The Heart of the Matter: Cardiovascular Disease and the New Health Crisis in Asia

Judith Mackay
Author, World Health Organization (WHO) Atlas of Heart Disease and Stroke

Asia Society Hong Kong Center
November 28, 2006

Program Sponsored by Pfizer.

Before I start I should mention that I got an e-mail this morning from the Bloomberg Foundation in New York and they said there were four societies in the world that we really need to speak to and one of them is the Asia Society. I sent them an e-mail back at about 10 o'clock this morning and I said, "Well, actually I'm speaking to them today." And they could really quite hardly believe that. I gather you've got branches in New York as well, but I thought you might be interested to know that you are very high on the radar in terms of Mayor Bloomberg in New York, and I will come back to some of the work that I will be doing with Mayor Bloomberg at the end of the talk.

I have been asked to speak today on cardiovascular disease and the new health crisis in Asia. Whatever way you look at it I think there is an alarming escalation of cardiovascular disease in this region, and I think one of the alarming aspects is how very quickly that this has happened. We've moved from diseases of want to diseases of plenty in probably about a 30-year period. It's happened very, very quickly indeed, and, for example, publications like this, "A Race Against Time: The Challenge of Cardiovascular Disease in Developing Countries", they all address the problem of how quickly this epidemic has come upon us and what we need to do to address it.

How serious is cardiovascular disease in the world? I think many people don't realize it is now the top cause of death globally. There are about 17 million deaths a year from cardiovascular disease. It's the main cause of death, and within cardiovascular disease it is principally stroke and coronary heart disease. There are still things like rheumatic heart disease, inflammatory heart disease, but essentially it is stroke and coronary heart disease that top this list. The interesting thing is that this is actually no longer an epidemic of Western countries. The top three countries in the world in terms of the numbers for cardiovascular diseases are India, China and then Russia; further down, there is Indonesia. This is an epidemic upon us already and I think this has taken quite a lot of people by surprise who thought of cardiovascular disease as rather a Western disease.

Now when I did this atlas a lot of people said to me why did I choose this little Asian girl to go on the front cover? Did she have congenital heart disease? And I said, "No, I chose her for three reasons, and really to actually try and get rid of some of the myths of cardiovascular disease." First of all, three-quarters of it is now in developing countries. Secondly, males equal females. Again there has been this perception that it is rich middle-aged men in Western countries who have it, but actually the incidence for women and men is equal. Men get a bit more heart disease and women get a bit more stroke, principally because they live rather longer, but if you add these together the male and female rates are equal, so we must never forget women when we are thinking of cardiovascular disease.

And then finally, because the risk factors for all of these epidemics start when people are surprisingly young. If you look around the world today 18 million children under the age of five are now overweight. Fourteen percent of 13 to 15 year-olds around the world currently smoke cigarettes. And they even looked at the coronary arteries in post mortems done on children as young two who have died and they are beginning to find they've got fatty plaques in the arteries of these practically toddlers. So I think one of the things to emphasize is how early the whole pattern of behaviour starts in terms of cardiovascular disease.

Some of the things you can't change. You can't change your hereditary. You can't change your gender. You can't change the fact that you are getting older. You can't change your race. Some things are fixed, there is nothing you can do about them, but for many of other things you can in fact do something about them. There are many, many new causes that are emerging such as whether people have high homocysteine or not. And, in fact, Tony Hadley at the University here just told me yesterday that of all the deaths from pollution in Hong Kong he estimates that 40% of them are cardiovascular disease deaths.

But if we look at the causes of cardiovascular disease we have to do is to focus on the top seven because these top seven causes cause most of the deaths. Yes, there are other much smaller causes, but if we are looking at making a difference for cardiovascular disease we definitely have to look at the biggies. First of all I would put high blood pressure because half of all cardiovascular disease is associated with high blood pressure. We haven't got that much data about it in Asia, but this slide is from India and it shows middle-aged Indian men in their 40s from 1942 up to 1997, and you can see that the systolic blood pressure of these people is going up with time.

