correspondence Pascal Bovet, University Institute of Social and Preventive Medicine, Bugnon 5, 1005Lausanne, Switzerland. Fax: +41 21 314 7373; E-mail: pascal.bovet@inst.hospvd.chThe challenge of the cardiovascular disease epidemicis not whether it will occur at all in the developingcountries but whether we respond in time to telescopethe transition and avoid the huge burden in young andmiddle age adults. The question is not whether we canafford to invest in cardiovascular disease preventionin the developing countries, but whether we canafford not to (Ruth Bonita).This statement by the director for the surveillance of non-communicable diseases at the World Health Organization(WHO) forcefully summarizes critical issues related tocardiovascular disease (CVD) in developing countries: theupsurge of the CVD epidemic and the need for an urgentresponsetopreventanimpendingadditionalburdenthatcanhardly be afforded by low and middle-income countriesalready plagued with scarce resources and a large burden ofinfectious diseases. Global–regional–local interrelations arecentral to these considerations. Globalization fuels theepidemic even to the remotest communities by spreadingmany unhealthy behaviours and environments conducive toCVD. However, globalization can also provide powerfulmeans to tackle CVD at broad and local levels.The rise in CVD in developing countries can be bestunderstood in the light of the epidemiological transition(Omran 1971; Reddy & Yusuf, 1998), an evolutionaryframework linking demographical and social change todisease patterns. The rapid ageing of populations indeveloping countries is the first engine in the emergence ofCVD. This demographic transition results from improvedsanitation, nutrition and infectious disease control, partic-ularly in childhood, which accompany urbanization andindustrialization. Prolonged survival allows for longerexposure to CVD risk factors and this inevitably results inlarger total numbers of CVD cases. In addition to ageingpopulations, industrialization and urbanization also bringabout several changes in lifestyles such as sedentary habits,tobacco use and unfavourable dietary patterns, whichfurther increase the incidence of CVD and other chronicdiseases. While the mix between specific chronic diseases inpopulations, particularly cerebrovascular disease andischaemic heart disease, can differ substantially betweendeveloping countries, the shift from early transitiondiseases (infections and malnutrition) to late transitiondiseases (CVD and other chronic diseases) is rapid, largeand consistent among most developing countries (Yusufet al. 2001a, b).It is not often appreciated that the current CVD burdenin developing countries is already high. Approximately78% of the burden of non-communicable diseases and85% of the cardiovascular burden worldwide arose fromthe low- and middle-income countries in 1998 (WHO1999). Furthermore, the CVD burden is expected to furtherincrease significantly over the next decades. The combinedmorbidity and mortality burdens (expressed as disability-adjusted years of life lost) caused by ischaemic heartdisease and cerebrovascular disease in developing countriesare anticipated to rank first and fourth in 2020, com-pared with sixth and seventh in 1999 (WHO 2000a, b). Itis also often not realized, possibly because of very highmortality rates from other diseases, that age-specific deathrates from non-communicable diseases are higher indeveloping than developed countries (Murray & Lopez1996). For example, the probability of stroke death isseveral folds higher, at all ages, in Tanzania than in the UK(Walker et al. 2000).A number of factors could exacerbate the CVD epidemicin developing countries compared with its course inwestern countries. Urbanization in settings of povertydiffers from that which occurs in prosperous economies,and the vulnerability to unhealthy behaviours is likely to beincreased in a context of loose social network, stressfulwaged labour and restricted resources for public healthresponse. This points to the higher prevalence of CVD andCVD risk factors among people of low socio-economic
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