Education and income: double-edged swords in the epidemiologic transition of cardiovascular disease

The 2002 World Health Report warns that the allies of poverty and ignorance are joining forces with the new formidable enemies of health. This describes the epidemiologic transition of burden of disease from infectious and parasitic diseases to that of noncommunicable diseases. All parts of the world, with the possible exception of sub-Saharan Africa, have well-established epidemics of coronary heart disease and stroke. Hypertension contributes significantly to mortality everywhere and is a leading global problem. Education and wealth have strong influences on the epidemiologic transition and might serve as a double-edged sword of benefit and risk. While improved education and enhanced resources are necessary to reduce infectious, parasitic, and perinatal diseases, these factors are also associated with adoption of deleterious health behaviors, which lead to the atherosclerotic diseases. The diffusion of innovation theory describes the early adoption of unhealthy lifestyles in the educated and wealthy, who soon recognize the costs to their community and modify these lifestyles. The uneducated poor may adopt these unhealthy lifestyles later, but, once that occurs, are left with higher risk and burden of cardiovascular disease. One possible reason for this is that discretionary income and the desire for modern conveniences quickly attract unhealthy products (tobacco, high fat/high salt foods) and unhealthy behaviors (sedentary entertainment transportation without physical exertion). The commercial interests of these products have been efficient and effective in delivering their messages to developing societies. Heart health organizations must be more aggressive in their assessment of needs for programs, education of people over a broad range of education levels, assurance of access to heart health services, alteration of the environment to facilitate heart health, and the development of policies and laws to limit deleterious products and behaviors. These late-adopter communities are assumed to require additional efforts and services to counterbalance deleterious influences. Sub-Saharan Africa is the only WHO region in which cardiovascular disease is not the leading cause of death. There is no precedent to support the notion that Africa will, without special efforts, avoid progression to later stages of the epidemiologic transition. The goal of improved education and eradication of poverty in Africa should not and need not carry the unhappy consequence of a cardiovascular disease epidemic.