give you an overview of heart disease in
the world heart disease and strokes
these ideas are built not by me but by a
large number of people around the world
and the chief architect of this thinking
was my mentor Richard Peto now Sir
Richard Peto so the first thing is you
know when you think about heart disease
you’d say how can we make progress and
then once you accept we can make
progress in reducing it can we really
have heart disease in the world and I’m
going to add another word and say having
heart disease prematurely that’s before
the age of 70 within a generation
so within 30 years that is huge
so premature definition of premature
changes as you get older it gets pushed
out so the first thing is to accept that
death in old age is inevitable but death
before old age is not and the other
thing is the causes of death in very
young people children in sort of youth
and young adulthood that is five to
thirty four years and in adulthood that
is say 35 to 69 years are different but
they tend to be similar within each
category and the issues can be Harvard
in each range and I’m going to focus
largely on the 35 to 69 today in the
world there are 53 million deaths every
year give or take a few million now of
these 30 million are below the age of 70
and 23 million are over the age of 70
and in those below the age of 70 about 7
million deaths occur between the ages of
0 & 4
another five million occur between five
and thirty four but the last majority 18
million occurs between 35 and 70 and
that’s the focus of my talk today
sometimes she looked forward and to what
will happen in the future you got to
look backwards and let us look at the
mortality rates in a country like
England that kept very good statistics
for a long time so I’m going to show you
data in 1910 1960 and 2010 and look at
the risks at the age of five and at the
age of 70 so these are the survival
curves and you will see that at the
bottom end here is what happened in 1910
you will see that by the age of 10 about
20 percent of children were dead compare
that by 1960 where it was under 5% and
by 2010 it’s under 1% these are huge
changes within 100 years let’s take the
age of 50 and you will see but in 1910
about 50% of the people who over born
were dead by the age of 50 compare that
in 1970 we’re still 90 percent were
alive and by 2010 about 95 percent were
alive and if you look at 70 you will see
that even at the age of 70 there are
many more people who are alive in 2010
compared to 1910 and soon we will have
that will have a lot of people living
beyond hundred so the last 100 years has
seen the biggest advance in human health
compared to the history of mankind ever
and this has been a tremendous hundred
years now let us look at what the main
reasons were so what is given in shaded
are deaths from tobacco what’s on the
white is the added number from known
tobacco deaths and you will see for 1916
men to 2010 right now you will see
there’s a marked decline
for nineteen thousand deaths down to
four thousand over that period of time
as seventy five percent reduction in
that short period of time and if you
look at the rest you will see there is a
decline but nowhere near there this is
two messages
the biggest killer the mankind has known
ever in the history is tobacco more than
the plague more than Wars more than
anything else the second thing is that
you can actually make big changes in
relatively short times for instance
fifty years in as a fraction of human
health or is tiny fifty years as you
know as a proportion of the number of
years people have been in the world so
catchy made big changes in a short time
now coming back to those same numbers of
the fifty three million this is just to
remind you you know zero two four seven
million five to thirty four five million
and 35 to 70 eighteen million and I’m
not going to focus on the 70 plus
million now if you look at this
worldwide because I showed you
numbers for England if you look at it
worldwide we’re seeing a parallel
decline 1950 25% of was the childhood
mortality by 2010 it was five percent
this is huge to see that worldwide this
happened both in the rich countries and
in the poor countries and this happened
in the countries with a lot of
technology and those with relatively
little technology so this is telling you
that social changes and some aspects of
healthcare like a midwife going in
looking at ending a bird is what made a
difference as opposed to high-tech care
now this one is looking at the world
mortality by the different age groups so
when you look at this
what you’re seeing is down down here the
earlier period you know 1970 down here
this is 2010 and you will see in
age group 0 to 4 in the world as a whole
that is the left panel there’s a decline
5 to 49 declines 0 to 49 that is least
you put together decline and 50 to 70 a
decline you are seeing that in the
low-income countries you’ve seen that in
the high-income countries and you sing
that in the low middle and the upper
middle if we take the world as a whole
you have 20% of the world is high-income
countries 20% is low income countries
60% are middle-income countries with
half being high middle and half being
low middle that’s an easy way to
remember now one way to look at what’s
happening is to take the 25 most
