Abstract
A conference in Cork, Ireland, in February 2004 involving representatives of the 25 Member States (MS) of the European Union (EU) reached agreement on strategies to prevent heart disease in the general population and to reduce the risk of recurrence in those who have already suffered an event [1, 2]. The conclusions, as agreed by the Council of the EU (Employment, Social Policy, Health and Consumer Affairs), are reproduced in this issue of the EJPCR [3].
The Council conclusions arising from the Cork conference may be summarised as follows:
Cardiovascular diseases (CVD) are important causes of mortality, morbidity and reduced quality of life in EU citizens.
There is substantial knowledge about the risk factors for cardiovascular disease and sufficient evidence to warrant intervention to reduce risk and promote cardiovascular health.
Population and high-risk strategies are important and complementary, aimed respectively at the total population and at those who already have CVD.
Priority components of such strategies were identified, including health impact assessment of public policies, risk estimation using evidence-based guidelines and tools, lifestyle advice and risk factor intervention for those identified as being at high risk, and education and training for health care professionals, and
Actions, which may be taken by MS or by the European Commission to support such strategies, were agreed.
The Council conclusions were published in June 2004. Those who advocate for cardiovascular health should now consider the implications of the Cork conclusions for the health of Europeans. What can professional societies and non-governmental organisations (NGOs) do to maximise the benefits, that may arise from the conclusions? Adopting the principle of thinking globally but acting locally, how can those interested in cardiac prevention and rehabilitation utilise the agreement so as to make a difference in their own country or local area?
Evolving epidemiology and European dynamics
The process by which the conclusions were developed and agreed is of itself likely to have a positive impact on the development of health promoting policies in Europe [4]. The EU Commission held a preparatory meeting in Luxemburg in December 2003 to consult with MS about the prevention of CVD. The prevalence of chronic cardiac conditions is increasing in most MS and this trend will continue due to the increasing prevalence of obesity and diabetes [5]. Even those MS with relatively low levels of mortality are challenged to provide timely access to high quality treatment services for CVD. It was clear from the outset that there was substantial agreement between the MS that CVD and related conditions were major contributors to disease, disability and reduced quality of life.
The EU has a remit for health promotion but health care and health systems are the responsibility of the MS. Some countries, such as Germany and Sweden, devolve responsibility for the provision of health services to regional authorities. Consequently, it was unclear to what extent the MS would be willing to address issues, that could be construed as relating to health services, such as prevention in those at high risk. It is a measure of the importance which MS attach to the reduction of CVD risk that discussion was supportive at all times, with queries and proposed textual changes all seeking to strengthen the Cork conclusions.
As in any family, EU MS learn over time about the likelihood of proposals being acceptable to other States. With the expansion of the EU in 2004 from 15 to 25 MS, the dynamics of the European family are changing. National policies of many of the MS, which joined in May 2004 place strong emphasis on prevention. The recognition by many MS of the increased burden of disease coinciding with the expansion of the EU meant that the overall thrust of the discussions was very positive, encouraging even potentially reluctant MS to support the conclusions.
The evolution of health policies in the EU
European Union policies and actions to promote health have been greatly strengthened in recent years, for example in relation to tobacco control. The positive thrust of discussions in Cork, as well as the actual conclusions, will encourage the further development and implementation of policies which place greater emphasis on health and less on narrow sectoral interests. While discussions in Cork focussed on heart health, what is good for European hearts and blood vessels, addressing tobacco, nutrition and physical activity, is relevant to the other major causes of mortality and morbidity in Europe.
A paper titled ‘Enabling good health for all—a reflection process for a new EU health strategy', published by David Byrne, European Commissioner for Health and Consumer Protection, sets out the case for stronger policies for health in Europe [6]. Its sentiments can be strongly supported by those with an interest in heart health.
‘If the EU is to help its citizens achieve good health, it must address the behavioural, social and environmental factors that determine health.'
‘The EU needs a better health impact assessment system.'
‘Health needs to be integrated into all policies, from agriculture to environment, from transport to trade, from research to humanitarian aid and development.'
The European Heart Network (EHN) was a partner with the Irish Government in the Cork Consensus Conference. The conclusions provide a basis for organisations such as the EHN to advocate and lobby in support of stronger policies to support heart health in Europe.
An important development for CVD prevention in Europe
The Cork conclusions mark an important stage in the history of CVD prevention in Europe. Twenty years ago there were heated arguments in the British Isles about the causes of CVD. The reports emanating from such discussions provided inconsistent and confusing messages to the public. People could justify unhealthy lifestyles, believing that ‘the experts’ did not agree on the factors that increased risk or on the extent to which risk could be reduced. The Task Forces on Prevention in Clinical Practice of the European Society of Cardiology in collaboration with a range of scientific societies emphasised that there was consensus among cardiologists and other experts as to the main causes of CVD, and on prevention in clinical practice.
The Cork conclusions now clearly indicate that the governments and health ministries of the 25 EU MS are in agreement about the evidence on causality and risk reduction, and on the implications for health promotion and disease prevention. This provides a very clear message for the public. Vested interests may be less likely to attempt to provide misleading information about their products. Those advocating for heart health can more easily provide counter arguments, drawing on documents such as the Cork conclusions and the Report of the Third Joint Task Force [7].
The health sector
The European Society of Cardiology (ESC) was a key player at all stages of the process leading to the Cork conclusions and the process was strongly influenced by the Report of the Third Joint Task Force [7]. Professional organisations at national level can quote the conclusions to strengthen support for the prevention of CVD and the development of high quality preventive cardiology services.
At national level, cardiac societies and professional organisations can advocate, as per the conclusions, for the development of policies to promote heart health. Focussing on what the health and related sectors can deliver, priority could be given to advocacy for health impact assessment, and the establishment of CVD surveillance systems—‘standardised surveillance systems for cardiovascular mortality, morbidity, health behaviours and risk factors'.
The ESC can also prioritise those actions on which it can itself have greatest impact. The Society can continue to advocate that the EU Commission ‘consider the identification of best practice guidelines, in consultation with Member States, to enhance the co-ordination of population and high risk groups’ health and prevention policies and programmes’ and ‘strengthen the comparability of data on healthy lifestyles and behaviours data across Member States, as well as study the possibility of using standardised procedures and methods for monitoring and surveillance of cardiovascular disease mortality, morbidity and risk factor data across Member States'.
The constituency of the ESC goes far beyond the EU. The Society has a key role in disseminating information on prevention strategies, and in supporting monitoring and surveillance, so that countries, which are not EU members, can benefit from the ongoing EU developments.
The highest priority at this time is to disseminate the conclusions as widely as possible. Through persistent advocacy, European and national societies can build on the Cork conclusions, working with national governments and the European Commission, to promote heart health and the prevention of CVD.