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“Reverse Targeting”“Reverse Targeting”
Professor Shahryar A. SheikhPresident, World Heart Federation
1st Annual Dr. Abdul Haque KhanMemorial International Cardiology SymposiumKarachi14 March 2008
Effect of Socioeconomic Status
on Cardiovascular Care
39 %
26 %16 %
19 %
Population, %Population, %
3 %
11 %
15 % 71 %
Health $, PPP, %Health $, PPP, %
Distribution of Global Population & Health Expenditure, by Income in 2000
Distribution of Global Population & Health Expenditure, by Income in 2000
■ High, >$16,000
■ Higher Middle, $ 6-16000
■ Lower Middle, $ 2 - 6000
■ Low, <2000
■ High, >$16,000
■ Higher Middle, $ 6-16000
■ Lower Middle, $ 2 - 6000
■ Low, <2000
Globalization Research Centre, 2004;1:10% GDP to Health0 2 4 6 8 10 12 14
United States
GermanyFrance
Greece
Italy
OECD avg.
Japan
Spain
Poland
Mexico
Turkey
1222
786
569
169 147
37 25 18
0
200
400
600
800
1000
1200
1400
North Australia Europe MEAN South Russia Asia Africa
Nu
mb
er o
f C
ases
The Number of cardiac surgical procedures performed on an annual basis globally (Reproduced from Unger F. Worldwide survey on cardiac intervention 1995. Cor European 1999;7:128-46: with permission of Springer-Verlag)
Unger F, Cor Europpaeum. 1999;7:128-46
Cardiac Surgical Procedures Performed on an Annual Basis
GloballyWorldwide Survey on Cardiac Interventions, 1995
Cardiac Surgical Procedures Performed on an Annual Basis
GloballyWorldwide Survey on Cardiac Interventions, 1995
Under-5 mortality rates per 1000 live births by socioeconomic quintile of household
Inequalities in health between and within countries: poverty and inequality
Inequalities in health between and within countries: poverty and inequality
0
20
40
60
80
100
120
140
160 Poorest fifth2nd poorest fifthMiddle fifth
2nd richest fitthRichest fifth
Indonesia Brazil India Kenya
Death rates from CHD by socio-economic class,Death rates from CHD by socio-economic class,age 15 or 20 to 74 years, England and Walesage 15 or 20 to 74 years, England and Wales
Death rates from CHD by socio-economic class,Death rates from CHD by socio-economic class,age 15 or 20 to 74 years, England and Walesage 15 or 20 to 74 years, England and Wales
0
50
100
150
200
250
1970/72 1990/93
Deaths per 100,000
Drever et al Pop. Trends 1996;86:15-20
Professional
Intermediate
N Skillednon-manual
M Skilled manual
Partly skilled
Unskilled
SOCIAL INEQUALITIES IN MALE MORTALITY IN FROMSMOKING AND FROM ANY CAUSE (1996)
SOCIAL INEQUALITIES IN MALE MORTALITY IN FROMSMOKING AND FROM ANY CAUSE (1996)
P Jha et al., Lancet 2006; 368:367
50
40
30
20
10
0
Englandand Wales
USA Canada Poland
Social class NeighborhoodIncome
EducationEducation
Ris
k o
f d
yin
g a
t a
ge
s 3
5-69
ye
ars
(%)
High (I
/II)
Med
(III/
IV)
Low (V)
Low (<12
yrs
)
Med
(12
yrs)
High (>
12 y
rs)
Low (<12
yrs
)
Med
(12
yrs)
High (>
12 y
rs)
High (2
0%)
Med
(60%
)
Low (20%
)
43%
31%
21% 20%
37%
34%36%
21%24%
26%
50%
32%
22%
10%
5%6% 8%
13%14% 15%
4%4%
10%
19%
SmokingAny Cause
Rural: Economic Status, % Rural: Economic Status, %
(SE%)(SE%)Urban: Economic Status, % Urban: Economic Status, %
(SE%)(SE%)
Age Range, yAge Range, y LowLow MiddleMiddle HighHigh LowLow MiddleMiddle HighHigh
Infectious diseaseInfectious disease
