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 general 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 Commission 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 future 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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