Global Hearts: Confronting the Cardiovascular Disease Crisis

Thursday, September 22, 2016
Cris Toala Olivares/Reuters

Director, Centers for Disease Control and Prevention

Paulyn Rosell-Ubial

Secretary, Department of Health, Republic of the Philippines

John Boyce

Minister of Health, Barbados

Richard E. Besser

Chief Health and Medical Editor, ABC News

Introductory Remarks
Michael R. Bloomberg

Founder, Bloomberg LP and Bloomberg Philanthropies; Global Ambassador, World Health Organization

Margaret Chan

Director-General, World Health Organization

Barbados Minister of Health John Boyce, Director of U.S. Centers for Disease Control and Prevention Thomas R. Frieden, and Secretary of the Philippine Department of Health Paulyn Rosell-Ubial join ABC News Chief Health and Medical Editor Richard E. Besser to discuss the growing crisis of cardiovascular diseases. The introductory remarks are given by Michael R. Bloomberg, founder of Bloomberg LP and Bloomberg Philanthropies, and Margaret Chan, director-general of the World Health Organization. Experts discuss the growing crisis of noncommunicable diseases, specifically cardiovascular diseases, and initiatives by the World Health Organization and the Centers for Disease Control and Prevention in countering these threats globally.

BESSER: Well, good afternoon, and welcome to today’s session of the Council on Foreign Relations on “Global Hearts: Confronting the Cardiovascular Disease Crisis.”

I think you’re in for a fascinating session. This is an incredibly important health issue and a new global public-health initiative.

In 2014 the Council put out a report on the emerging crisis in non-communicable diseases, and in that report called for a rebalancing of the global public-health portfolio so that it wasn’t focusing just on infectious diseases and maternal child health, but was taking into account the importance of cancer, of injuries, mental health, and today’s topic, heart disease.

We’re going to have two short talks to kick off the session and frame it, and then we’ll have a panel discussion with some of the countries that have been doing some work to already implement aspects of this new initiative.

In the interest of time, I’m going to keep the introductions short. I could definitely fill up the hour with the accomplishments of our panel today and our speakers.

Our first speaker is Dr. Margaret Chan, who is the director general of the World Health Organization. She came to that position in 2006 after a long and distinguished career in public health. And she’s now nearing the end of her second term as director general. I had the pleasure and honor of working with her during the start of the 2009 H1N1 pandemic.

Dr. Chan. (Applause.)

CHAN: Thank you, Rich, for that introduction.

Good afternoon. It’s just past 12. Good afternoon to all of you. It’s so good to see so many of you here. And, of course, I like to say Tom is my good friend. Thank you for the collaboration. And let’s please join me to welcome the WHO Global NCD ambassador, Mike Bloomberg. (Applause.)

Colleagues, many people have been reminding me that NCD do not get its due recognition and the kind of political support. And that’s why I’ve been looking around, searching around the world. I cannot find another person better than Mike Bloomberg. Right? He has been mayor in this city. You know him. He would do everything possible to make sure that people, including government during his administration, to take the right public-health actions to protect people.

I want to recognize, you know, your contribution, Mike. And thank you for accepting, being the WHO global ambassador on NCD, because we need somebody of his stature to really move the needles and making sure that people can take the right public-health actions, governments—(inaudible)—and to protect people.

And I also want to thank the governments of Barbados, India, Philippines, Sri Lanka, and, of course, the United States for cosponsoring this event.

And thanking the Council on, you know, Foreign Relations for hosting us. We are running out of venue. Thank you; you come to our rescue. (Laughter.) New York, you know, in the margins of the U.N. General Assembly, is crazy.

Oh, my dear Lori, you are in the audience. So good to see you. (Laughter.)

Now, truly, this is a wonderful, wonderful collaboration between WHO and the U.S. Center for Disease Control and Prevention. And we are partner in this initiative. The Global Heart Initiative we are about to launch today can save many millions of lives. Cardiovascular disease are the number-one killers, you know, on the list.

I shall not go into all the details of the figures. You know that. I just want to make three points. Tom, I’m not going to pay intellectual property right to you, because this is exactly what we need to do. We need technical competence. We need operational excellence. And we need political leadership.

Now, this heart initiative, global heart initiative has three packages. And the three packages are, you know, grounded in solid science so, you know, you will know the details on what works and that’s good.

Operational excellence. This is why we need partners to work with countries, to support countries to implement what is being known. Because by taking actions, some wealthy countries, like USA, reduce deaths from cardiovascular diseases by more than 40 percent, and in Finland reduce deaths from cardiovascular disease in men by 80 percent. We do not need to reinvent the wheel. We need—we know what to do. We just need to move all these workable solutions to support countries who are experiencing the highest epidemic in terms of NCDs.

So the third point is about political leadership. And I’m happy to see, you know, minister from Barbados here. Thank you for your leadership. And, of course, Mike, your leadership, going around the world on behalf of so many people, including WHO, to champion for actions on NCDs.

So, friends, colleagues, thank you. (Applause.)

BESSER: Thank you very much, Dr. Chan.

