FROM AROUND THE WORLD: FOCUS ON EUROPE
Cardiovascular Health in Europe: A Global Problem
Philip A. Poole-Wilson, MD, FRCP, FMedSci
British Heart Foundation Simon Marks Chair of Cardiology, Faculty of Medicine, National Heart and Lung Institute, Imperial College London, London, United Kingdom
In the last 25 years, the world has become smaller for the cardiovascular physician in the sense that scientists and medical specialists have been able to communicate in a manner that was previously unknown. There are 2 key reasons. The first is the airplane, which has allowed physicians from all over the world to travel to clinical and scientific meetings, to mix more frequently with colleagues from many countries, and thus to establish new friendships and collaborations. The second, more recent reason, is the development of the Internet. A consequence is that physicians, patients, health workers, and politicians have access to an immense, and hitherto unthinkable, range of knowledge. All can exchange opinions more quickly than ever before. Indeed, there is now such a surfeit of Internet sites providing so-called news in cardiology that one surmises there is a need to create news.
A key difference between the medical profession and others, such as law or accountancy, is that the underlying reason for the existence of the medical profession is the prevention and treatment of disease, which is common to all humankind. It might be argued that crime also is common to all societies. So it is, but whereas there are key difference in the legal systems of countries, there is no reason for there to be any fundamental difference in the treatment of an identical disease in different countries. Cultures may determine different approaches to disease, but the fundamental treatment of, say, pneumococcal meningitis is universal. Medicine has become a global specialty without borders.
The expectation would be that all treatments for all diseases would become similar in all countries, a form of regression to the mean. Experience shows that is not so. Much might be learned from examining these differences and, for that reason, a series of articles will appear in the Journal identifying attitudes and differences relating to medical practice in Europe and the world. Some continents have a perceived advantage over Europe, which has poorly defined borders, and even those have varied in the course of history. Asia contains large countries, such as India and China, with central governments. The U.S. comprises 50 clearly defined states with a single constitution. Europe and the U.S. have strong historical links ever since tobacco was offered to Christopher Columbus and the potato was brought to Europe by the Spanish, possibly from Peru, and to my own country, the United Kingdom, from Spanish Galleons or by Sir Francis Drake or Sir Walter Raleigh. The precise history is uncertain.
Nevertheless, there are considerable similarities with the health problems that are now being faced by both the continents of the world and Europe. These include structures for the delivery of health services, the financing of health services, the financing of medical research, the perception of the benefit to accruefrom medical research, the development of careers for clinicians, clinical scientists and scientists and, finally, the role of the doctor in modern society. The problems often are reflected in what appear superficially to be small alterations within existing organizations. For example, the British Cardiac Society this year changed its name to the British Cardiovascular Society. Cardiology is seen by some to be a limiting word rather highjacked by the interventional cardiologist and not portraying adequately a comprehensive approach to the people or patients who are a risk of cardiovascular disease.
At the same time, there are more complex problems. Professionalism in the medical world is being challenged, authority is no longer accepted, the concept of the expert is refuted, and public trust is diminished. The provision of medical care and the actions of doctors may be at the whim of nonmedically qualified managers; good management is not to be disparaged but management in excess separated from medical knowledge, often is to the disadvantage of the patient.
One reason for current difficulties is success. During the last century, a shift has occurred in the causes of mortality from infection diseases to chronic diseases. The mean life expectancy has increased from approximately from 45 years to 80 years. There is now a similarity in the life expectancy of the richer countries of the world (Fig. 1). In almost all countries, substantial increases have occurred in the last few decades. Healthy life-years also have increased despite access to services being dissimilar because of the many different organizational structures for health delivery. At the same time, substantial variation exists in expenditure on health expressed as a percentage of gross domestic product (GDP) (Fig. 2). The proportion of monies directed into health services from public and private sources also varies between countries. Large differences are found in the expenditure expressed per capita (Fig. 3), but in almost all countries expenditure on health has increased. These are crude overall measures of health and expenditure, but a simple interpretation would suggest that those countries that maintain a high mean life expectancy at the lowest GDP are the most efficient. Such an argument hides many other decisions to be made within society, particularly questions relating to quality of life and health expenditure in the last years of life.
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Figure 1 Life Expectancy at Birth in Countries of the World, Year 2002 or 2004
Source: World Health Statistics 2006, World Health Organization. Blue bars = life expectancy at birth (years), males; green bars = life expectancy at birth (years), females; pink bars = healthy life expectancy at birth (years), males; gray bars = healthy life expectancy at birth (years), females.
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Figure 2 Health Expenditure Expressed as a Percentage of Gross Domestic Product (GDP)
Source: World Health Statistics 2006, World Health Organization. Green bars = privately funded; blue bars = publicly funded.
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Cardiovascular disease is now the leading cause of death and disability in most advanced countries, although the greater problem is in developing countries, where the population is larger and 80% of deaths due to cardiovascular disease occur. And yet, in Europe, the public perception is different, which is a consequence of the 5 great myths of cardiovascular medicine. Cardiovascular disease represents a pleasant way to die, not a sentiment to be expressed bythose with heart failure. Cardiovascular disease is disease of affluence, denying the role of poverty and societal pressures. Cardiovascular disease is a personal responsibility not to be taken on by government, thus transferring costs to the individual. Cardiovascular disease is a disease of the elderly. Cardiovascular disease is a problem of male gender, an idea vigorously countered by initiatives relating to heart disease in women begun in the U.S. and now evident across the world and promoted by the World Heart Federation. Some of these myths are partly the consequence of the public and politicians misunderstanding statements from the cardiovascular community. Perhaps the greatest of these is to misunderstand the fact that age-adjusted mortality can be declining at the same time as the total prevalence of a disease is increasing. The enthusiasm to portray success can conceal the nature of the health threat to the population.
The countries of Europe and the world do, to a large extent, represent a laboratory in which different health systems have been tested and in which different approaches have been taken to the delivery of health services and to the funding of clinical research. There is much to be learned by studying the merits or otherwise of these differences. Future articles will focus on many topics but will include the teaching and training of doctors, the regulation of doctors, the funding of research, the validity and consistency of guidelines, and what measures are being taken to respond to the epidemic of cardiovascular in particular parts of Europe. The intent is that this exchange of views will inform doctors across the world, initiate discussion, provide ideas for change, and allow doctors and health professionals to have knowledge of the problems of others and perhaps become aware of possible new solutions.
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