1. “Reverse Targeting” Professor Shahryar A. Sheikh President, World Heart Federation 1 st Annual Dr. Abdul Haque Khan Memorial International Cardiology Symposium Karachi 14 March 2008 Effect of Socioeconomic Status on Cardiovascular Care

2. 80% Advance Cardiac Care Advance Cardiac Care

3. 39 % 26 % 16 % 19 % Population, % 3 % 11 % 15 % 71 % Health $, PPP, % 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 Health United States Germany France Greece Italy OECD avg. Japan Spain Poland Mexico Turkey

4. Number of Cases 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 Globally Worldwide Survey on Cardiac Interventions, 1995 Cardiac Surgical Procedures Performed on an Annual Basis Globally Worldwide Survey on Cardiac Interventions, 1995

5. Under-5 mortality rates per 1000 live births by socioeconomic quintile of household Inequalities in health between and within countries: poverty and inequality Indonesia BrazilIndiaKenya

6. Death rates from CHD by socio-economic class, age 15 or 20 to 74 years, England and Wales Death rates from CHD by socio-economic class, age 15 or 20 to 74 years, England and Wales 0 50 100 150 200 250 1970/721990/93 Deaths per 100,000 Drever et al Pop. Trends 1996;86:15-20 Professional Intermediate N Skilled non-manual M Skilled manual Partly skilled Unskilled

7. SOCIAL INEQUALITIES IN MALE MORTALITY IN FROM SMOKING AND FROM ANY CAUSE (1996) SOCIAL INEQUALITIES IN MALE MORTALITY IN FROM SMOKING AND FROM ANY CAUSE (1996) P Jha et al., Lancet 2006; 368:367 50 40 30 20 10 0 England and Wales USACanadaPoland Social classNeighborhood Income Education Risk of dying at ages 35-69 years (%) High (I/II) Med (III/IV) Low (V) Low (<12 yrs) Med (12 yrs) High (>12 yrs) Low (<12 yrs) Med (12 yrs) High (>12 yrs) High (20%) 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% 10% 19% Smoking Any Cause

8. Rural: Economic Status, % (SE%) Urban: Economic Status, % (SE%) Age Range, y LowMiddleHighLowMiddleHigh Infectious disease Annual episodes of diarrhea 0-5 11.0(0.8) 11.3(0.8) 12.7 a (1.5) 12.4(1.0) 10.5(1.1) 7.9(0.8) Nutritional status Anemia0-5 68.1(3.0) 66.2(3.5) 65.0(6.6) 65.6(6.0) 64.2(3.9) 52.8(8.6) Wasting0-5 18.3(2.0) 14.1(2.5) 10.0(2.2) 14.5(2.4) 12.8(2.4) 12.5(2.3) Anemia, males, 15-44 28.0 a (3.2) 20.5(2.6) 17.8(4.5) 16.8(3.9) 13.6(2.6) 11.5(3.5) Anemia, females 15-44 51.5(3.8) 38.7(3.3) 32.8(4.1) 47.5(6.7) 40.7(3.6) 38.0(4.6) Underweight25-64 32.9 a (1.5) 25.6 a (2.1) 15.1(2.8) 24.1(3.6) 17.7(1.4) 10.3(1.5) Overweight25-64 9.1 a (0.8) 14.6 a (1.4) 27.0 a (4.8) 21.2(2.5) 27.1(1.8) 41.9(2.7) Chronic disease risk factors Hypertension45-64 22.0(1.8) 32.2(3.5) 52.1(4.7) 29.7(4.2) 40.7(3.3) 46.0(3.8) High Cholesterol 45-64 13.7 a (1.8) 16.9(2.5) 26.7(5.7) 22.1(3.7) 22.6(2.9) 27.8(4.0) Male smoking 25-64 35.5 a (2.3) 33.6 a (2.4) 33.7(5.0) 57.0(5.0) 45.5(2.8) 33.0(3.3) Female Smoking 25-64 4.0 a (0.7) 4.8(1.1) 2.3(1.2) 9.1(2.1) 5.0(1.6) 2.4(1.0) Selected Health Status Indicators: National Health Survey of Pakistan, 1990–1994 Selected Health Status Indicators: National Health Survey of Pakistan, 1990–1994 G. Pappas, W.C. Hadden, T. Akhtar, A J of Public Health 2001;91:93-98