Our next speaker is going to be Mayor Michael Bloomberg. As mayor of New York City between 2001 and 2010, he set a new standard for using government policy to drive improvements in health. And we saw an increase in life expectancy in New York of 36 months, which was two years longer than the national average.

Due to his track record in addressing non-communicable diseases, both as mayor and through his philanthropies, Dr. Chan asked him to be the WHO global ambassador for non-communicable diseases.

Mayor Bloomberg. (Applause.)

BLOOMBERG: Thank you, Richard.

I was thinking when Margaret said thank you for accepting, anybody that’s ever tried to say no to Margaret—(laughter)—knows that that is an ingenuous thing for her to say. She does not give up easily.

And it reminded me, the secretary-general asked me to go around and do something or other with some fancy title and I said, well, I don’t know if I have time. He said, well, we’ll give you a diplomatic passport. So I thought to myself, boy, that sounds pretty good. I didn’t grow up in a family where we had diplomatic passports. As a matter of fact, I didn’t grow up in a family where we had passports. (Laughter.) I was sure I was the first one in my family in 1968 to go outside of the country. My parents had gotten married in Niagara Falls, but they never went over to Canada. And so I was the first one, I went to Val d'Isère to learn how to ski and speak French. I was the only one that didn’t speak French and nobody spoke English, but I did find a girl to spend the week with, so it turned out OK. (Laughter.) And I did eventually learn how to ski, although not to speak French.

But anyways, I tell you the passport story. This is about two years ago. I’m in Paris and I had to fly from Paris to Detroit to do something for somebody who had an organization in Detroit, I promised to give a speech. And I decided, OK, I’ll use my diplomatic passport because I had never used it before. And so I get to Immigration in Detroit and I hand them this red passport and the Immigration guy looks at it, looks at it, says, what country is this from? (Laughter.) That tells you why we’re in trouble here.

Anyways, Dr. Besser, thank you and good afternoon to everyone. And I did want to seriously thank the WHO for initiating this collaboration, and particularly Margaret for leading it. She has been a force for good in this world.

And when you look in the mirror, you should have a big smile on your face because an awful lot of people are still alive because of you and everything your organization does, so congratulations. (Applause.) Yes, they deserve it.

And Bloomberg Philanthropies is honored to be able to work with WHO and do some things together. I was honored last month when Margaret asked me to serve as the WHO global ambassador for non-communicable diseases, which is one of the world’s most urgent challenges.

Needless to say, thanks to Dr. Kelly Henning who runs all of our public health stuff at Bloomberg Philanthropies I have some numbers for you. Thirty-seven million people are killed by non-communicable diseases each year; 16 million of these people die before their 70th birthday and more than 80 percent of those premature deaths are in low and middle-income countries. So the bottom line is, if you’re not educated, you don’t know what’s going to damage your health. That’s where the cigarette companies and the full-sugar drink companies and all these companies focus their efforts on people that don’t know any better. And so the challenge really, as Margaret said, we know what to do, it’s a question of how you tell people and explain to them that they’re in control of their own destiny. And if they want to live, they should do something.

Somebody said, well, how am I going to learn how to stop smoking? And I said here’s what you do. Close your eyes, think about the person that you hate the most. Now, do you want to go to their funeral or you want them to go to yours? (Laughter.) If that doesn’t get you to stop smoking, it’s a lost cause, there’s nothing we can do about that.

But we can’t accept these numbers, we have to do something about it, for example addressing cardiovascular disease is one of the great opportunities since it is the leading cause of premature death in virtually every corner of the globe. And the steps outlined in the Global Hearts program that we’re launching today can prevent more than 2 million premature deaths every year. And that would be a great achievement. And I know that together we really can make it happen.

You know, if you don’t smoke and you’re not overweight and you get some exercise and you don’t overdo salt and a few other things, the chances of you living a lot longer really are dramatically better. And people say, well, I don’t care. Yeah, you know, there’s no atheists in foxholes, the old joke, but I think as you’re getting close and the doctor gives you a diagnosis that you didn’t want to get, the thought of dammit I should have done what they told me to do probably comes to your head.

I did want to thank the Council on Foreign Relations and my friend Richard Haass for helping us. He is not here today. He is an old friend. We spend a lot of time together. I was with him yesterday; I was with him last Friday. Enough of Richard, so maybe you’re lucky that he isn’t here. You can tell him I said that. I came to his place and he didn’t care enough. (Laughter.) His wife is also a close friend, so I am going to call her later on.

Seriously, I want to welcome all of the distinguished guests from around the world who are here helping us. And I really am encouraged to see so many people from the highest level of governments that are starting to become committed to this cause. And it sets a great example for other countries around the world when some of you come here.

I also wanted to mention Tom Frieden and his team at CDC for their partnership. You may know, before President Obama chose Tom to lead the CDC, he had been our health commissioner in New York City, and hiring Tom was one of the best decisions I made as mayor and one of the best that President Obama has made. And it’s great to have this opportunity to work together again.

