Skip to main content


Cardiovascular Disease and the Changing Face of Global Public Health: A Focus on Low and Middle Income Countries


Eighty percent of the global 17 million deaths due to cardiovascular disease (CVD) occur in low and middle income countries (LMICs). The burden of CVD and other noncommunicable diseases (NCDs) is expected to markedly increase because of the global aging of the population and increasing exposure to detrimental lifestyle-related risk in LMICs. Interventions to reduce four main risks related to modifiable behaviors (tobacco use, unhealthy diet, low physical activity and excess alcohol consumption) are key elements for effective primary prevention of the four main NCDs (CVD, cancer, diabetes and chronic pulmonary disease). These behaviors are best improved through structural interventions (e.g., clean air policy, taxes on cigarettes, new recipes for processed foods with reduced salt and fat, urban shaping to improve mobility, etc.). In addition, health systems in LMICs should be reoriented to deliver integrated cost-effective treatment to persons at high risk at the primary health care level. The full implementation of a small number of highly cost effective, affordable and scalable interventions (“best buys”) is likely to be the necessary and sufficient ingredient for curbing NCDs in LMICs. NCDs are both a cause and a consequence of poverty. It is therefore important to frame NCD prevention and control within the broader context of social determinants and development agenda. The recent emphasis on NCDs at a number of health and economic forums (including the September 2011 High Level Meeting on NCDs at the United Nations) provides a new opportunity to move the NCD agenda forward in LMICs.


  1. 1.

    World Health Organization. Global status report on noncommunicable diseases 2010. Geneva: WHO; 2011.

  2. 2.

    World Health Organization. 2008–2013 Action plan for the global strategy for the prevention and control of noncommunicable diseases. Geneva: WHO; 2008.

  3. 3.

    United Nations. Political declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases-Resolution adopted by the General Assembly. New York: UN; 2011.

  4. 4.

    The World Bank. The growing danger of non-communicable diseases–Acting now to reverse course. Washington DC: The World Bank; 2011.

  5. 5.

    World Health Organization and World Economic Forum. From burden to “best buys”: reducing the economic impact of non-communicable diseases in low-and middle-income countries. Geneva: WHO and World Economic Forum; 2011.

  6. 6.

    The World Bank. How we classify countries? Washington DC: The World Bank; 2011. Available from URL: (Accessed 13 May, 2012).

  7. 7.

    Beaglehole R, Bonita R, Horton R, Adams C, Alleyne G, Asaria P, et al. Priority actions for the non-communicable disease crisis. Lancet. 2011;377:1438–47.

  8. 8.

    Omran AR. The epidemiologic transition: a theory of the epidemiology of population change. 1971. Milbank Q. 2005;83:731–57.

  9. 9.

    Olshansky SJ, Ault AB. The fourth stage of the epidemiologic transition: the age of delayed degenerative diseases. Milbank Q. 1986;64:355–91.

  10. 10.

    Bovet P, Shamlaye C, Paccaud F. Stroke mortality in the Seychelles: methodological issues. Lancet Neurol. 2009;8:700; author reply 700.

  11. 11.

    Bovet P, Viswanathan B, Shamlaye C, Romain S, Gedeon J. Addressing non-communicable diseases in the Seychelles: towards a comprehensive plan of action. Glob Health Promot. 2010;17(2 Suppl):37–40.

  12. 12.

    Guthold R, Louazani SA, Riley LM, Cowan MJ, Bovet P, Damasceno A, et al. Physical activity in 22 African countries: results from the World Health Organization STEPwise approach to chronic disease risk factor surveillance. Am J Prev Med. 2011;41:52–60.

  13. 13.

    Danaei G, Finucane MM, Lu Y, Singh GM, Cowan MJ, Paciorek CJ, et al. National, regional, and global trends in fasting plasma glucose and diabetes prevalence since 1980: systematic analysis of health examination surveys and epidemiological studies with 370 country-years and 2.7 million participants. Lancet. 2011;378:31–40.

  14. 14.

    Farzadfar F, Finucane MM, Danaei G, Pelizzari PM, Cowan MJ, Paciorek CJ, et al. National, regional, and global trends in serum total cholesterol since 1980: systematic analysis of health examination surveys and epidemiological studies with 321 country-years and 3.0 million participants. Lancet. 2011;377:578–86.

  15. 15.

    Finucane MM, Stevens GA, Cowan MJ, Danaei G, Lin JK, Paciorek CJ, et al. National, regional, and global trends in body-mass index since 1980: systematic analysis of health examination surveys and epidemiological studies with 960 country-years and 9.1 million participants. Lancet. 2011;377:557–67.

  16. 16.