One piece of really bad news - there is bad news and good news in this talk - but one bit of bad news is that if you look at virtually every single risk factor for cardiovascular disease in Asia it is getting worse and will probably get worse in the next 20 or 30 years, and this is just one example to show how blood pressure is drifting up. There is a Hindu proverb about salt which goes something like "salt is the best of all the condiments", and of course high blood pressure is linked to salt.

If we look at lipids, again you can see that lipid levels are high in Asia. In China and other countries around here the levels of cholesterol have gone up surprisingly quickly. We always thought these were much lower than in Western countries, but the most recent data show that actually we've got a problem in Asia right now, especially in China. And, in fact, in Beijing, from 1964 to 1999 you can see in men and in women that cholesterol levels drifted upwards over that period of time.

My own particular topic is, of course, tobacco. I use this slide quite a lot because it shows why I am in the business of working in tobacco control. I've got a series of about ten pictures of a little boy lighting his cigarette and smoking like a professional, and one-fifth of cardiovascular disease is caused by smoking. Now, you may think that is actually quite a small percent, but it's just worth remembering that most smokers don't die from cancer. Most smokers die from cardiovascular disease. Because cardiovascular is responsible for so many more deaths, a fifth of cardiovascular is bigger than lung cancer. It is very, very strongly linked indeed. And if we look around the world what we see here again in Asia is very high levels of smoking amongst men, in China in particular, Russia, Mongolia, and so on, and rates that are actually now lower in the West.

The interesting thing is that the year I was born in the United Kingdom, 81% of the men there smoked. This has come down to something like 25%. The good news about tobacco is that you can actually bring these rates down. If you look at Japan, the rates in Japan used to be over 80% 15 years ago. In a 15-year period the male smoking rates in Japan have come down from over 80% to under 50%, so it actually can be done. You can actually do things about this epidemic. It is not just somehow fatally written in stone.

And the other bit of good news is the really low levels for smoking among women in Asia, somewhere between 2 to 10%, and in fact if you look at China it's gone from 5% down to 2%. Interestingly enough we made a prediction about 30 years ago that smoking rates in Asia would rise because women would become more independent, they'd have more money to spend, they would listen less to their parents, etc. That has not happened, and we are not quite sure why. It could be that health education getting through, or the traditional constraints of an Islamic society like Indonesia, or the sort of Confucian ideology that still remains in China. We actually don't really know the answer to this, but it has to be excellent news. Our challenge is to ensure, particularly as the tobacco industry targets women in Asia with advertisements for women's cigarettes like Virginia Slims and long, cool, menthol cigarettes, that female rates don't slide up, but at the moment there is good news on this front.

I am not sure if I even need to describe the next slide. Cardiovascular disease doesn't impact only the arteries to the heart or to the brain or to the legs, it impacts arteries that go anywhere, and smoking is well-known to be associated with impotence. It causes other problems in reproduction as well, such as infertility, but it is certainly well-associated with impotence. The French, in fact, have a saying which I am just going to have to look up to get it exactly right but it is something like "From short pleasure can come a long repentance." And I think the French were probably speaking about sex when they said that, "a short pleasure can come long repentance," but I think actually it fits the bill very well if we are talking about impotence. And it is one of the health messages that do affect younger men. Most children feel, "oh, cancer at 60, heart disease at 65," it bears no relevance to their lives. This one tends to do so.

So do people know about the link between smoking and cardiovascular disease? And the answer is actually no. The statistics in China show that in spite of these massive increases in the incidence of cardiovascular for smokers, a 100% for heart disease, 400% for aortic aneurisms, only 4% of smokers and non-smokers in China even know that smoking is linked to cardiovascular disease, so there is a vast body of ignorance about this link. And I am showing this, a picture from the South China Morning Post at the height of the SARS campaign, to show that many people don't understand the relative risk as well. This is in a bar in Lamma I think. This guy is smoking cigarettes. This one is obese and overweight. They are both sitting down drinking a lot of beer and looking quite sedentary, and yet what do the worry about? They worry about SARS. Now we had 350 deaths from SARS in Hong Kong in total. We have 6,000 a year from tobacco alone. And if you go to China they too had about 350 deaths in the whole SARS epidemic. They have a million a year from tobacco, a million a year, and yet in the public mind something like SARS is much more dangerous than smoking. And I would put it to you that indeed it is not.