His successor had exactly the same initials, Tom Farley, and I chose Farley because we didn’t want to have to change the monograms on the towels at the health department. But Farley also made a big difference in this city. And together, as Richard said, life expectancy increased by three years in New York City and it’s a couple of years greater than the national average.

So if you have loved around the country who are thinking about, for example, retiring to Florida, tell them to move to Flatbush and they will live a couple of years longer. (Laughter.) Now, I can’t guarantee everyone, but on average that really is true.

Our foundation’s work and our administration’s work in New York City are things that I’ve been very proud of. And it shows you that government and nonprofits and businesses, if they work together, can really make things happen.

I’ll give you a couple of examples. Tobacco will kill 1 billion people this century. That’s right, a billion with a B this century, and many of them from cardiovascular diseases. But if we can get people to stop smoking you can stop that and we’ve been working closely with WHO, nonprofit partners and governments around the world to reduce that number and I’m glad to report that we really are making progress.

Over the last 10 years, 1.5 billion people have been protected by policies that are proven to reduce smoking such as smoke-free public places, which we did in New York City. When we first proposed New York’s smoke-free law in 2002, people thought we were crazy, particularly my staff, who thought I would get massacred and it would be a disaster to our economy if it passed.

In fact, just the reverse happened. It was incredibly popular and it helped our bars, restaurants, and hotels attract record numbers of customers and that encouraged other cities and countries to follow suit. I remember Christie Whitman, who was then governor in New Jersey, when we passed the smoking ban called and said, thank you so much—you’ve done the most wonderful thing for New Jersey. And I said, why. She said, because everybody’s going to come here for dinner. (Laughter.)

Three months later, she called me—it’s a true story—you can ask her—she’ll confirm this—and she said, I just want you to know I’ve just introduced a smoking ban law in New York—in New Jersey and I said, why. She said, because my son hasn’t spent a night in New Jersey in three months. (Laughter.) So that—that was one of the things. You know, you really can help, although doing a parade on Staten Island after I put the smoking ban in was not the easiest thing in the world. (Laughter.) I did get a lot of one-finger waves. (Laughter.) But today, something like 50 countries have adopted smoke-free laws and they really are—you can go to Italy and France and places you’d say in a million years they’d never stop smoking and they have.

And even in Beijing they’re starting to put in some laws that you can’t smoke where other people are and the Chinese own the tobacco companies. But this is common sense and I’ve always thought it’s not the hardest battle to win because 20 percent of the people smoke. Eighty percent don’t. So it isn’t like everybody does it. But if you are sitting next to a person smoking, through no fault of your own you’re getting hurt, and so you will be on our side of pressuring people to not smoke. And next time you go out in the streets just look outside buildings. You do not see the 10 and 20 people out there anymore smoking. Now, if they do smoke they put it behind their back. They’re ashamed of it. And we have a handful of people in our company that I see outside, and every once in a while I get the urge to just walk up and say, you know, you want to work here. I’d like you to work here. But I want you to work for a long time and this is not going to happen if you keep smoking so stop it. But I don’t do that. (Laughter.) There’s probably some stupid state law that would prevent me from doing it. There is actually a law—(laughter)—you cannot—you cannot fire somebody because they smoke. I did check on that and it’s—(laughter).

My foundation is applying many of the lessons I think we’ve learned from spreading tobacco control policies to the fight against obesity, another huge contributor to cardiovascular disease. We supported Mexico’s efforts to pass a one peso per liter tax on sugary drinks and consumption fell by 12 percent by the end of the year. They passed I think it was 10 percent on full-sugar drinks and 8 percent on fast foods and it’s really made a difference, and after it was passed about a month later in the middle of the night the Mexican legislature at the federal level of government passed a law—Kelly, am I right?—it was 400 to 40 to overturn the smoking ban, put it back, and two days later the uproar was such they kept saying, I didn’t vote for that, I didn’t vote for that, and they took another vote and it came out exactly the reverse.

So the public gets behind this. The public is not as stupid as people think. They just want to be told what they have to do and, you know, nobody’s going to be perfect about it. But you can rally people behind. It is the elected officials that are just so afraid of a handful of people complaining, and it is only a handful in all of these things. The people that complain, the handful that get on television and you think oh, it’s everybody. It isn’t. When you walk down—if there’s a bad story about you in the paper, everybody read it. Nobody read it. (Laughter.) I mean, I don’t know how to break this to you. They don’t know who the hell you are—(laughter)—and what’s more, they don’t care. So, you know—(laughter)—so go ahead and take the shot and try to, you know, help people.

Anyways, we’ve also supported efforts in Berkeley, California and in Philadelphia. This—Philadelphia, actually, this year became the largest U.S. city to adopt a soda tax and it really is a promising start. Cities will adopt taxes because they need the revenue to pander to the voters so they’re happy to do that and if you can hide it say well, we’re doing it for public health reasons, it helps you get it passed. And the truth of the matter is full-sugar drinks, because they don’t make—they don’t fill you up, they don’t tell you you’re full if you drink them, it’s all the calories from full-sugar drinks are additive. And there’s something like 12 teaspoons of sugar in one 12-ounce can of Coke or Pepsi. You cannot dissolve that in your tea—in one cup of tea. It just—it saturates it and it doesn’t dissolve.