    Danaei G, Finucane MM, Lin JK, Singh GM, Paciorek CJ, Cowan MJ, et al. National, regional, and global trends in systolic blood pressure since 1980: systematic analysis of health examination surveys and epidemiological studies with 786 country-years and 5.4 million participants. Lancet. 2011;377:568–77.

  17. 17.

    Anand SS, Yusuf S. Stemming the global tsunami of cardiovascular disease. Lancet. 2011;377:529–32.

  18. 18.

    Abegunde DO, Mathers CD, Adam T, Ortegon M, Strong K. The burden and costs of chronic diseases in low-income and middle-income countries. Lancet. 2007;370:1929–38.

  19. 19.

    Stringhini SS, Didon J, Gedeon J, Paccaud F, Bovet P. Declining stroke and myocardial infarction mortality between 1989 and 2010 in a country of the African region. Stroke. (in press). 2012.

  20. 20.

    Rodriguez T, Malvezzi M, Chatenoud L, Bosetti C, Levi F, Negri E, et al. Trends in mortality from coronary heart and cerebrovascular diseases in the Americas: 1970–2000. Heart. 2006;92:453–60.

  21. 21.

    Stuckler D. Population causes and consequences of leading chronic diseases: a comparative analysis of prevailing explanations. Milbank Q. 2008;86:273–326.

  22. 22.

    World Health Organization. The World Health Report–Health system financing. Geneva: WHO; 2010.

  23. 23.

    World Health Organization. Commission on the Social Determinants of Health. Geneva: WHO; 2008.

  24. 24.

    Stuckler D, Basu S, McKee M. Drivers of inequality in Millennium Development Goal progress: a statistical analysis. PLoS Med. 2010;7:e1000241.

  25. 25.

    The World Bank. Toward a healthy and harmonious life in china: stemming the rising tide of non-communicable diseases. Washington DC: The World Bank; 2011.

  26. 26.

    World Economic Forum. Global Risks 2010–A Global Risk Network Report. Geneva: World Economic Forum; 2010.

  27. 27.

    Nugent R, Feigi AB. Where Have All the donors gone? Scarce donor funding for non-communicable diseases. Washington: Center for Global Development; 2010.

  28. 28.

    World Health Organization. Preventing chronic diseases: a vital investment. Geneva: WHO; 2005.

  29. 29.

    World Health Organization. Mortality and burden of diseases estimates for WHO Member States in 2004. Geneva: WHO; 2009.

  30. 30.

    Mahal A, Karan A, Engelgau, M. The economic implications of non-communicable diseases for India. HNP Dicussion Paper. Washington DC: The World Bank; 2010.

  31. 31.

    Asaria P, Chisholm D, Mathers C, Ezzati M, Beaglehole R. Chronic disease prevention: health effects and fnancial costs of strategies to reduce salt intake and control tobacco use. Lancet. 2007;370:2044–53.

  32. 32.

    Lim SS, Gaziano TA, Gakidou E, Reddy KS, Farzadfar F, Lozano R, et al. Prevention of cardiovascular disease in high-risk individuals in low-income and middle-income countries: health effects and costs. Lancet. 2007;370:2054–62.

  33. 33.

    Nikolic IA, Stanciole AE, Zaydman M. Chronic emergency: Why NCDs matter. Washington DC: The International Bank for Reconstruction and Development–The World Bank; 2011.

  34. 34.

    World Health Organization. Scaling up action against noncommunicable diseases: How much will it cost? Geneva: WHO; 2011.

  35. 35.

    The Oxford Health Alliance. Chronic diseases: an economic perspective. London: The Oxford Health Alliance; 2006.

  36. 36.

    Papadakis S, Moroz I. Population-level interventions for coronary heart disease prevention: what have we learned since the North Karelia project? Curr Opin Cardiol. 2008;23:452–61.

  37. 37.

    Meyers DG, Neuberger JS, He J. Cardiovascular effect of bans on smoking in public places: a systematic review and meta-analysis. J Am Coll Cardiol. 2009;54:1249–55.

  38. 38.

    Zatonski W, Campos H, Willett W. Rapid declines in coronary heart disease mortality in Eastern Europe are associated with increased consumption of oils rich in alpha-linolenic acid. Eur J Epidemiol. 2008;23:3–10.

  39. 39.

    Uusitalo U, Feskens EJ, Tuomilehto J, Dowse G, Haw U, Fareed D, et al. Fall in total cholesterol concentration over five years in association with changes in fatty acid composition of cooking oil in Mauritius: cross sectional survey. BMJ. 1996;313:1044–6.

  40. 40.