9. Male, % (SE%) Female, % (SE%) Age Range, y United States Pakistan Pakistan Nutritional Status Anemia15-44 1.5 a (0.3) 20.6 b (1.8) 10.4 b (0.7) 44.4 a (2.4) Underweight25-64 0.8 a (0.2) 25.0 b (1.3) 3.2 b (0.4) 3.2 b (0.4) 25.3(1.4) Overweight25-64 61.8 a (1.0) 13.2 b (1.0) 51.9 b (1.3) 22.6 a (1.3) 22.6 a (1.3) Chronic disease risk factors High cholesterol 45-64 66.6 a (1.7) 15.3 b (1.6) 71.0 b (1.6) 20.29 a (1.9) Hypertension45-64 36.2(1.9) 28.8 b (1.8) 32.8(1.6) 32.7(2.1) Smoking25-44 36.7 a (1.3) 40.6(1.7) 30.0 b (1.3) 3.9 a (0.5) 3.9 a (0.5) Smoking45-64 31.3 a (1.7) 35.1(2.2) 25.1 b (1.2) 5.4 a (0.8) 5.4 a (0.8) Note. NHANES III= Third National Health and Nutrition Examination Survey. a Probability less than.05 that men and women within country are at equal levels. b Probability 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, 1988–1994 G. Pappas, W.C. Hadden, T. Akhtar, A J of Public Health 2001;91:93-98 Selected Health Status Indicators Comparing the United States and Pakistan:

10. Male, % Female, % Male, SE % Female, SE % United States Pakistan Pakistan Pakistan Pakistan Hypertension Not aware 31.9 a 86.7 b 21.5 b 70.5 a 2.52.21.83.0 Aware, not treated 19.6 6.2 b 14.6 b 13.5 b 2.01.41.71.9 Treated, not controlled 25.4 4.7 b 28.8 b 11.3 a 1.81.32.11.9 Controlled 23.0 a 2.4 b 35.1 b 4.81.70.92.51.4 Dental health Decayed and missing teeth 9.910.4 10.1 b 15.2 a 0.40.50.40.7 Any filled teeth 78.0 2.3 b 77.4 b 2.01.40.61.40.6 Note. NHANES III= Third National Health and Nutrition Examination Survey. a Probability less than.05 that men and women within country are at equal levels. b Probability less than.05 that US men and women are at equal levels with Pakistani men and women, respectively. Indicators of Access to and Appropriateness of Health Care for Adults National 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

11. Income Quartile Percent Overall Rates Men Income Quartile Percent Effects of Socioeconomic Status on PCI & CABG Alberta, Canada Effects of Socioeconomic Status on PCI & CABG Alberta, Canada Income Percent Women Am. J M, 2007, 120, 33-39

12. Income Quintile Ratio 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

13. Socioeconomic Status Access to Cardiac Procedures and Mortality Socioeconomic Status Access to Cardiac Procedures and Mortality Days after Acute Myocardial Infarction Kaplan-Meier Survival Curves According to Quintile of Neighborhood Median Income David A. alter.,NEJM 1999;341:1359-67

14. Cardiovascular Care in Pakistan In Patients (2006) In Patients (2006) 60 % 21 % 10 % 9 % Out Patients (2006) Out Patients (2006) 8 % 7 % 77 % Total PCI 1886 Total PCI 1886 64 % 7 % 13 % 16 % ■ Paying ■ Poor ■ G. User ■ Entitled S. Sheikh, ESC, 2007

15. ■ Paying ■ Poor ■ G. User ■ Entitled In Patients 60 % 21 % 10 % 9 % PTMC 6% 3 % 6 % 85 % PCI 64 % 7 % 13 % 16 % Socioeconomic Status and Cardiovascular Disease S. Sheikh, ESC, 2007

16. Socioeconomic Gradient and Cardiovascular Care 39% 11% 22% 9% S. Sheikh, ESC, 2007

17. The World’s Priorities? Annual Expenditure Basic 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

18. 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)

19. 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.

20. Socioeconomic gradient remains the most important barrier amongst the countries, or within a developing country, for appropriate application of cardiovascular care.

22. 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