It really—this stuff is not great for you. There are plenty of other things you can drink and Coke and Pepsi can sell other products and that’s exactly what they’re doing. They’re not stupid. They know that the public is walking away from it and we got—we tried to ban—well, we tried ban the full-sugar—we tried to have portion control here where the cup size had to be 16 ounces, so if you wanted to buy 32 ounces you have to carry two and you probably wouldn’t do the second one, and the courts stopped it.

But we won the battle. Coke and Pepsi sales around the world are plummeting except in those places where people are uneducated. But people really do listen to all of this. The same—this really is a good start—the same is true of reducing salt, particularly in processed foods, and I’m glad that’s a big focus of this program because I happen to love popcorn covered with salt and Cheez-Its and things like that.

But the truth of the matter is it’s the salt in processed foods that you don’t taste that real—the real damage is—the quantity. There’s more in a—more salt in a muffin, I think, than in a pack of Lay’s Potato Chips. I think so. Something—when Tom says yes I think I’m right there. Anyways—(laughter)—we’re making some progress and success in one city or in one country leads to success in another. So we really are making a difference and, once again, I want to thank Dr. Chan—Margaret—for WHO for bringing here all of these people to address. And when you go home tonight, look in the mirror. You know, by being here and working on this we really can make a difference. So thank you and enjoy the panel. I’ve got to go on to something else. Richard, thank you. (Applause.)

BESSER: Thanks very much, Mr. Mayor. I’d like to invite the panel to come up and take the stage. In the interest of time, I am going to go really short on the introductions. Tom Frieden Mayor Bloomberg introduced is the current director of the CDC. He’s been in that role since 2009. Next to Tom is Mr. John Boyce, who is the minister of health for Barbados, a role he’s held since 2013, and next to Mr. Boyce is Dr. Paulyn Rosell-Ubial, who is the secretary of the Department of Health for the Republic of the Philippines and she’s been in public office for 27 years.

 In the audience we also have Dr. Salim Yusuf, who is the president of the World Heart Federation, an organization representing the professional community, and I’ll be tossing a question his way as well.

Well, Mayor Bloomberg set the stage very nicely for this initiative and many of the areas that are involved, and Dr. Rosell-Ubial, I’d like to start—start with you. One of the areas that the Philippines has done a lot of work in is reduction of smoking and implementing the provisions from the WHO Framework Convention on Tobacco Control, and I wanted to just ask you why you’ve undertaken this as a major focus of activity and what kind of success you’ve had.

ROSELL-UBIAL: Yes, your excellencies, ladies and gentlemen, the Philippines is pleased to be part of the Global Hearts initiative. At least one in every four Filipinos die from heart disease, stroke or another non-communicable disease before the age of 70. Many of those deaths can be prevented, provided people can obtain the health services they need.

Four years ago, finances to cover non-communicable diseases care at both individual and country level were strained. Poor and indigenous populations had two options: skip treatment because they could not afford it or seek care and be forced to go deeper into debt.

The problem was the universal health care program aimed at ensuring every Filipino receives affordable, quality health care services was not reaching the most vulnerable and remote populations. It lacked resources to fund insurance premiums, and recruit the health care workers, and build additional health facilities in poor and remote areas.

But signing the sin tax law in December 2012 drastically changed the country’s health care financing system. The sin tax law, that taxes tobacco and alcohol, restructured and increased taxes so that 85 percent of incremental revenues was earmarked to health.

The Department of Finance in 2016 is now more than two-folds higher than it was compared to the 2013 budget level of 53 billion (pesos). It’s now 122.6 billion pesos. The incremental revenues also enable the government to increase coverage of the poor with free health insurance by 100 million families, from 5.2 million in 2012 to 15.3 million by the end of 2015.

Risk assessment and management of high-risk individuals are provided through our health facilities. Given the decentralized nature of our health system, local governments have taken up innovative actions in improving health and development at local levels, like, for example, there’s a city in Luzon that has a program for zero or a generation without tobacco. And they’re using senior citizens to tell people not to smoke tobacco.

A set of highly effective interventions with support tools as technical packages will be a major boost to the program implemented in the Philippines.

BESSER: Thank you very much.

Dr. Boyce, Barbados has undertaken a lot of work in terms of prevention and treatment of hypertension. And, you know, the initiative that’s being launched, a lot of the activities are around prevention, but there’s also a lot around low-cost treatment and the benefit that can have in terms of saving lives.

And I wanted to see if you could share your experience in terms of some of the challenges of getting medications out to those people who need them.

BOYCE: Thank you very much.

And let me say, first of all, that I was proud to be part of this program today. And our indices in terms of the threats of non-communicable diseases are very similar to the experiences throughout the world; a small island, of course, of just 270,000 people and 160 square miles in the beautiful waters of the Caribbean, which I invite you to enjoy. (Laughter.) (Charm is good ?).