populous countries in the world that
constitutes 75% of the global population
and Canada doesn’t count you know so
this doesn’t include Canada but includes
the United States and the UK in other
countries where the trends are identical
and we look at the mortality in these
three age groups the first thing to do
is to look at mortality zero to four and
you’ll see in practically every country
there’s a decline so what you’re seeing
on the top is the earliest period which
is 1970 and that 40 years later 2010 and
this blob there like the head of a sperm
is the most recent and in every case the
head of the sperm is swimming downwards
you know going south and you’ll see that
every country you’ll see that in the
rich countries at the far right end
which started low but kept on going
lower and the poor countries at the left
hand like the Democratic Republic of
Congo that started high and still
remains high so that’s good news so
whatever we did globally hug everybody
now this is between the ages of 5 and 49
generally the same pattern except for a
few chain of differences you will see in
countries like South Africa and the left
it actually went up and this is the HIV
epidemic you will see countries like
Iran barry’s Iran somewhere there
well Iran when they had the war with
Iraq several million people died so then
war can interfere with it or you can
look at countries like Russia which is
down here you’ll see that she went up
and that is social upheaval
after the fall of the Soviet Union and
yells during elseís time there was
massive chaos and then alcoholism
increased
deaths from violence increase so barring
those two two or three exceptions in
every country went down and some of
these arrows Oh are over India and some
of them are over China to show you that
even the poor countries changed now this
is 50 to 69 again the same pattern you
will see indeed came down ETOP
one of the big countries in Africa came
down I think that’s China and this is
the u.s. so rich and poor countries in
different continents came down and what
you’re seeing out here is that again you
know this is Russia you’ll see
alcoholism violence and social upheaval
was was destructive so this is bringing
me to my second point the determinants
of health are the big dial issues in
society it’s not necessarily medical
care in Western countries where social
circumstances are more or less stable
medical care plays a much bigger role in
the poorer countries where social
factors dominate social factors play a
bigger role now worldwide there are only
four or five causes that are the big
causes of death premature deaths the
first is tobacco which I talked about
HIV an epidemic like HIV or even
epidemic like Ebola spread worldwide
that would be a disaster
alcohol adiposity and war and these are
the only things that have fluctuated
between populations over time so let me
give you an example of the UK and these
are male mortality the top line and the
bottom is female mortality the X is the
time I finished my PhD it had nothing to
do
the with the with the decline it’s just
that that’s the way of me remembering
and you will see this massive big
decrease where it was about what is it
about 20% or so I can’t read it from 25%
of the debts in males down to about 5%
in that 30 40 years that’s huge
75 percent reduction you’ll see women as
well showed that decline however not all
countries showed this this is Hungary
that showed initially an increase in men
and then a decline and this is to do
again with the fall of the Soviet empire
that the initial reaction was chaos
whenever a regime is overthrown you’re
going to get chaos it had happened in
England during the Civil War after the
Civil War
it happened in France it happened in
Russia it’s happening right right now in
the Middle East so you’ve got to
anticipate once you have regime change
it’s chaos for a few decades
and then it starts to stabilize and you
can see in women it was fairly stable
and then both in men and women it
declined this is Russia show you the
erratic nature especially in men less so
in women but there was no improvement of
women till more recent times so the
question is can be harvested of
mortality and the first thing is if you
had a heart attack or a stroke
we have enough treatments today that
collectively put together can reduce the
risk of another heart attack
by 50% to 70% and what you can what you
do is you get people to stop smoking
give them aspirin cholesterol-lowering
and a blood pressure lowering drug and
you can reduce it by 70% now there are
new medications that combines everything
except the smoking part of it and you
can make big big impacts
there’s no reason today it’s available
about 25 cents a day there’s no reason
in future it can’t be available at five
cents a day so imagine having a
medication at five cents a day
high-risk people reducing mortality by
50 to 60% and then on top of that if you
get people to stop smoking you added to
75% that is huge isn’t it now that’s the
same thing now what I want to show you a
slide on how bats tobacco’s and how bad
tobacco is in women and the reason I
focus on women in zin today in Canada
young women are more often smokers than
men men have declined historically women
were more sensible than men today it’s
reversed so what this is showing you is
