even for very low income countries. Welfare cost studies are, by definition, modeling exercises, and the results should not be confused with actual expenditures on CVD. • The primary outcome measures for economic studies of CVD impacts are ex- pressed in monetary terms. Study authors choose a currency and base year to express results, and it is preferable that these be easily comparable across stud- ies. Ideally, studies use international dollars or purchasing power parity (PPP) dollars to measure costs and report results. These adjust for differences in prices across countries and, thus, can be compared from one place to another. Economic costs are often presented as a proportion of a relevant denominator, such as GDP or total health expenditures. Economic studies employ a wide range of assumptions about economic condi- • tions prevailing in the populations studied and about local health care costs. These assumptions affect the conclusions in significant, but not always transparent, ways. For instance, a common assumption is that reduced productivity from having a chronic disease will reduce a country’s labor supply and thus have macroeconomic impacts. This is a tenuous assumption under conditions of less than full employ- ment, and it can inflate the estimated economic loss from chronic disease. Conclusion 3.3: The economic impacts of CVD are detrimental at national levels. Foregone economic output stemming from lower pro- ductivity and savings can reach several percent of GDP each year, with a significant cumulative effect. The toll is most severely felt in low and low-middle income countries, which can ill afford the lost economic output in light of already insufficient health resources. Microeconomic Measures of CVD Impacts The immediate impacts of CVD on households could derive both from expenditures incurred in preventing or treating disease and from lost earn- ings when work is reduced because of illness or premature mortality. The

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0 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD TABLE 3.1 Macroeconomic Impacts from CVD and Chronic Diseases, Various Cost-of-Illness Studies Country or Economic Health Outcome Region Costs Included Measured Year Currency Economic Impact China Direct medical Diabetes, CHD, 2003 RMB Yuan $2.74 billion; Zhao et al., costs plus hypertension, and % 3.7% of 2008 transport stroke health costs national medical expenditures Brazil Direct IHD, CVD, 2000 U.S. dollars $34 billion; World Bank, medical, diabetes, $72 billion (social 2005a Social capital COPD, cancer capital approach) African Direct and Diabetes 2005 PPP dollars $6.7 billion countries indirect for 33 (2000 base direct; Kirigia et al., low-middle year) $5 billion indirect 2009 income countries African Direct and Diabetes 2005 PPP dollars $523 million countries indirect for (2000 base direct; $2 billion Kirigia et al., 6 low- and year) indirect 2009 upper-middle income countries U.S. (for Direct medical Obesity and 2003 U.S. dollars $100 billion; comparison) costs overweight and % of 5-7% of national Finkelstein health care health care et al., 2005 expenditures expenditures NOTE: COPD = chronic obstructive pulmonary disease; ISD = ischemic heart disease. fact that CVD affects people in developing countries at a younger age than in developed countries implies the potential not only for a more widespread national effect on productivity and earnings in developing countries, but also for potentially more dire effects on the long-term welfare of house- holds. Longer-term economic effects on households and individuals can occur when savings are reduced or less is invested in building the earnings potential of adults or children in the family. Unfortunately, there is little information that measures how CVD af- fects household-level economic output in developing countries. Based on a review of studies primarily in high income countries, barriers to employ- ment for people with chronic diseases and risk factors are likely to arise from productivity limitations, costs of disability, and in some cases, stigma (Suhrcke et al., 2006). In addition, Suhrcke et al. (2007) reviewed the avail- able literature for Central and Eastern Europe and the Commonwealth of Independent states and found that, generally speaking, the presence of