However, like most countries in the world—and Mayor Bloomberg, and indeed my fellow panelist has referred to her experiences in the Philippines—the experience in Barbados is probably summed up best by our late prime minister, who stated in 2008, as far back as then, if left to chance, all the gains achieved in the Caribbean during the march from poverty to relative affluence since independence can be wiped out by non-communicable diseases. And it’s based on that kind of thinking that we took our thrust into this attack on NCDs.

As you indicated, the important thing is to try to gather standardized data for the measurement of the most appropriate medicines and the most appropriate applications that can be given. We do this in the setting of our primary-care health system, which is dealt with mostly in our polyclinic system throughout the island, which are strategically placed across Barbados in different what we call parishes. This enables us to reach out into the communities in a much stronger way.

Of course, then there’s the entire question of the whole lifestyle change. Again, Mayor Bloomberg spent a lot of time talking about these challenges. We in Barbados introduced as far back as 2015 a 10 percent tax on sweetened beverages. Of course, the response for the industry—the first response, of course, was to absorb that 10 percent. And it was in their profit margin. So we obviously have to tackle this problem again and to try to see how we can strengthen our approach. Then we have to tackle the whole problem of salts in our foods and our approaches to that.

Of course, the question of smoking; we again have made it illegal for us to smoke in enclosed buildings. But, of course, what happens? Our people step outside, as was indicated, just outside the door, and proceed to smoke. So, again, we probably have to establish extents in terms of how far outside of the building one has to be, because the challenges to persons by way of side-stream smoke are extreme.

So the challenge, like has been indicated, so much as that of lifestyle change. What do we eat? How often do we eat? What portions do we take? A country, again, like Barbados, accustomed to high-sugar beverages and high-sugar foods, may I say, sometimes quite large portions too. So we’ve got to train our people, train our younger people especially, into the habits of changing your lifestyle, reduce your sugar, eliminate sugars if possible. Consume a lot more water, for instance, basic water—extremely cheap, almost free in most countries. And we’re seeing that happen. Then, of course, is the old adage that we need to exercise daily.

So, again, we’re going into our schools and we are practicing programs for daily exercise. And this is beginning to become part of our community efforts springing up around the country in a number of community programs. We see groups coming together in free programs, led by community leaders as part of their social program. And I think these are the measurements that we want to make over the next couple of years so as to strengthen our whole approach to the question of non-communicable diseases and the challenges.

BESSER: Thanks very much.

Dr. Frieden, let me pull you in. Part of the initiative is providing technical assistance globally, but it’s also looking at heart disease and heart health in the United States. And in 2011, you launched the Million Hearts Initiative and made a commitment to save 1 million lives from heart disease and stroke by 2017.

That’s an incredibly bold goal, and it’s not that far away. How close are you coming to achieving that? And what are some of the challenges that you still face?

FRIEDEN: We proposed to prevent a million heart attacks and strokes over a five-year period in the U.S. and proposed to do that through three—through two broad categories of action—community-based action to eliminate trans fat, reduce sodium, and do tobacco control, and clinically-based action to improve what we’ve called the ABCs—aspirin use, blood-pressure control, cholesterol management, smoking-cession services—in the clinical system.

We’ve had significant progress. Later this year we’ll project what we’re going to do. There have been lessons. Some things took longer than we’d like. It’s harder to change or improve health care quality than anyone would like.

I think of it really in terms of four areas of accountability. The first is accountability of governments. There are lots of things that work. We know what to do—tobacco taxes, smoke-free spaces, restrictions on advertising, promotion, marketing of tobacco, hard-hitting anti-tobacco ads.

If a government isn’t doing those things, it is, in some way, ethically responsible for the tobacco-caused deaths of their people. That’s the first accountability.

Second accountability is in the health care system. A few years ago, when I was health commissioner here in New York City, we put in electronic health records in the poorest, sickest neighborhoods of New York City—Harlem, Bed-Stuy, and the South Bronx—and we asked a really simple question. All right, now that we’re putting these in, how can we save the most lives through health care?

And the answer was not readily apparent from doing a MEDLINE search. So we had to do our own analysis. And the answer is actually extremely clear. It’s do a better job on cardiovascular-disease prevention. Far and away the most lives can be saved in most countries through cardiovascular-disease prevention, particularly hypertension treatment more than any other thing.

And yet, if we look at our health systems around the world and have that as the second accountability, how are we doing? Lousy. Basically one out of six patients with hypertension around the world has it controlled, including in India and China. In this country, we’re only at 54 percent. In the U.K., even with universal health coverage, they’re at 36 percent. Canada, which is focused on it, is closer to 70 percent. So this core accountability of systems—it’s not enough to provide health care as a good or a commodity or even a right. You have to make sure that it delivers health.

The third accountability is individuals. I think sometimes there’s a false dichotomy with non-communicable diseases in particular. Oh, it’s a lifetime—lifestyle disease. If you were only better educated or took more care of yourself, you wouldn’t get sick. And I think we have to get beyond that and say, absolutely, we’re not absolving anyone of responsibility, but what we want to do as a society is make the default value the healthy value, so that if you go with the flow, you won’t end up smoking or obese by the time you’re an adult. And that kind of understanding, that it’s not either societal responsibility or individual responsibility, it’s both.