Annual episodes of diarrhea Annual episodes of diarrhea 0-50-5 11.011.0(0.8)(0.8) 11.311.3(0.8)(0.8) 12.712.7aa(1.5)(1.5) 12.412.4(1.0)(1.0) 10.510.5(1.1)(1.1) 7.97.9(0.8)(0.8)
Nutritional statusNutritional status
AnemiaAnemia 0-50-5 68.168.1(3.0)(3.0) 66.266.2(3.5)(3.5) 65.065.0(6.6)(6.6) 65.665.6(6.0)(6.0) 64.264.2(3.9)(3.9) 52.852.8(8.6)(8.6)
WastingWasting 0-50-5 18.318.3(2.0)(2.0) 14.114.1(2.5)(2.5) 10.010.0(2.2)(2.2) 14.514.5(2.4)(2.4) 12.812.8(2.4)(2.4) 12.512.5(2.3)(2.3)
Anemia, males,Anemia, males, 15-4415-44 28.028.0aa(3.2)(3.2) 20.520.5(2.6)(2.6) 17.817.8(4.5)(4.5) 16.816.8(3.9)(3.9) 13.613.6(2.6)(2.6) 11.511.5(3.5)(3.5)
Anemia, femalesAnemia, females 15-4415-44 51.551.5(3.8)(3.8) 38.738.7(3.3)(3.3) 32.832.8(4.1)(4.1) 47.547.5(6.7)(6.7) 40.740.7(3.6)(3.6) 38.038.0(4.6)(4.6)
UnderweightUnderweight 25-6425-64 32.932.9aa(1.5)(1.5) 25.625.6aa(2.1)(2.1) 15.115.1(2.8)(2.8) 24.124.1(3.6)(3.6) 17.717.7(1.4)(1.4) 10.310.3(1.5)(1.5)
OverweightOverweight 25-6425-64 9.19.1aa(0.8)(0.8) 14.614.6aa(1.4)(1.4) 27.027.0aa(4.8)(4.8) 21.221.2(2.5)(2.5) 27.127.1(1.8)(1.8) 41.941.9(2.7)(2.7)
Chronic disease risk factorsChronic disease risk factors
HypertensionHypertension 45-6445-64 22.022.0(1.8)(1.8) 32.232.2(3.5)(3.5) 52.152.1(4.7)(4.7) 29.729.7(4.2)(4.2) 40.740.7(3.3)(3.3) 46.046.0(3.8)(3.8)
High CholesterolHigh Cholesterol 45-6445-64 13.713.7aa(1.8)(1.8) 16.916.9(2.5)(2.5) 26.726.7(5.7)(5.7) 22.122.1(3.7)(3.7) 22.622.6(2.9)(2.9) 27.827.8(4.0)(4.0)
Male smoking Male smoking 25-6425-64 35.535.5aa(2.3)(2.3) 33.633.6aa(2.4)(2.4) 33.733.7(5.0)(5.0) 57.057.0(5.0)(5.0) 45.545.5(2.8)(2.8) 33.033.0(3.3)(3.3)
Female SmokingFemale Smoking 25-6425-64 4.04.0aa(0.7)(0.7) 4.84.8(1.1)(1.1) 2.32.3(1.2)(1.2) 9.19.1(2.1)(2.1) 5.05.0(1.6)(1.6) 2.42.4(1.0)(1.0)
Selected Health Status Indicators:Selected Health Status Indicators: National Health Survey of Pakistan, 1990–1994National Health Survey of Pakistan, 1990–1994Selected Health Status Indicators:Selected Health Status Indicators: National Health Survey of Pakistan, 1990–1994National Health Survey of Pakistan, 1990–1994
G. Pappas, W.C. Hadden, T. Akhtar, A J of Public Health 2001;91:93-98
Male, % (SE%)Male, % (SE%) Female, % (SE%)Female, % (SE%)
Age Range, yAge Range, y
United United StatesStates PakistanPakistan
United United StatesStates PakistanPakistan
Nutritional StatusNutritional Status
AnemiaAnemia 15-4415-44 1.51.5aa(0.3)(0.3) 20.620.6bb(1.8)(1.8) 10.410.4bb(0.7)(0.7) 44.444.4aa(2.4)(2.4)
UnderweightUnderweight 25-6425-64 0.80.8aa(0.2)(0.2) 25.025.0bb(1.3)(1.3) 3.23.2bb(0.4)(0.4) 25.325.3(1.4)(1.4)
OverweightOverweight 25-6425-64 61.861.8aa(1.0)(1.0) 13.213.2bb(1.0)(1.0) 51.951.9bb(1.3)(1.3) 22.622.6aa(1.3)(1.3)
Chronic disease risk factorsChronic disease risk factors
High cholesterolHigh cholesterol 45-6445-64 66.666.6aa(1.7)(1.7) 15.315.3bb(1.6)(1.6) 71.071.0bb(1.6)(1.6) 20.2920.29aa(1.9)(1.9)
HypertensionHypertension 45-6445-64 36.236.2(1.9)(1.9) 28.828.8bb(1.8)(1.8) 32.832.8(1.6)(1.6) 32.732.7(2.1)(2.1)
Smoking Smoking 25-4425-44 36.736.7aa(1.3)(1.3) 40.640.6(1.7)(1.7) 30.030.0bb(1.3)(1.3) 3.93.9aa(0.5)(0.5)