One of the bits of good news about tobacco is that after quitting smoking very, very quickly, within a couple of years, your risk for heart disease starts to improve. In fact, even within an hour of not having a cigarette your cardiovascular risks start to get better, and within a week there are measurable, noticeable differences in your blood pressure and your lung function, and your heart rate, and all the risks of cardiovascular disease. So I think again one of our really important health education messages is that these risk factors can be changed and, in fact, even if you stop smoking at 70 or 80 you can measurably improve your health for the rest of your life.

Physical inactivity is also linked to heart disease. It increases the risk by 1.5 times. Now again traditionally up to now in Asia people have been fairly active. That again is beginning to change. We are seeing more cars, we are seeing more elevators, and we are seeing people sitting down in front of computers. So this again is a problem that we haven't really been able to measure very well, but certainly one can forecast it is going to get worse. This slide from the U.S. shows peoples' perception of doing exercise. And what are these people doing? They are going up the elevator. I would just put it you that people need to get it ingrained in their minds a bit better that we need to do some regular exercise. And, in fact, if you look at the number of motor vehicles per thousand populations in the world, of course the U.S. is way up, China and India are right down at the bottom. Very few still and yet if we look at the predictions for 2025 of the number of vehicles on the road, bicycles are on their way out and motor vehicles will substantially increase as the century progresses and much of that increase will in fact be in developing countries.

Obesity - there is very good data from the U.S. now about the epidemic in the States and a hugely significant proportion of people who live in the United States are now overweight. Obesity is way up now to 15% among very young children in the US. Now this again is happening in this part of the world. This picture was published in the South China Morning Post and it is basically describing summer camps for children in China to try and help them lose weight. It is really getting as bad as that. And, in fact, if you look at the overall statistics about China there are now 70 million Chinese who are overweight, 70 million, so that's why I say the epidemic has come upon us.

If we look at the risk of obesity is it better to be an apple or a pear? You can see that the difference in the shape: This is obesity around the waist; this is obesity around the hips, a bit further down. Does anybody want to guess as to whether it's better to be an apple or a pear? Do any of you know which one is the dangerous one? Yes, it is the apple. If you are apple shaped it is much more dangerous. We actually don't know why, but it is much more dangerous in terms of cardiovascular disease risk than having weight around your hips as with the pear. This is the one that we've got to watch out for.

If we look at overall food consumption in the world we can see that per capita the amount of calories taken in, this is from 1964 with predictions to 2015, is going up in the rich countries at the top, but look at what is happening in the developing countries. There is an even greater rise in calorie intake in developing countries so they are, in fact, catching up with where the developed countries used to be.

Now there is quite a bit of disagreement in the world as to whether we should be eating low-glyceamic foods, or more cereals, or more salads, or meat, and there is quite a bit of dispute and disagreement about what actually constitutes a healthy diet. But everybody has agreed that we should have five helpings of fruit and vegetables a day. I think we have probably had two by this meal. We had a salad to start with and then we had a bit of vegetable with our main course. But five helpings a day, you've got to work at it a bit to have five helpings a day, but everybody is agreed that this is the best way to avoid not just cardiovascular disease but cancer and many of the other chronic diseases too. And you can actually measure this. This is the percent reduction for every ten grams more per day you have of dietary fibre in fruit, of cereals, and of total dietary fibre. This is how much you can reduce cardiovascular disease by eating more fibre in your diet, it is quite measurable.

The next risk factor, which is tied up with all the others-it is tied up with being physically inactive, it is tied up with obesity, but essentially it is diabetes. And again the numbers here are much greater in the Middle East than they are in Asia at the moment. In India and China there will be a doubling or a trebling of diabetes by the year 2030. So the risk of diabetes is going up as well.