The fourth and final accountability I think is to all of us—government, society, scientists—to figure out the answers to the questions we don’t yet know. No society has, outside of starvation, reversed obesity. And we’re not 100 percent sure what is driving the obesity epidemic. There are lots of good theories. There are lots of things that make sense to do. We need to try things, see what works, and then use that to reverse what is a very troubling trend, not just the U.S., but around the world.

BESSER: Just briefly, to follow up on that last point, when I looked at the initiative, I don’t see much there on obesity prevention. And hearing Dr. Boyce and Mayor Bloomberg talk about the impact of soda taxes and the impact of soda on obesity and then heart disease, why is that not a component of the initiative?

FRIEDEN: We selected specifically things that we knew if implemented would have a measurable, actually projectable, impact. And unfortunately, with obesity prevention, we don’t yet have an example of success that can then be applied elsewhere. That’s why we need for obesity practice-based evidence. Try things. See what works. Rigorously document them. And then scale that up.

BESSER: Dr. Yusuf, I want to pull you in briefly into the conversation. You’ve done a lot of work around the globe implementing interventions to reduce premature deaths from cardiovascular disease. What do you see as cost effective measures that would have the most value from implementation, that at this point don’t have a lot of penetration, aren’t being used broadly? And in the interest of time, if you could be brief.

Q: Well, thank you. I’ve been called many things, but never Dr. UNICEF. Thank you. (Laughter.)

BESSER: Did I say UNICEF? Yusuf. Yusuf.

Q: That’s fine. I’ve been called Dr. Useless in the past. (Laughter.) But you’re being so kind.

Well, you know, I represent the World Heart Federation, which is an umbrella organization of the professional societies for cardiovascular diseases, the heart foundations from over a hundred countries. And the World Heart Federation works in many areas. But to directly answer your question, we think first trying to get the message across that cardiovascular disease is a major problem—just getting that message across is important. So we do that through the World Heart Day, which is in a week’s time, on the 29th of September. And our main message, both to individuals and to society and government, is collect information. Know your own numbers and know the numbers in your country because if you don’t measure it, it doesn’t count. So that’ the first thing.

The second thing I want to say is we—I want to emphasize that today’s the launch of the Global Hearts initiative that the WHO, CDC, World Heart Federation, World Stroke Organization together have come together. And I want to congratulate the WHO for expanding its vision from public health alone to public health plus clinical interventions. And I would say the three areas to prioritize is tobacco, the second one would be hypertension control. Our own data’s very—matches what Tom Frieden says. Thirteen percent control globally of hypertension. So that’s a big killer. And the third one is people already have disease trying to get—like a heart attack or a stroke—trying to do something about it. There are effective therapies that can prevent recurrence in 80 percent of people.

In addition to this, we’re doing—it’s one thing to proselytize. It’s another thing to actually have mechanisms to do it. So we’re working with countries around the world to train young people—what we called the Emerging Leaders Program—in how to translate evidence into practice. And we’ve started courses in primary prevention because that’s where, in general practice—whether it’s doctors, nurses, pharmacists—that’s where really prevention would happen. So I would say almost something very parallel to what Dr. Frieden said, which is let’s implement what we know. If we implement what we know for sure, we’ll make a big difference. And I think we have the tools not just to achieve the 25 percent reduction by 2025 in premature cardiovascular disease globally. We actually have the tools to halve cardiovascular disease globally.

And this may echo what Richard Besser says, because we work closely together. So I think collectively today is a very important day. I want to congratulate the team at the WHO, CDC, the two governments we have met, Bloomberg. And thank you for giving us a chance to make a difference. One little thing I’d say is those of us in the West should have some humility. We can learn a lot from the low- and middle-income countries. And I was reading a book on health care systems by Mark Britnell, and he had 10 examples. And from Africa was the best example of what patients can teach you. Thank you.

BESSER: Thank you very much. (Applause.)

I’m going to take one more question and then open it up to members for their questions. And this one I would pose to either Dr. Rosell-Ubial or Dr. Boyce. The United—and this has to do with tobacco control and the importance of that. And the United States has never ratified the WHO framework convention on tobacco control. And in fact, the U.S. Chamber of Commerce has worked very hard around the globe to try and prevent implementation of many of the policies that have been implemented in, say, New York City. What impact do those efforts have on your ability to do what you’d like to do in terms of reducing tobacco usage, if any?

ROSELL-UBIAL: In the Philippines, we’ve tried to use the WHO strategy of empower. So we’ve been able to reverse the usage of tobacco and bring it down to less than 24 percent. So for the first time in history, tobacco usage is going down in the Philippines, because of the empower strategy.

BOYCE: In Barbados, certainly, we have signed onto the framework for tobacco control. And we have in place, as I said, legislation to deal, first of all, with smoking in public places. The next step, of course, is to introduce legislation which is, again, on the cards in terms of advertising tobacco and using actually images to help to present the consequences. The other very important approach, and I heard from my colleague the importance of government lead in the process as partly the success—the opportunity for success.