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 DEVELOPMENT AND CARDIOVASCULAR DISEASE chronic illness had a negative impact on individual labor productivity (as measured by the wage rate), the likelihood of labor force participation, and in some cases contributed to a significant loss of household income. Chronic illnesses also increased the likelihood that individuals would retire early. A growing body of evidence from the employer side also demonstrates that productivity is strongly and adversely affected by chronic diseases. Global corporations monitoring the bottom line impacts of worker ill- health, particularly from chronic diseases, are showing dramatic returns on investment of up to $6 in greater productivity for every $1 spent on health promotion for their employees. Their results also show the indirect losses from absenteeism and “presenteeism” far outweigh the direct costs of health care (WEF, 2009). However, all these estimates are derived from particular labor market and economic conditions in different countries and cannot be generalized. There is more information about how households are affected by and cope with health care expenses in developing countries, although very little is specific to chronic disease. Because poor households are rarely covered by insurance, there are often severe consequences for the entire household when sudden and significant health expenditures, or “health shocks,” oc- cur. Surveys covering 89 percent of the world’s population suggest that 150 million people experience financial disaster due to health care expenses, and 100 million are pushed into poverty (Xu et al., 2007). Much of the burden imparted by these “health shocks” is from the suddenness of payment re- quirements (McIntyre et al., 2006). It is less clear how households are affected specifically by CVD health care expenses, which is largely comprised of the long-term costs of drugs, routine doctors’ visits, and preplanned procedures rather than acute, short- term spending. In Vietnam, where out-of-pocket expenditures constituted 84 percent of all health care spending in 1998, catastrophic spending (de- fined as an expenditure that exceeds 10 to 40 percent of a household’s ca- pacity to pay) was dominated by communicable disease needs. One reason may be that high costs of chronic disease care prevent lower-income groups from accessing treatment (Thuan et al., 2006). However, CVD events can also result in “catastrophic” health costs. Seventy-one percent of hospital- ized Chinese stroke survivors experienced catastrophic financial impacts (defined as out-of-pocket health expenses in the 3 months after stroke that meet or exceed 30 percent of reported household income). Those without health insurance were hit particularly hard. Out-of-pocket expenses from stroke pushed 37 percent of patients and their families below the poverty line; 62 percent of those without insurance were pushed into poverty (Heeley et al., 2009). Households employ a variety of methods to cope with these expenses, from dipping into savings accounts, to increasing the number of earners in

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD the family, to selling assets. In general, however, poor families have little flexibility to draw on savings to finance health needs. More often, they re- duce basic consumption, sell assets that form the basis of their livelihood, and go into debt (McIntyre et al., 2006). Across 15 countries in Africa, 50 percent of households that had a hospitalized family member turned to borrowing and selling assets to pay for health expenditures. In most of the countries, inpatient expenses were more likely to cause distress selling of assets and borrowing than outpatient and routine health care by both rich and poor households, although the behavior was more predominant among the poor (Leive et al., 2008). In India, the risk of distress borrowing and distress selling increases significantly for hospitalized patients if they are smokers or even just belong to households with a member who smokes or drinks (Bonu et al., 2005; Suhrcke et al., 2006). In Burkina Faso, when a household member has a chronic illness, the probability of catastrophic consequences increased by 3.3- to 7.8-fold (Su et al., 2006; Suhrcke et al., 2006). A further household burden is the direct expense of harmful lifestyle behaviors related to CVD risk. Many households experience dramatic shifts in spending and forgo other expenditures in order to buy tobacco and alcohol, two major risk factors for CVD. In India, for example, households that consumed tobacco had lower consumption of milk, edu- cation, clean fuel, and entertainment. These households also had lower per capita nutritional intake compared to tobacco-free households (Bump et al., 2009; John, 2008). In a sample of low income workers in Eastern China, smokers spent an average 11 percent of personal monthly income on tobacco and reported foregone savings and foregone consumption of health care and major household goods compared to non-smokers (Bump et al., 2009; Hesketh et al., 2007). In another study in rural China, to- bacco spending negatively affected spending on health, education, farming equipment, seeds, savings, and insurance. For every 100 yuan spent on tobacco there was an associated decline in spending on education by 30 yuan, medical care by 15 yuan, farming by 14 yuan, and food by 10 yuan (Suhrcke et al., 2006; Wang et al., 2006). Frequently, alcohol expendi- tures increase hand-in-hand with tobacco expenditures. Families in Delhi, India, that had at least one member that consumed three or more drinks per week spent almost 14 times more on alcohol each month (resulting in fewer financial resources for food, education, and daily consumables) and more were in debt, when compared to families with no member consum- ing more than one drink (Saxena et al., 2003; Suhrcke et al., 2006). In conclusion, the economic burden of CVD in developing countries is currently borne most directly by patients and their families, either through out-of-pocket expenses that reduce their provision of basic needs, or through reduced productivity and earnings. By contrast, in middle income