I said at the beginning that traditionally people think of heart disease as affecting wealthy people in Western countries. The Nepalese have this proverb that I put at the bottom that, "Wealth is both an enemy and a friend." As far as cardiovascular disease goes wealth is a friend because what we are seeing is that cardiovascular is now a disease of poor people, quite contrary to what is the popular belief. Cardiovascular disease is now a disease of poor people, whether it is by income or, here as you can see, by education. The more educated people, more than 12 years education, they have much lower levels of smoking. It is not just cardiovascular disease itself, it is the risk factors. If you look at obesity, smoking, physical inactivity, this tends now to be much more amongst people who have got no education or even minimal education. And this, in fact, is another of the myths of cardiovascular disease. And, in fact, if you talk about risk factors I would imagine there are probably very few people in the audience here today who would be smokers. If you go to a construction site in Hong Kong they are all smoking their heads off. I mean that is the kind of thing that is now happening around the world. It was the richer educated people who first smoked, and they are the first group to quit smoking now that information on cardiovascular disease is coming out.

Is there anybody in the audience here who understands this food pyramid because I certainly can't myself? It has all got proportionality and personalisation. It's used to be a very simple pyramid in the past but this one to my way of thinking is completely unintelligible. It is supposed to be the world's standard. I was at a cardiovascular meeting recently and a cardiologist said this to all the cardiologists in the audience.

But WHO has come up with a much simpler pyramid to show all the things that you shouldn't do and I think this is much more understandable to everybody. Don't' smoke cigarettes, don't eat all these hamburgers and soft drinks and so on, don't go around by cars, and again don't be a couch potato and sit in front of your computer and watch TV all the time. I think that to my way of thinking this is much more understandable than this other very, very complicated one, well, you really have to study it hard to understand what it is you are supposed to do.

Now with cardiovascular disease are women a special case? I have said before that they are equal. The interesting thing with women is that if they have the same level of smoking, for reasons that again we don't understand, the same level of triglycerides, they have more cardiovascular disease. Secondly, there is more obesity, there is more depression, and there is more diabetes among women, so simply because of that they get more heart disease. And then of course there are things like taking the oral contraceptive pill or hormone replacement treatment that is linked to cardiovascular disease. So, indeed, women are a special case and yet they are often forgotten in this epidemic. Wherever they have done studies they find that women's symptoms are not taken as seriously, there are fewer hospital admissions, they are not given drugs to the same degree that men are given drugs. It is a neglected epidemic-the epidemic of smoking among women, but we must never ever forget them.

Interestingly enough men tend to come with a bit of pain in their chest. Women tend to come saying that they are feeling really tired. They have slightly different symptoms, which doesn't make it easy, but we have got to keep - I always keep saying this - we have got to keep women on the agenda.

If you look at the economic costs, and I was asked to speak about this by the Asia Society, looking at some of the economic aspects of this epidemic, the economic costs of non-communicable diseases in total, that is everything, even including mental health and road traffic accidents, for cancer and heart disease. At the WHO even less than 5% of the budget goes to all non-communicable diseases combined whereas they cause at least two-thirds of the world's deaths. Now this is not exactly the fault of WHO. This budget is voted in by all the member states, it is all the governments in the world who decide on this budget. So what you can see at a glance is that it is disproportionate. There is no proportionality with it. They will spend more money on SARS or Guinea worm or something that causes far less by way of disease and disability and death in the world, and this is mimicked by many national governments as well. The funding for tobacco control and for cardiovascular disease is very small.

We just started to look at some of the economic aspects and looking at the cost of tobacco to the economy. China has done a study, it's billions. In fact, this study was particularly interesting because what it showed was that tobacco is costing the Chinese government more than it is contributing in terms of tax and employment. This was a really, really important survey because I think it illustrated that the tobacco companies whether they are national or international will also say how important they are to an economy. They employ people and yet more people die from tobacco actually and therefore lose their jobs than people who lose their job within the industry. So this is in its infancy, looking at some of the costs of these diseases and cardiovascular disease.

And we have even looked at costs to the smoker, and here in Sri Lanka, here in Laos, how many pairs of socks you can buy, how many fish you can buy for the cost of a packet of Marlboro cigarettes. And if you look at Vietnam you will see on average smokers spend 3.6 times more on tobacco than on education, 2.5 times more on clothes, and almost twice more than for health care. So a lot of family income in Asia is being diverted from providing clothes and houses and education towards buying not just Marlboro cigarettes but tobacco in general.