And we’ve also taken the approach of a multi-sectoral approach towards this whole matter. So it’s not a Ministry of Health problem alone, but we ensure that the ministries of agriculture who do the food production, education with our children, youth in sports, and commerce and transport—because, remember, commerce—we are very dependent on importations. So we’ve got now to develop the clout, the will, to say we are going to accept this product as against that product. So it’s this kind of emphatic government-sponsored programs that have to be put in place in order to make—have success.

BESSER: Tom, did you want to comment?

FRIEDMAN: Well, I think I’d like to step back for a minute and reiterate that today is the launch of the Global Hearts program. And this is a big deal. It’s not a big deal that it gets sexy coverage in the media, but this is a package that could save a million, two million lives a year, many of them in the most productive years. The challenge of non-communicable disease is partly it moves slowly. People don’t think of it as a crisis. And yet, it is. Heart attack, strokes, cancers—they’re largely preventable, and largely with tools that we have today.

What Global Hearts tries to do is say let’s see how to go from a clinical program to a public health program in the clinical setting. Let’s see how to go from a health care system that only treats the patients coming in, to one that’s going to take accountability for all the patients in the community and get a level of control that will have an impact on the whole population. And it does that through a very specific technical package, where you involve all members of the team, you ensure medication supply, you get rid of barriers to patients, you have an information system, you’re continuously innovating and looking what is the actually situation locally.

And there are countries in Africa, Latin America, and elsewhere, that can do this at a fraction—tiny fraction—of the cost that we do it in the U.S., using lay health care workers, using protocol-driven care, using generics, once-a-day medications, three and six month prescriptions. You should be able to get the cost of a year of blood pressure control down to $10 or less.

BESSER: I’d like to invite members in the audience to join the conversation. A reminder that this meeting is on the record. Wait for the microphone to come to you. Please stand, state your name and affiliation, and please limit it to one question, and a short question given the time.

We’ll start here in the front row, and then on the aisle in the back.

Q: Bettye Musham.

We all know that what’s good for the heart is also good for the brain. And we also know that exercise is good for the heart and may delay the symptoms of Alzheimer’s. So is there any way to coordinate this package so that it has a little more stimulus to improve your heart, to improve your brain?

BESSER: So are any of the activities you’re undertaking looking at physical activity as part of the package?

ROSELL-UBIAL: Yes, of course. In the Philippines we have a program on health promotion that focuses on regular physical activity, a healthy-heart diet, stop smoking, and regular medical follow-up. So that’s basically our program.

FRIEDEN: I would say the challenge with physical-activity promotion is going to scale. And some of the things that have the most promise are design issues—walkability, bike-ability, making it part of people’s regular routine.

But you make another point, which is very powerful. There’s emerging evidence that better control of blood pressure in middle age prevents cognitive decline later in life, not only from stroke, but also from other forms of dementia. So it’s not just about preventing a heart attack.

The challenge with hypertension is that it’s asymptomatic generally. And people have a misconception that they know when their pressure is up. And that’s something we have to correct.

BESSER: Here on the aisle.

Q: Thank you. Henry Greenberg, School of Public Health at Columbia.

I’d like to suggest one thing for the Global Heart Initiative to consider. Most of the major American schools of public health do not have a very warm embrace of global chronic disease in their curriculum at all. In part it’s because they’re grant-supported. But as the money starts to flow and I see events like this and others around the world, I think it will happen—45 years post-Omran’s article, but nonetheless will happen. And the schools are going to be unable to supply a public-health workforce. And this may be true in schools in other parts of the world. I suspect it is, but I don’t know that.

So I’d just like to put that out on the agenda for the Global Hearts Initiative, which I think is a wonderful start to a new, exciting era. Thank you.

BESSER: I want to ask a question coming off that, and it has to do with resource allocation and how you make decisions. Barbados, like 60 or more other places, is faced now with a crisis around Zika virus, which is making news, unlike cardiovascular disease, which is taking lives.

How do you balance in your portfolio the resources that you put into Zika, which is very much in the press and in the consciousness, and heart disease, which is having a much bigger impact on your population?

BOYCE: Certainly in the case of the Zika virus and the threat, we have depended a lot on existing programs to eliminate and control the aegypti mosquito, which is the source of the Zika virus. And again, I think we have recognized the value of getting our communities, our households, involved in these prevention projects so that, rather than depending only on the resources that the country itself has to put towards the acquisition of pesticides and the movement of inspectors around the country, we are trying to build a responsibility within our population which sees householders being fully aware of the kind of program that will eliminate or control the breeding of the mosquito and the spread of disease. And this has worked wonderfully well in terms of keeping our indices down and making sure that the society is—the threat of the Zika virus is under control.

BESSER: Question there in the back; woman with her hand up, two in from the aisle.

Q: Thank you. Ella Gudwin with VisionSpring.