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 DEVELOPMENT AND CARDIOVASCULAR DISEASE and high income countries where social and private insurance is available to finance health expenses, the financial costs of CVD are spread more widely. Social Inequalities and CVD In addition to the effects of CVD on household-level economic status, there is strong evidence that social inequalities contribute to CVD mortal- ity and incidence. Thus, poverty plays a role both as a risk factor and as a consequence of CVD. Poverty, as a contributing factor to CVD, is related to the lack of access to health care and health information among the poor as well as exposure to multiple risk factors that increase CVD risk. Further, several studies have highlighted the effects of social and economic factors on health even when those factors are not directly related to major risks and specific treatments (CSDH, 2008). In Brazil, for instance, the prevalence of hypertension was consistently and dramatically higher (30 to 130 percent higher) among the less educated, those with lowest income, and Afro-Brazilians. The poor had a 1.2 relative risk of dying from CVD compared to the wealthy (World Bank, 2005a). Demographic and Health Surveys from seven African countries show a 35 percent average increase in overweight and obesity between the early 1990s and 2000s, with the largest increase among the poor. The almost 50 percent rise in overweight and obesity among poor women is attributed to changing nutritional habits and urban lifestyles (Ziraba et al., 2009). The income gradient of CVD in low and middle income countries mirrors that which has already taken place in developed countries. For example, in Scotland, a six-fold differential in CHD mortality is seen be- tween the poorest and most affluent groups aged 35 to 44 years (O’Flaherty et al., 2009). The major causes for the social class differentials were related to unfavorable trends in risk factors, mainly related to tobacco use and poor diet. Similar findings have been reported for the United States, United Kingdom, Australia, and across Western Europe, where racial and ethnic differences in prevalence are also apparent (Mackenbach et al., 2003; Wang and Beydoun, 2007). These factors of tobacco use, poor diet, and unequal access to care can explain the tendency for CVD to become more concentrated among the poor and near-poor within low and middle income countries. One reason worth highlighting is the transition to a more energy-dense diet. In addition to the trends in production and consumption related to the nutrition transi- tion that were described in Chapter 2, global prices of edible oils, animal- based products, and sweeteners have declined for the past 20 years. But even while improving overall caloric and protein intake, the poor are now more likely to consume diets heavy in fats, salt, and sugar. In middle income

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 PROMOTING CARDIOVASCULAR HEALTH IN THE DEVELOPING WORLD countries, the poor are also reducing physical activity while consuming additional calories (Drewnowski and Darmon, 2005; Popkin, 2003). Gov- ernment policies often play a role, directly and indirectly, in subsidizing overconsumption of energy-dense foods. In Egypt, where more than two- thirds of women and half of men are overweight or obese, food subsidies encourage consumption of energy-dense foods (Asfaw, 2006). However, both government food policies and nutrition conditions among the poor are highly country-specific and should be examined on that basis. Conclusion 3.4: There is growing evidence that CVD and its risk fac- tors affect the poor within and across countries, both as a cause and as a consequence of poverty. In most countries, CVD hits hardest among the poor, who have greater risk-factor exposure, tend to be uninsured, and have less financial resilience to cope with the costs of disease management. One promising way to stem this increasing burden on the poor in low and middle income countries may be through programs that are specifically tailored and targeted to reach the poor (Gwatkin et al., 2005). Programs already targeted to the lowest income population, such as those to reduce undernutrition in children and for the chronic management of infectious diseases, offer opportunities to ensure an early healthy nutritional start for children and to integrate cardiovascular health promotion and disease prevention. CONCLUSION CVD risks arise on the path to an advanced stage of economic devel- opment, driven in part by a range of development-related factors such as population aging and urbanization; shifts in agriculture; and the multifari- ous influences of globalization. CVD can affect the entire economy of a de- veloping nation. Disability, early mortality, and direct health expenditures can divert resources from savings, investment, and other productive uses, affecting economic well-being at the household level and growth potential at the national level. Therefore, developing countries need to maneuver diligently and carefully to avoid cementing in place long-term roadblocks to healthy economic progress. The pattern of rising CVD risks with development reflects a complex interaction among average per capita income in a country, trends in lifestyle and other risk factors, and health systems capacity to control CVD. Devel- oping countries at different stages of development face different challenges in choosing public health strategies to reduce the burden of CVD. The chal- lenge facing low income developing countries is to continue to bring down

