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EDITOR - The Heartbeat Wales programme should be congratulated on its
achievements and clear reporting. We agree that contamination of the
"control" area appears likely (1). The aetiological evidence for coronary
heart disease is now well established, principally smoking, poor diet,
elevated cholesterol, hypertension and poverty (2). This risk factor
model helps to explain the trends within countries, and the large
differences between countries. (2,3). But how can we actually achieve the
ten fold lower coronary disease mortality rates seen in Japan and France?
Ebrahim and Davey Smith suggest that, in isolation, all community
based interventions have low effectiveness (4). Might it therefore be
useful to examine the bigger picture? In Finland, coronary heart disease
mortality has now dropped by 73% in North Karelia, and by 65% elsewhere
(5). Why is this more than twice the fall in Britain, a country with very
similar cardiovascular epidemiology? Might it reflect the striking
differences in public health strategy? In Finland, a comprehensive,
integrated programme
of prevention and treatment started in 1972 in North Karelia, and extended
to the rest of Finland five years later (5). The response was rapid and
impressive. The components and key principles of the Finland programme
have now been refined and extended to many countries through the WHO CINDI
programme (5). The key principles include a comprehensive programme at
the national, regional, community and individual levels, a medical
framework covering primary prevention and a population perspective, and a
social/
behavioural framework which involves social marketing, behaviour
modification, communication, innovation / diffusion and community
organisation (5).
Could the CINDI model be applied to the UK? The autocratic
imposition of a carbon-copy North Karelia programme will clearly be
neither welcome nor effective. However, after decades of resistance, a
growing professional and political consensus may now be visible in the
very similar public
health Green Papers. Most now recognise that 1) existing patients need
to be treated, and 2) that the effective prevention of future disease
requires comprehensive
integrated multi-agency programmes addressing poverty and the wider
determinants of ill health including employment, food and
transport(2,4,5). This implies programmes which are multi-agency, multi-
disciplinary, participatory, democratic, flexible, and well resourced
(1,5). Adequate
monitoring and evaluation will be essential (1,2,3,5).
Past and current prevention schemes in the UK have achieved much.
However, from the international perspective, they may appear a little
uncoordinated and half-hearted, and also costly in terms of future
increases in the burden of entirely preventable cardiovascular disease.
Does it have to be like this? Given the growing consensus among the
stake holders, is the time now right for effective action? Might
political will even translate into adequate resources? If so, could this
promote a model for the first of a series of national public health
policies in Britain, and in Scotland?
Dr Simon Capewell,
Senior Lecturer
Prof James McEwen,
Head of Department,
Department of Public Health, University of Glasgow, GLASGOW, G12 8RZ.
Dr James Dunbar, General Practitioner,
Downfield Surgery, 325 Strathmartine Road, DUNDEE, DD3 8NE.
Prof Pekka Puska, Head of Department
KTL National Public Health Institute, Mannerheimintie 166, FIN 00300,
Helsinki, Finland.
REFERENCES
1. Tudor Smith C, Nutbeam D, Moore L, Catford J. Effects of the
Heartbeat Wales programme over five years on behavioural risks for
cardiovascular disease: quasi-experimental comparison of results from
Wales and a matched reference area. Br. Med J 1998; 316 : 818-22.
2. Tunstall-Pedoe H. Cardiovascular diseases. Oxford Textbook of
Public Health, Oxford University Press, Oxford 1997.
3. Capewell S, Morrison C.E, and McMurray J.J.V. Contribution of
modern cardiovascular treatment to the decline in coronary heart disease
mortality in Scotland between 1975 and 1994. J Epid C H 1997; 51: 583.
4. Ebrahim S & Davey Smith G. Effects of the Heartbeat Wales
programme. Effects of government policies on health behaviour must be
studied Br. Med J 1998; 317 : 886.
5. CINDI. Country-wide Integrated Non-communicable disease
Initiatives. Protocol and Guidelines for Monitoring and Evaluation;
Process of Policy Development and Implementation. W.H.O. Copenhagen 1997.
Effects of the Heartbeat Wales Programme: Lessons From Finland?