this is a study where they took a
million women in the UK and then follow
us them do you smoke
how much do you smoke when did you quit
and you will see even as little as ten
cigarettes a day doubles the risk of
death 15 three triples and 20 quadruples
so if any of you know people who smoke
just the biggest favor you can do them
do for them is to persuade them to smoke
smoking and the other thing about this
is not only the risk rate for people who
smoke but if you get people to stop
smoking before the age of 40 you can
virtually eliminate the risk of smoking
so the perfect way to smoke is start to
smoke when you’re born and keep on
smoking till you’ve become 39 years and
then stop and then you’ll live forever
so these are the data that shows us so
this is people stopping smoking at the
age of 20 and this is the risk that is
three folders in the people who continue
to smoke and for the next 20 years so if
they stopped at the age of 20 and and
seriously they may have smoked for five
years the risk is not increased if they
smoke around thirty years you’ll see the
risk is only increased by five percent
it’s not huge if they stopped at the age
of 40 the risk is only one point to fall
competitor percent and somebody
continued to smoke so
and obviously they smoked stop
at 50 you still avoid most of the deaths
due to smoking so stopping smoking at
any age is very important but smoking
stopping smoking before the age of 30 or
40 it will nearly eliminate most of the
risk of smoking the other thing is
elevated blood pressure if your blood
pressure is higher than by about 10
millimeters now most of you know that
the average blood pressure in a
population is around 125 to 130 or so
that is systolic the upper number okay
now if it is lowered in people with high
blood pressure by 10 millimeters and you
can do that today easily by one or two
low doses of one or two blood pressure
lowering drugs which together needing to
be more than 10 or 15 cents a day you
can reduce the risk by 1/4 that’s big
and cholesterol is the other big cause
of heart disease and strokes and if you
give a drug called a statin that impairs
the production of the bad cholesterol
LDL cholesterol or what’s called the
low-density lipoprotein cholesterol all
if you know these good cholesterol and
bad cholesterol this is the bad
cholesterol if you can reduce it by 2
million moles that is by about a third
you’ll reduce the risk by 40% so smoking
big effect blood pressure big effect
cholesterol lowering big effect and if
you put it all together you’ll have big
effects now one of the things about
smoking I’ve heard people say is we
beaten tobacco there’s nothing more
incorrect than that in the last century
that’s down at the bottom in yellow 100
million people died from tobacco in this
century if the current rates of tobacco
smoking continues 1 billion people will
die and the reason is in the last
century the rates of smoking increased
till the 1950s and 60s especially in
women it was later
whereís and second it was confined
largely to Western countries
in this century we have exported the
epidemic of tobacco to China to India
which are much more populous than Canada
the u.s. of the UK and remember this is
smoking through the whole century and in
the next 20 years that’s a top-line 2000
to 2019 hundred million will die those
hundred million are current smokers so
advising children to stop smoking won’t
touch those hundred million deaths the
next 20 to 30 years 2020 to 2050 250
million will die half of them are
current smokers half of them will be new
smokers and obviously from 2050 to 2100
there will to be 500 million deaths and
all of them will be new smokers so the
best way to have an impact in the next
30 years is to get people to quit and if
you get them to quit their children will
not start smoking right now a public
health strategy is emphasizing childhood
cessation over quitting programs like in
Hamilton is practically no quitting
program for tobacco control so this is
the kind of thing we need now one of the
biggest things you can do to control
tobacco is a policy and the policy is to
have laws that reduce the use of tobacco
and of those the most important one is
increasing the prices in the UK they had
two big price increases one in 1947 and
in one in 1981 and during that time
immediately the rates of tobacco smoking
came down now there is now remember
government’s make a ton of money from
the taxes on tobacco and one of the
reasons they are reluctant to increase
the price of tobacco too much because
they are concerned what will happen to
their revenues so in South African
France the experiences suggest if you
triple the price of cigarettes smoking
rates were high but despite having it
government revenues will still be
doubled so now this can obviously go on
indefinitely because at some stage the
numbers of people smoking will be very
low
so I’ll stop here by reminding you that
are really five main causes worldwide or
premature death
these are tobacco HIV which I didn’t
talk about it has nothing to do with
heart disease alcohol adiposity that is
obesity and war and of this alcohol
tobacco and adiposity that is obesity
affects heart disease so remember death
in old age is inevitable but that before
old age is not thank you [Applause]