The backdrop to this picture I took in Ho Chi Minh City in Vietnam is Vietnam's top cancer hospital, and I think it sort of illustrates that this epidemic is going to economically have costs upon these countries. These are not just relatives sleeping out in the courtyards, some of these are patients. I think health care systems throughout Asia will not be able to cope with an epidemic of this size that is coming upon them in the form of chronic diseases. It is not just somebody being ill and getting better, these tend to be long-term diseases.

If we look at the United Nations' millennium developments goals that we are all supposed to achieve by the year 2015, not a single mention. Isn't it unbelievable? Not a single mention of non-communicable diseases, not one in the whole of this really important document which is the template for what countries are supposed to do. There are the most amazing blind spots about cardiovascular disease and cancer. Only 35% of countries have national CVD plans.

Now some of the good news about it is that these issues are being addressed. WHO since it was formed in the 1940s has always had the right to have a convention, like there is the UNICEF Rights of the Child, or the convention on CEDAW, the Convention for the Elimination of Discrimination Against Women. Just out of interest I will tell you what the first ever UN convention signed by Hong Kong was, and I'm sure you will never ever guess, it was in the 1940s and we signed a convention on street signs. I kid you not, street signs. We are now under an international covenant that requires us to put up readable street signs in Hong Kong, so conventions can be very variable.

This is WHO's first ever convention which is the Framework Convention on Tobacco Control, and basically it reads like a good national plan, but at an international level of requirement. Health warnings, smoke-free areas, ban advertising, put up the tax, stop smuggling, etc. All those things are in this Framework Convention. It has been signed by 168 countries and member states and already ratified by 142. This has to be the quickest UN convention, the fastest convention of all time, and what it does is that it will place governments - China has signed it and has been very specific that Hong Kong and Macau come under this - they signed it and that will now require China and us to report regularly, to adopt various protocols and to come under the same kind of international scrutiny and responsibility as with all the other UN treaties.

It was Cicero who I think said that the welfare of the people is the ultimate law, and I think that is actually very applicable to the Framework Convention. Also throughout Asia we are now, as you can see, virtually every country is now celebrating World Heart Day which now occurs every year, so there is a lot of health education beginning to come out on tobacco.

If we look at treatment there is good news and bad news. The good news is that if you use categories of drugs, the ace inhibitors, aspirin, beta blockers, and lipid lowering drugs, each of these will reduce heart disease. If you have once had a heart attack it will reduce your risk of having another one by about 25% each. If you use all four drugs it is 75%. This is amazing. We have the tools of pharmacological intervention that will cut -quite separate from the risk factors - we have these tools that we know will make a huge difference to heart disease, and yet really most people in the world, even in the rich countries, are not being properly treated, and they are certainly not being treated in developing countries. But WHO has estimated that the number of people who die and are disabled by cardiovascular disease could be halved by the wider use of combination drugs that costs just US$14 a year, so we have the tools. We know what we can do and yet it is just not quite happening. Aspirin of course remains this almost wonder drug in terms of heart disease, the least expensive drug. But I think it's true to say there is at least one intervention that every country can do. It need not be a massively expensive campaign. Every country can do something in terms of heart disease.

But just summarizing this, if you look at everything from cardiovascular disease to the number of smokers, to the number of diabetics, up to 2030, this has to be causing considerable alarm and concern in terms of where our future lies in Asia because they all seem to be heading upwards, every single one of these. And this was said in the Victoria Health Declaration on Heart Health, "We have the scientific knowledge to create a world in which most heart disease and stroke could be eliminated." I mean that is an amazingly brave statement. We have eliminated small pox, we could eliminate heart disease and stroke to a very large extent and yet we are not doing it.

And one of the problems is this dilemma is personal responsibility. In other words, you are smoking, you are overweight, you are not exercising, this is your fault. You know, it is your responsibility to make the various changes versus people who think it is the government's responsibility. And I have put in a quote from Goethe here, although I am not sure he was talking about heart in the sense we are talking about it today, but he said, "All the knowledge I possess anyone else can acquire, but my heart is all my own." So is it our personal responsibility, or as the World Heart Federation says, "While heart disease and stroke are eminently preventable, decision makers and government funding agencies are overall neglecting this public health issue."