As someone who’s worked with teams in El Salvador to integrate particularly hypertension control in our clinic, I wanted to just get your feedback on electronic—the use of electronic health records. We’ve found that introducing poverty-related risk factors to do with indoor—so it’s not just smoking, but exposure to indoor fires, and women particularly, or things like severe malnutrition in childhood—damage to the pancreas, inclined to get diabetes later in life. How do we look at differentiating between really common risk factors—smoking, et cetera—and the really poverty-related risk factors? And how do we mainstream those?

And then, related, loading up community health workers with an additional burden, a lot of countries experimenting with how to have those focus on maternal child health, as differentiated from those on NCDs. Can you just talk about how that’s going, particularly ministers in your countries?

BESSER: Would you like to start on that?

SIRISENA: Yes. I think the risk factors related to poverty has to be approached in different light with the risk factors related to lifestyle. And the health workers in our country are trying to involve more and more not just volunteers, because we believe that volunteer workers work better if they are paid. (Laughter.) So we’re trying to strike a balance with additional resources of actually providing better incentives for our health workers and to differentiate the health workers that focus on maternal and child health, that focus on infectious diseases, and focus on non-communicable.

So we don’t want to overburden one health worker with so many concerns. Particularly they didn’t undergo the full education requirement to be a doctor or a nurse or a midwife, so they have their particular focus.

BOYCE: I think I’ll just add a comment to that. And I really appreciate the question, because the truth is that poverty is sort of related to all of the challenges that we face in our communities, be it education, be it health, or anything else. And what we’ve certainly found again to be a way of dealing with this is, as I referred earlier, not only depending on the work of the health worker per se, but our social work, our social program, is all designed so as to feed back into the health program, to feed back into the education program. So we identify the trouble spots as early as we can. We can put our resources, our direct resources, effectively to deal with these areas.

BESSER: Tom Frieden.

FRIEDEN: The issue of the effective involvement of community health workers is crucial. And paying them is very important. There are examples around the world—Ethiopia is one—where community health extension workers are very effective. And there are certain characteristics that allow them to be effective. They’re well trained. They’re well supervised. They are supported with logistics. They have a referral network so that when something is beyond their capacity to serve the community, they can refer.

And if you have that kind of structure, it’s not a question of burdening them more. It’s a question of empowering them more to deal with the major problems in their community.

BESSER: We have time for just a couple more questions. Laurie here in the middle.

Q: Thank you. Fantastic gathering. And I want to call out on my colleague, Tom Bollyky, who put this together; brilliant job.

Question has to do with what I see on the ground. Country after country, all over the world, you could talk about NCDs, but the doctors come back saying and that’s why we want MRIs and that’s why we want CT scans and that’s why we need another tertiary-care facility. And you can go to the poorest country in the world, and instead of talking about let’s teach people how to do cuffs for hypertension or decide whether to distribute polypills to, you know, provide statins and beta blockers and what have you, they want to say, you know, give me a place for multiple bypass surgery and that sort of thing.

So how do we strike that balance? And how do we motivate the health providers themselves, the physicians, to take on the prevention side of this?

BESSER: Want to take that?

FRIEDEN: Let me ask Dr. Yusuf to address that.

SALIM YUSUF (World Heart Federation): What you said is an absolute challenge, and it’s true. That’s why I said we have more to learn from the developing countries than to teach them. So the polypill is key. The WHO, the World Heart Federation, is championing the polypill to get into the essential medicines. That’s step one.

The problem is the polypill right now is not tracked commercially to any major producers.

BESSER: Could you say what a polypill is?

YUSUF: A polypill is a combination of two or three blood-pressure-lowering pills, statins, and those who already have had vascular disease; aspirin as well. I’ve been working on the polypill for a decade, and we have major trials going around the world. But the hardest part is the commercialization of it and getting it to market at a reasonable cost. But it is possible to—if we are successful, as Tom said—to produce it so that it’s no more than $15 a year for the high-risk people. And it will reduce cardiovascular disease, maybe not by 80 percent as was initially promised, but 50 percent is possible. That is huge. So I think the polypill is a big thing.

The second thing is it’s always going to be the case that people want treatments when they’re ill. So you can’t get away from the fact that many societies will want high-tech medicine. But what we need to do is to use that opportunity to say, OK, your father had a heart attack, your father need coronary bypass graft surgery, so wouldn’t it make sense if you stop smoking, if you exercise? And use that sentinel case to spread the message of prevention. Of course, no single message is going to get it across. So you’re right, it’s a very tough problem.

And part of the problem is the image of what a good health care system—two decades ago was what was being done in Canada or the U.S., which was high-tech medicine. We now have to get the word out that that is not necessarily the right image. The right one is a more holistic approach, like the Scandinavians have. I mean, there’s no single country with the right health care system, you know.

FRIEDEN: I think, to Laurie’s question, that’s what Hearts is all about. Hearts is saying this is within reach. Now the challenge to countries and to donors and to those interested is to get it implemented.

BESSER: Well, I think we could be talking for many, many hours about this initiative and this launch, but unfortunately we are out of time. I want to invite you all to stay for lunch, which is served right after this. But please join me in thanking our initial two speakers and our panelists for this moment. (Applause.)


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