SmokingSmoking 45-6445-64 31.331.3aa(1.7)(1.7) 35.135.1(2.2)(2.2) 25.125.1bb(1.2)(1.2) 5.45.4aa(0.8)(0.8)Note. NHANES III= Third National Health and Nutrition Examination Survey.aProbability less than .05 that men and women within country are at equal levels.bProbability less than .05 that US men and women are at equal levels with Pakistani men and women, respectively.
National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994
G. Pappas, W.C. Hadden, T. Akhtar, A J of Public Health 2001;91:93-98
Selected Health Status Indicators Comparing Selected Health Status Indicators Comparing the United States and Pakistan:the United States and Pakistan:
Selected Health Status Indicators Comparing Selected Health Status Indicators Comparing the United States and Pakistan:the United States and Pakistan:
Male, %Male, % Female, %Female, % Male, SE %Male, SE % Female, SE %Female, SE %
United United StatesStates PakistanPakistan
United United StatesStates PakistanPakistan
United United StatesStates PakistanPakistan
United United StatesStates PakistanPakistan
HypertensionHypertension
Not awareNot aware 31.931.9aa 86.786.7bb 21.521.5bb 70.570.5aa 2.52.5 2.22.2 1.81.8 3.03.0
Aware, not treatedAware, not treated 19.619.6 6.26.2bb 14.614.6bb 13.513.5bb 2.02.0 1.41.4 1.71.7 1.91.9
Treated, not controlledTreated, not controlled 25.425.4 4.74.7bb 28.828.8bb 11.311.3aa 1.81.8 1.31.3 2.12.1 1.91.9
Controlled Controlled 23.023.0aa 2.42.4bb 35.135.1bb 4.84.8 1.71.7 0.90.9 2.52.5 1.41.4
Dental healthDental health
Decayed and missing teethDecayed and missing teeth 9.99.9 10.410.4 10.110.1bb 15.215.2aa 0.40.4 0.50.5 0.40.4 0.70.7
Any filled teethAny filled teeth 78.078.0 2.32.3bb 77.477.4bb 2.02.0 1.41.4 0.60.6 1.41.4 0.60.6
Note. NHANES III= Third National Health and Nutrition Examination Survey.Note. NHANES III= Third National Health and Nutrition Examination Survey.aaProbability less than .05 that men and women within country are at equal levels.Probability less than .05 that men and women within country are at equal levels.bbProbability less than .05 that US men and women are at equal levels with Pakistani men and women, respectivelyProbability less than .05 that US men and women are at equal levels with Pakistani men and women, respectively..
Indicators of Access to and Appropriateness Indicators of Access to and Appropriateness of Health Care for Adultsof Health Care for Adults
Indicators of Access to and Appropriateness Indicators of Access to and Appropriateness of Health Care for Adultsof Health Care for Adults
National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994National Health Survey of Pakistan, 1990–1994, and NHANES III, 1988–1994
G. Pappas, W.C. Hadden, T. Akhtar, A J of Public Health 2001;91:93-98
0
10
20
30
40
Q1 Q2 Q3 Q4
CABGPCI
Income Quartile
Per
cen
t
Overall Rates
0
10
20
30
40
Q1 Q2 Q3 Q4
CABGPCI
Men
Income Quartile
Per
cen
t
Effects of Socioeconomic Status on PCI & CABGAlberta, Canada
Effects of Socioeconomic Status on PCI & CABGAlberta, Canada
0
10
20
30
40
Q1 Q2 Q3 Q4
CABGPCI
Income
Per
cen
t
Women
Am. J M, 2007, 120, 33-39
0
0.2
0.4
0.6
0.8
1
1.2
1.4
1.6
1 2 3 4 5
Angiography within 6 mo
Waiting time for angiography
Mortality at 1 yr
Income Quintile
Ra
tio
Adjusted Relative Rates of Angiography within Six Months after Acute Myocardial Infarction, Waiting Times for Angiography, and One-Year Mortality According to Income Quintile.