We have examples in Hong Kong of some quite good practices. The walkways in Central have to be one of them. They encourage people to walk around instead of jumping into a taxi to go from A to B. You see all these people walking, you know, two or three flights up around Central. But the government's responsibility is everything from bicycle tracks to even making stairwells. I went to the American Cancer Society last year, and it's a six storey building and there are no lifts except for the disabled, and interestingly enough all the staircases are beautiful. They have got lovely thick carpets, they have got light purple walls, they have got works of art up on the wall. And the president, the CEO of the American Cancer Society said if we want people to walk we have to make it nice for them to do so and not have horrible staircases, you know, yellow with pipes and things like that. Nobody wants to go walking up steps like that.

Or even if you look at school meals, there is a lot of interest in the UK at the moment as to the responsibility of actually providing much healthier school meals for children. So these issues are all coming up and I think are being addressed.

But I think one of the bits of good news is that really interventions can make a difference. It can make a difference at a personal level and it can make a difference in terms of what governments can do and, indeed, have the responsibility to do. And when we are talking about personal action, it can reverse quite quickly. And I've just put up an old Turkish proverb here which says, "No matter how far you have gone down the wrong road, turn back." There is an opportunity to really do that with heart disease in a much easier way than, for example, if you have already got lung cancer. But with heart disease that reversibility is really there because the truth is that these diseases mostly affect us as we get older, and as Auber, the French composer, said, "Aging seems to be the only available way to live a long life." Thank you.

MODERATOR: Thank you for that very interesting but rather sobering talk. I hope everyone is walking back to the office. We have some time for questions. I will start with two. One is a simple factual question. You mentioned that the rates for cardiovascular disease were approximately 16 ½ million, what are the numbers for say cancer and HIV AIDS? And the second question is about prevention. It seems that there is a lot of emphasis on the part of governments, hospitals, and insurance companies on treatment, but very little on prevention. Most insurance companies will not cover simple tests for cardiovascular disease. Can you talk about that and what are some of the solutions?

JUDITH MACKAY: Yes, I am reluctant to get into some kind of race between different problems, you know. I think all of us recognize the problem of pollution in Hong Kong, and yet it causes a much smaller number of deaths, so I don't want to sort of say this is more important than that, but cardiovascular disease is now the number one. Cancer is the number two, it comes in, you know, fairly shortly behind. Asia is a long way down the line yet. I mean it remains to be seen what happens with the AIDS epidemic but these ones stand out at front and I can give you the exact numbers later. I haven't got them in my head at the moment, but as I said, I think you have got to be careful. I mean tuberculosis is still a problem even in Hong Kong so we must not start saying this is more important and don't direct our concern and attention to other things as well. But cardiovascular disease is way out front in Hong Kong as well as globally. It has overtaken cancer as our number one killer in Hong Kong. I think that is right, I think there is a lot of emphasis on the curative aspects of this epidemic, but, you know, if there is a take home message from this talk it has to be prevention, prevention, prevention. It has to be teaching children, you know, the ways to a healthier diet. I mean it is all these boring health education messages that we have known for the last 30 years, they actually kick in. And the truth is you can pretty much get away with abusing yourself until you are maybe 40-50 years old, but believe you me after that they all start having an effect. But if we are all going to live to 80 or 90, as it seems we now are, it is actually very important to keep that second half of life healthy, and I think that, you know, looking at some of these risk factors: keeping your weight down, exercising. In Japan now almost everybody wears one of these pedometers to do their 10,000 steps a day, just a useful reminder to keep walking, to keep going. Walk up the stairs if you can find a nice stairwell rather than always just taking an escalator or a car. I think that the emphasis on prevention is really important, and I agree with you, the resources that have been put into it are not enough.