    Ford ES, Bergmann MM, Kroger J, Schienkiewitz A, Weikert C, Boeing H. Healthy living is the best revenge: findings from the European Prospective Investigation Into Cancer and Nutrition-Potsdam study. Arch Intern Med. 2009;169:1355–62.

  41. 41.

    Ford ES, Capewell S. Proportion of the decline in cardiovascular mortality disease due to prevention versus treatment: public health versus clinical care. Annu Rev Public Health. 2011;32:5–22.

  42. 42.

    Swinburn BA, Sacks G, Hall KD, McPherson K, Finegood DT, Moodie ML, et al. The global obesity pandemic: shaped by global drivers and local environments. Lancet. 2011;378:804–14.

  43. 43.

    World Health Organization. WHO report on the global tobacco epidemic, 2011: warning about the dangers of tobacco–MPOWER. Geneva: WHO; 2008.

  44. 44.

    Webster JL, Dunford EK, Hawkes C, Neal BC. Salt reduction initiatives around the world. J Hypertens. 2011;29:1043–50.

  45. 45.

    Matsudo VK, Matsudo SM, Araujo TL, Andrade DR, Oliveira LC, Hallal PC. Time trends in physical activity in the state of Sao Paulo, Brazil: 2002–2008. Med Sci Sports Exerc. 2010;42:2231–6.

  46. 46.

    Bovet P, Gervasoni JP, Mkamba M, Balampama M, Lengeler C, Paccaud F. Low utilization of health care services following screening for hypertension in Dar es Salaam (Tanzania): a prospective population-based study. BMC Public Health. 2008;8:407.

  47. 47.

    Bovet P, Burnier M, Madeleine G, Waeber B, Paccaud F. Monitoring one-year compliance to antihypertension medication in the Seychelles. Bull World Health Organ. 2002;80:33–9.

  48. 48.

    World Health Organization. Strengthening health systems to improve health outcomes. Geneva: WHO; 2007.

  49. 49.

    Lonn E, Bosch J, Teo KK, Pais P, Xavier D, Yusuf S. The polypill in the prevention of cardiovascular diseases: key concepts, current status, challenges, and future directions. Circulation. 2010;122:2078–88.

  50. 50.

    Wald NJ, Law MR. A strategy to reduce cardiovascular disease by more than 80%. BMJ. 2003;326:1419.

  51. 51.

    Ndindjock R, Gedeon J, Mendis S, Paccaud F, Bovet P. Potential impact of single-risk-factor versus total risk management for the prevention of cardiovascular events in Seychelles. Bull World Health Organ. 2011;89:286–95.

  52. 52.

    National Institute for Health and Clinical Excellence. Prevention of cardiovascular disease at population level. London: NICE; 2010.

  53. 53.

    Institute of Medecine. Committee on Preventing the Global Health Epidemic of Cardiovascular Disease: Meeting Challenges in Developing Countries. Promoting cardiovascular health in the developing world: a critical challenge to achieve global health. Fuster V, Kelly BB, editors. Washington DC: National Academies Press; 2010.

  54. 54.

    Weintraub WS, Daniels SR, Burke LE, Franklin BA, Goff DC, Jr., Hayman LL, et al. Value of primordial and primary prevention for cardiovascular disease: a policy statement from the american heart association. Circulation. 2011;124:967–90.

  55. 55.

    Cecchini M, Sassi F, Lauer JA, Lee YY, Guajardo-Barron V, Chisholm D. Tackling of unhealthy diets, physical inactivity, and obesity: health effects and cost-effectiveness. Lancet. 2010;376:1775–84.

  56. 56.

    Beaglehole R, Bonita R, Alleyne G, Horton R. NCDs: celebrating success, moving forward. Lancet. 2011;378:1283–4.

  57. 57.

    United Nations General Assembly 66th Session. Political Declaration of the High-level Meeting of the General Assembly on the Prevention and Control of Non-communicable Diseases. A/66/L.1 New York: UN; 2011.

  58. 58.

    Smith R. Health ministers pledge to tackle non-communicable diseases with global action. BMJ. 2011;342:d2796.

  59. 59.

    Marrero SL, Bloom DE, Adashi EY. Noncommunicable diseases: a global health crisis in a new world order. JAMA. 2012;307:2037–8.

Download references

Author information

Correspondence to Pascal Bovet MD, MPH.

Rights and permissions

Reprints and Permissions

About this article

Cite this article

Bovet, P., Paccaud, F. Cardiovascular Disease and the Changing Face of Global Public Health: A Focus on Low and Middle Income Countries. Public Health Rev 33, 397–415 (2011).

Download citation

Key Words

  • Cardiovascular disease
  • noncommunicable disease
  • global public health
  • low and middle income countries
  • health systems
  • prevention
  • policy
  • intersectoral action