West meets East: breaking barriers to prevention in Asia and America

R has this Chinese proverb (Figure 1) elicited as enthusiastic a response as it did at the Preventive Cardiology Conference and Fourth Certification Course in Cardiac Rehabilitation held in Hong Kong, February 17 to 20, 2001. The meeting provided a unique opportunity for local and international experts to exchange information and gain insights into barriers to cardiovascular disease (CVD) prevention, and to discuss strategies to keep the growing global epidemic of CVD at bay. In China, as in America, CVD ranks as the leading cause of death, claiming 2.6 million lives per year, more than double the number of Americans who die of CVD each year.1 Increasing trends of major CVD risk factors are a significant public health challenge in China. According to a recent survey, 63% of Chinese men smoke and the prevalence of smoking is increasing among adolescents; therefore, rates of CVD are likely to continue to climb without widespread effective prevention programs. There is an increasing incidence of hypertension, which is coupled with low rates of awareness (26.3%), treatment (12.1%), and control (2.8%). Hypertension contributes substantially to morbidity and mortality due to CVD in China, especially for stroke. Although mean cholesterol concentrations are lower in China compared with most western countries, it is one of the few places where levels are increasing. Data from a prospective study conducted in 11 Chinese provinces showed that the incidence of CVD increased significantly when low-density lipoprotein (LDL) cholesterol was .2.6 mmol/L, and that nearly 60% of events occurred at what is currently described as a “desirable” level of LDL cholesterol.2 Dr. Liu of the Beijing Institute of Heart, Lung & Blood Vessel Disease suggested that a major barrier to prevention is the need to develop national guidelines for treatment of cholesterol that are based the distribution of risk levels within the Chinese population. Comprehensive secondary prevention and cardiac rehabilitation are challenging in many Asian countries, but often for different reasons. Dr. S.W. Li, Director of the Rehabilitation Unit at Tung Wah Hospital, Hong Kong, described China and Hong Kong as one country with two health systems: “Hong Kong is a capitalistic society with a public health care system, whereas China is a socialistic society with a predominately self-pay system,” he stated. Hospitalized patients only have to pay $8 US per day for all health care services in Hong Kong, including coronary bypass grafting and medications. He gave us a tour of his state of the art Cardiac Rehabilitation and Prevention Center at the University of Hong Kong, and pointed out that unlike Mainland China, where the lack of facilities and resources are major barriers to prevention, it is a lack of understanding of the effectiveness of cardiac rehabiliation among physicians that contributes to the low rate of utilization (5.7%) of cardiac rehabilitation in Hong Kong. Not surprisingly, lack of space is a major barrier to the establishment of facilities for rehabilitation in Singapore, a country with 4 million people packed into 660 km. Because of the abundance of high rises, use of stairs as a mechanism for exercise training has been suggested as a reasonable alternative to formal cardiac rehabilitation. The 3 major rehabiliation centers in operation in Singapore are hampered by widespread variability in referral patterns and lack of telemetric monitoring.3 Moreover, limited resources are available for management of lifestyle and psychosocial factors. Cardiac rehabilitation is relatively recent in Thailand and ,5 institutes offer formal programs to the estimated 70 million Thai people.4 Factors that limit participation are lack of transportation (75%), no escort (13%), and time constraints and/or occupation (13%). In the Philippines, rehabilitation programs have been slow to develop, despite the efforts of Dr. Adolfo Bellisimo, who established a medical society to promote prevention in his country. He suggests that because cardiac rehabilitation is not a distinct subject in medical school, there is a lack of awareness of CVD From Columbia University College of Physicians and Surgeons, New York, New York. Manuscript received and accepted March 30, 2001. Address for reprints: Lori Mosca, MD, MPH, PhD, Columbia University, Preventive Cardiology, New York Presbyterian Hospital, ICCR PH 10-203D, 622 West 168th Street, New York, New York 10032. E-mail: ljm10@columbia.edu. FIGURE 1. Translation: Superior doctors prevent the disease. Mediocre doctors treat the disease before evident. Inferior doctors treat the full blown disease. From Huang Dee: Nai-Ching (2600 BC, First Chinese Medical Text).