Having said that, there is just one thing I would like to add and that is about the Michael Bloomberg initiative. Michael Bloomberg, who is currently the Mayor of New York, and will be for the next two years, has put US$125 million into tobacco control in developing countries, that is a billion Hong Kong. This is the first time, I have to say, that we have had a major, major kind of donation like this. And he has chosen, he has prioritised the countries by taking the percent of smokers, multiplying it by the population, and these are the numbers he has used to put the countries in order of importance. So China, India, Indonesia, Bangladesh, and Russia are the top five countries. They have got the world's most smokers. And he believes that if you make a small difference in a big population you actually affect far more lives than a very big difference in a small population, say like Mongolia, and the emphasis will be on prevention basically - there will be some aspects on quitting as well, but essentially it will be education, legislation, taxation, all the things we know that will bring this epidemic down. And I think this is really welcome. For 30 years we had almost no funding whatsoever for tobacco, it is quite a different problem now that we have suddenly got so much money, as to how to wisely use all this money for tobacco control. That is going to be my challenge for the next two years.

QUESTION: Hi, I'm Greg Karpinski from Arizona Heart International. My question has to do with the fact that given the severity of the problem and how quickly rates are increasing across Asia, have you seen any evidence of public private partnerships or programs by Ministry of Health and other agencies to try and encourage the private sector, which I am in? There is, for example, in China a huge lack of just facilities to treat cardiovascular disease, and part of it, in addition to just treating it, would also include prevention and wellness programs and all the rest. And if you've seen evidence of that I would really like to hear what those programs have been and whether they have been at all successful.

JUDITH MACKAY: I don't really know the answer to that question. There is certainly quite a lot of governmental and non-governmental cooperation on prevention, for example, days like World No Tobacco Day and World Heart Day, and interestingly enough one of the aspects of the Bloomberg grants is that they can be given to governments as well as to non-governmental organizations, which is quite an interesting step because that wasn't expected at the beginning. I think there is collaboration. I think it just simply is not enough. As far as treatment goes, I really don't know the answer to that question because my own field is looking at the statistics, but I actually don't know if there are government and private partnerships on treatment. I don't know, maybe Pfizer can answer that rather better than I can, to tell the truth.

PFIZER REPRESENTATIVE: It's a simple answer. No they don't exist.

QUESTION: You had a chart that showed a couple of things, cost of tobacco - of cardiovascular disease in different countries, and the figure for China was about 4 billion…

JUDITH MACKAY: That was just the cost for tobacco, that one. We haven't got country figures for Asia on the costs of cardiovascular disease.

QUESTION (contd.): Is that mainly because the cost structure is so different across countries? I mean that seems like very small compared to Australia and other places. And the second question is to what extent do you see the government in Beijing treating either tobacco or cardiovascular disease as a public education issue because that seems to me the most widely lacking?

JUDITH MACKAY: I think that China has signed this Framework Convention on Tobacco Control, and in fact the words that are now coming out of China is that it is a patriotic responsibility to implement. They have signed an international treaty and actually China's record on signing, on implementing international treaties is very good. If they sign them they seem to implement them. So I think the Framework Convention will be a huge hope as far as China will go. And I think what the tobacco epidemic has done in the middle of cardiovascular disease is to show that the medical model is not enough. I mean we have learned in tobacco control, more than some of the other people in heart disease, that really you have to bring in lawyers, you have to look at litigation, you have to bring in economists, you have to bring in women's organizations. The Women's Commission in Hong Kong has come out, you know, very much in favor of the recent legislation, for example. You have to have a much broader, wider range of partners than just simply health people because this epidemic will not be solved just within the corridors of hospitals. It will be solved in the corridors of power but also with quite wide partnerships. And I think the other risk factor, people are also learning this for example, is that more and more they are looking at the economic impact of diabetes or obesity upon the cost to a government because the reality is if you were to choose a single issue that either obstructs or encourages governments to take action in health it has to be looking at the economic equations. You know, what are the costs and benefits from it? Is it better to have old people living on? We have to have health economists. We have to do far more studies. And one of the problems with the tobacco studies is that you might just look at attributable health care costs, but actually you need to multiply that by about five to come to the societal costs in total, and that includes days off work, the cost of premature death, even, you know, the cost of walking over a mountain to get to a health centre. All of these kinds of things have to be included, so I think that - one of the things that has happened with the atlases is the recognition. I am really pleased to say that we need far more economic data than we have at the moment.