Socioeconomic Status Access to Cardiac Procedures and Mortality
Rates of Use of Procedures and Waiting Times
Socioeconomic Status Access to Cardiac Procedures and Mortality
Rates of Use of Procedures and Waiting Times
Socioeconomic Status Access to Cardiac Procedures and Mortality
Socioeconomic Status Access to Cardiac Procedures and Mortality
Days after Acute Myocardial InfarctionKaplan-Meier Survival Curves According to Quintile of Neighborhood Median IncomeKaplan-Meier Survival Curves According to Quintile of Neighborhood Median Income
David A. alter.,NEJM 1999;341:1359-67
Cardiovascular Care in PakistanCardiovascular Care in PakistanIn Patients
(2006)In Patients
(2006)
60 %
21 %
10 %
9 %
Out Patients (2006)
Out Patients (2006)
8 %8 %
7 %
77 %
Total PCI 1886
Total PCI 1886
64 %
7 %
13 %
16 %
■ Paying ■ Poor
■ G. User ■ Entitled
S. Sheikh, ESC, 2007
■ Paying ■ Poor
■ G. User ■ Entitled
In PatientsIn Patients
60 %
21 %
10 %
9 %
PTMCPTMC
6% 3 %6 %
85 %PCIPCI
64 %
7 %
13 %
16 %
Socioeconomic Status and Cardiovascular DiseaseSocioeconomic Status and Cardiovascular Disease
S. Sheikh, ESC, 2007
3047
1172 1145
3238
1200
136252 298
0
500
1000
1500
2000
2500
3000
3500
Paying G. User Entitled PoorCor. Angio PCI
3047
1172 1145
3238
1200
136252 298
0
500
1000
1500
2000
2500
3000
3500
Paying G. User Entitled PoorCor. Angio PCI
Socioeconomic Gradient and Cardiovascular CareSocioeconomic Gradient and Cardiovascular Care
39%39%
11%11%22%22% 9%9%
S. Sheikh, ESC, 2007
The World’s Priorities? Annual ExpenditureThe World’s Priorities? Annual ExpenditureBasic education for all $ 6 billion*
Cosmetics in the United States $ 8 billion*
Safe water and sanitation for all $ 9 billion*
Ice Cream in Europe $ 11 billion*
Reproductive health for all women $ 12 billion*
Perfumes in Europe and the United States $ 12 billion*
Basic health and nutrition $ 13 billion*
Pet food in Europe and The Unites States $ 17 billion
Business entertainment in Japan $ 35 billion
Cigarettes in Europe $ 50 billion
Alcoholic drinks in Europe $ 105 billion
Narcotic drugs in the world $ 400 billion
Military spending in the world $ 780 billion
*Estimated additional annual cost to achieve universal access to basic social services in all developing countries Human development Report 1998
Expanding gap between the wealthy and
the poor in our society represents the
single greatest threat to our free standing
democracy.
Expanding gap between the wealthy and
the poor in our society represents the
single greatest threat to our free standing
democracy. SENATOR BOB KERY
(Nebraska)
No other group of people in world can claim such a wonderful position in life or more rewarding job. Because of our unique talent and position in world’s social spectrum. We have social obligations that only we are capable of addressing.
Let us light a candle instead of deploring the darkness.
Socioeconomic gradient remains the most
important barrier amongst the countries, or
within a developing country, for appropriate
application of cardiovascular care.
Sharing Science/Building Capacity
2008 World Congress of Cardiology, Buenos Aires,
Argentina - http://www.worldcardiocongress.org
Next World Congresses:
2010 World Congress of Cardiology, Beijing, China