EDITOR - The Heartbeat Wales programme should be congratulated on its
achievements and clear reporting. We agree that contamination of the
"control" area appears likely (1). The aetiological evidence for coronary
heart disease is now well established, principally smoking, poor diet,
elevated cholesterol, hypertension and poverty (2). This risk factor
model helps to explain the trends within countries, and the large
differences between countries. (2,3). But how can we actually achieve the
ten fold lower coronary disease mortality rates seen in Japan and France?
Ebrahim and Davey Smith suggest that, in isolation, all community
based interventions have low effectiveness (4). Might it therefore be
useful to examine the bigger picture? In Finland, coronary heart disease
mortality has now dropped by 73% in North Karelia, and by 65% elsewhere
(5). Why is this more than twice the fall in Britain, a country with very
similar cardiovascular epidemiology? Might it reflect the striking
differences in public health strategy? In Finland, a comprehensive,
integrated programme
of prevention and treatment started in 1972 in North Karelia, and extended
to the rest of Finland five years later (5). The response was rapid and
impressive. The components and key principles of the Finland programme
have now been refined and extended to many countries through the WHO CINDI
programme (5). The key principles include a comprehensive programme at
the national, regional, community and individual levels, a medical
framework covering primary prevention and a population perspective, and a
social/
behavioural framework which involves social marketing, behaviour
modification, communication, innovation / diffusion and community
organisation (5).
Could the CINDI model be applied to the UK? The autocratic
imposition of a carbon-copy North Karelia programme will clearly be
neither welcome nor effective. However, after decades of resistance, a
growing professional and political consensus may now be visible in the
very similar public
health Green Papers. Most now recognise that 1) existing patients need
to be treated, and 2) that the effective prevention of future disease
requires comprehensive
integrated multi-agency programmes addressing poverty and the wider
determinants of ill health including employment, food and
transport(2,4,5). This implies programmes which are multi-agency, multi-
disciplinary, participatory, democratic, flexible, and well resourced
(1,5). Adequate
monitoring and evaluation will be essential (1,2,3,5).
Past and current prevention schemes in the UK have achieved much.
However, from the international perspective, they may appear a little
uncoordinated and half-hearted, and also costly in terms of future
increases in the burden of entirely preventable cardiovascular disease.
Does it have to be like this? Given the growing consensus among the
stake holders, is the time now right for effective action? Might
political will even translate into adequate resources? If so, could this
promote a model for the first of a series of national public health
policies in Britain, and in Scotland?
Dr Simon Capewell,
Senior Lecturer
Prof James McEwen,
Head of Department,
Department of Public Health, University of Glasgow, GLASGOW, G12 8RZ.
Dr James Dunbar, General Practitioner,
Downfield Surgery, 325 Strathmartine Road, DUNDEE, DD3 8NE.
Prof Pekka Puska, Head of Department
KTL National Public Health Institute, Mannerheimintie 166, FIN 00300,
Helsinki, Finland.
REFERENCES
1. Tudor Smith C, Nutbeam D, Moore L, Catford J. Effects of the
Heartbeat Wales programme over five years on behavioural risks for
cardiovascular disease: quasi-experimental comparison of results from
Wales and a matched reference area. Br. Med J 1998; 316 : 818-22.
2. Tunstall-Pedoe H. Cardiovascular diseases. Oxford Textbook of
Public Health, Oxford University Press, Oxford 1997.
3. Capewell S, Morrison C.E, and McMurray J.J.V. Contribution of
modern cardiovascular treatment to the decline in coronary heart disease
mortality in Scotland between 1975 and 1994. J Epid C H 1997; 51: 583.
4. Ebrahim S & Davey Smith G. Effects of the Heartbeat Wales
programme. Effects of government policies on health behaviour must be
studied Br. Med J 1998; 317 : 886.
5. CINDI. Country-wide Integrated Non-communicable disease
Initiatives. Protocol and Guidelines for Monitoring and Evaluation;
Process of Policy Development and Implementation. W.H.O. Copenhagen 1997.
Competing interests: No competing interests