Tackling the burden of stroke with primordial prevention

Abstract

Worldwide, stroke is the second leading cause of death and the third leading cause of death and disability combined, which makes World Stroke Day 2022 (Oct 29) a crucial opportunity to call on global, regional, and national decision makers to act on risk factors, primary and secondary prevention, treatment, and rehabilitation. However, to have a tenable effect on the future burden of stroke, public health campaigns also need to focus on an even earlier stage—ie, primordial prevention. In The Lancet Neurology Anniversary Lecture, Carol Brayne states that, for brain health, targeting individual-level interventions “ignores the magnitude of influence that commercial influences, social environment, and material circumstances have on options, opportunities, and behaviours”. Addressing the social and commercial determinants of neurological health is an essential component for tackling the burden of stroke that should not be overlooked. A strategy encompassing primordial prevention intends to stop risk factors for disease developing at all, whereas with primary prevention the goal is to modify existing risk factors to prevent development of disease. Thus, primordial prevention aims to change “the sociocultural conditions that lead to risk factor development”. Examples of sociocultural conditions that should be changed as part of a primordial prevention approach to stroke include those that tackle pollution, unhealthy diets, and lack of physical activity. Interventions to change these factors—eg, through regulation of food prices or development of healthy environments that promote exercise—will require commitments from national governments and international organisations. In Europe, initiating government action on stroke is the focus of the European Stroke Action Plan (SAP-E), which is a collaboration between the Stroke Alliance for Europe and the European Stroke Organisation. One of four key targets of the SAP-E encompasses both primordial and primary prevention. The target is to implement national strategies for “public health interventions promoting and facilitating a healthy lifestyle, and reducing environmental, socioeconomic, and educational factors that increase the risk of stroke”. However, even though the SAP-E was established in 2018, scant progress has been made on this target in most European countries, where implementing basic stroke care remains a primary focus. Another of the four targets of the SAP-E intends to provide a clear road map for governments to produce national plans for stroke, which will establish a pathway from primary prevention through to rehabilitation and life after stroke. National coordinators are working to formulate the stroke plans by 2030, but this work has become challenging since the beginning of the COVID-19 pandemic in 2020, because non-communicable diseases have fallen down the list of political priorities. Support to set up national stroke plans in Europe should now be garnered from the European Commission (EC) and its Healthier Together initiative, which was launched in December 2021. Over the 5-year period from 2022 to 2027, Healthier Together aims to support countries in the European Union to identify and implement policies to reduce the burden of major non-communicable disorders. The initiative includes five strands, of which mental health and neurological disorders is one, and within this strand is an initiative to support the reduction of health inequalities. At a meeting held on Oct 5, the EC Directorate-General for Health and Food Safety announced that the strand of mental health and neurological disorders will receive funding proposals in 2023–24. European governments can use this funding to take action on stroke, as a key cause of disease burden in the European population, and primordial prevention should be included in this process. Political interventions to change the sociocultural conditions that establish risk factors for stroke—eg, by increasing taxes on tobacco, limiting traffic in urban areas, or modifying foods to lower salt content—might be perceived as unacceptable curtailments of personal freedoms. Yet, these interventions also target overall population health, reduce health inequalities, and include vulnerable and disadvantaged groups. These sorts of intervention have been successfully implemented. For example, in India, indoor air pollution has been substantially reduced by a government policy to subsidise cooking gas. Moreover, global tobacco control, and WHO's Healthy Cities project in Europe, are key prevention initiatives that have become widely adopted. But more primordial prevention strategies are needed, and safeguarding the neurological health of the population should be among the highest priorities. The relevance of social and commercial determinants for neurological healthA disconnect has developed over the past two decades between neurological and neuroscientific research, which have seen notable innovation and development, and our increasing understanding of the role of social and commercial determinants of health, including the health of the nervous system. Over the next two decades, grounding neurological research in public health and epidemiological principles can bring about a paradigm shift, away from reductionism, over-medicalisation, and health inequities towards neurological research that reduces inequalities and has true relevance to the populations it aims to serve. Full-Text PDF