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 DEVELOPMENT AND CARDIOVASCULAR DISEASE prevalence of infectious diseases while avoiding an overwhelming rise in CVD, especially under conditions of resource limitations. This will require balancing competing population-level health demands while maintaining relatively low overall health expenditures. Investments in health will also need to be balanced with pressing needs to invest in other social needs and industrial development. The challenge facing middle income developing countries is to reverse or slow the rise in CVD in an affordable and cost-ef- fective manner. Although still not fully understood, the complex interrelationships in which economic development can contribute to and also be affected by the accelerating rates of inadequately addressed CVD and related chronic diseases in low and middle income countries supports the need for both urgent and carefully planned actions. REFERENCES Abegunde, D. O., C. D. Mathers, T. Adam, M. Ortegon, and K. Strong. 2007. The bur- den and costs of chronic diseases in low-income and middle-income countries. Lancet 370(9603):1929-1938. Agence-France Presse. 2008. C hina’s urban problem. h ttp://news.asiaone.com/News/ Latest%2BNews/Asia/Story/A1Story20081218-108758.html (accessed December 9, 2009). Ahsan Karar, Z., N. Alam, and P. Kim Streatfield. 2009. Epidemiological transition in rural Bangladesh, 1986-2006. Global Health Action June 2009(2). Asfaw, A. 2006. Do government food prices affect the prevalence of obesity? Empirical evi- dence from Egypt. World Development 35(4):687-701. Barquera, S., L. Hernandez-Barrera, M. L. Tolentino, J. Espinosa, S. W. Ng, J. A. Rivera, and B. M. Popkin. 2008. Energy intake from beverages is increasing among Mexican adoles- cents and adults. Journal of Nutrition 138(12):2454-2461. Becker, G. S., T. J. Philipson, and R. R. Soares. 2005. The quantity and quality of life and the evolution of world inequality. American Economic Review 95(1):277-291. Bonu, S., M. Rani, D. H. Peters, P. Jha, and S. N. Nguyen. 2005. Does use of tobacco or alcohol contribute to impoverishment from hospitalization costs in India? Health Policy and Planning 20(1):41-49. Bump, J. B., M. R. Reich, O. Adeyi, and S. Khetrapal. 2009. Towards a political economy of tobacco control in low- and middle-income countries. Washington, DC: World Bank. Collins, J., and J. P. Koplan. 2009. Health impact assessment: A step toward health in all policies. Journal of the American Medical Association 302(3):315-317. CSDH (WHO Commission on Social Determinants of Health). 2008. Closing the gap in a gen- eration: Health equity through action on the social determinants of health. Final report of the commission on social determinants of health. Geneva: World Health Organization. Danaei, G., E. L. Ding, D. Mozaffarian, B. Taylor, J. R. Rehm, C. J. L. Murray, and M. Ezzati. 2009. The preventable causes of death in the United States: Comparative risk assessment of dietary, lifestyle, and metabolic risk factors. PLoS Med 6(4):e1000058. Darnton-Hill, I., C. Nishida, and W. P. T. James. 2004. A life course approach to diet, nutrition and the prevention of chronic diseases. Public Health Nutrition 7(1 A):101-121. Drewnowski, A., and N. Darmon. 2005. Food choices and diet costs: An economic analysis. Journal of Nutrition 135(4):900-904.

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