Abstract
What should politicians be told about cardiovascular disease (CVD), and what can they do about it? In this issue of the journal, Zdrojewski et al. [1] describe one phase of a Polish programme to educate politicians and other decision-makers in CVD prevention. They assessed knowledge of CVD, and measured blood pressure, cholesterol, glucose and other risk factors in members of parliament, trade union officials, health care experts and journalists. They then compared the results with those in an age-matched sample of the Polish population. Their ambition was to generate greater political awareness of CVD in the hope that such awareness will be reflected in future legislation.
What is the nature of that heightened awareness, and what might this lead to in any future legislation? Almost certainly, the potential for cardiovascular prevention will be perceived by politicians to depend on measuring cardiovascular risk factors and identifying high-risk individuals in the population. Indeed, that is the main focus of the European Society of Cardiology Polish materials which the investigators used. The high-risk strategy that they employed has recently received support from an analysis of the Canadian Heart Health Survey data [2]. The purpose of this study was to compare the effectiveness of three preventive strategies. It found that a strategy to identify people at high risk of CVD due to a clustering of several risk factors could be substantially more efficient in preventing cardiovascular deaths than either a strategy based on treatment of only one risk factor or a population strategy based on Geoffrey Rose's classical proposal. Rose argued that shifting the distribution curve of a single risk factor by a small amount in the entire population will reduce death rates more effectively than treating only those individuals with high levels of that risk factor [3].
The greater effectiveness of the high-risk strategy has two main explanations: (i) improvements in CVD risk assessment algorithms and (ii) the development of well-tolerated effective drugs for reducing risk. Both of these elements are likely to become even stronger with new scientific knowledge. CVD risk prediction is likely to become more accurate and even more effective drugs are becoming available. Better biochemical markers of risk, including measurements of apolipoproteins and markers of arterial inflammation, are likely to improve risk assessment algorithms and, in wealthy countries, it is probably time to incorporate methods to image the artery wall formally into risk assessment. Advances in drug therapy include the potential to reduce low-density lipoprotein cholesterol safely to physiological plasma concentrations. These developments are likely to make the high-risk strategy even more effective than indicated by the analysis of Manuel et al. [2].
Thus, there are reasons to hope that politicians, especially if they have participated in programs such as that described by Zdrojewski et al. [1], will consider allocating more funding for preventive cardiology, which has one of the strongest scientific evidence bases of any aspect of medicine. Yet, does this approach not underestimate the responsibilities, and the potential for political action by members of our various parliaments, including the European Parliament? Targeting politicians as individuals without making them aware of the underlying political, economic and social causes of the atherosclerotic disease epidemic, and their role in making it worse or better, seems like an opportunity lost. After all, the rise of CVD in the mid-twentieth century was not due to a sudden loss of preventive and interventional cardiologists. There were none when the epidemic began, and the marvellous advances of modern cardiology came about not least because the epidemic was so obviously a serious matter. Training more cardiologists is important, but it does not remove the causes of the epidemic, for which political action is required.
Zdrojewski et al. [1] allude to ecological studies suggesting that rapid declines in cardiovascular mortality in Poland after 1991 could have been due to a major dietary switch from animal fats to vegetables and fruit [4]. Although that interpretation of the causes of the decline in Polish cardiovascular mortality was challenged [5], no one challenged the idea that major reductions in CVD rates are possible, and that they can be accomplished by societal as well as by medical interventions.
However, medicalization is the easier choice and it is encouraged not only by the medico–industrial complex, but also by a political culture that no longer considers social engineering to be an option. In the USA, Marion Nestle demonstrated the perverse influence of the food industry, including agriculture, on federal government health policy [6]. In Europe, Liselotte Elinder has demonstrated how the Common Agricultural Policy, conceived for other purposes just after World War II, is now an important factor in increasing the risk of CVD [7].
The high-risk strategy and the population strategy are not mutually exclusive, but we should not expect politicians to spend too much time becoming familiar with the distinction. They have gone into politics for other reasons, and with very different educational, social and political backgrounds. Measuring their cardiovascular risk factors will focus their attention, first on their personal risk of CVD and, second, on the need for a high-risk strategy for the general public. But should we not tell them that it is the population strategy for prevention that should be their primary responsibility? Shouldn't they be aware that policies for agriculture, the food industry, urban planning, taxation and education profoundly affect population risk of CVD? I have argued that case elsewhere [8], and Geoffrey Rose, above all, has explained the moral, social and political challenges of preventive medicine [3]. It is difficult to read Geoffrey Rose's splendid book without becoming a more socially responsible physician and a more health-knowledgeable politician. Educate politicians, yes, but show them the whole picture.