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CVJAFRICA • Volume 26, No 2, H3Africa Supplement, March/April 2015
Global trends reflecting challenges and opportunities in
achieving HLBS health include those existing on the domestic
front. The 2013 US National Healthcare Disparities report
demonstrates that there is ample room for improvement. The
risk-adjusted in-patient mortality rate for heart attack hospital
admissions fell significantly between 2001 and 2010 for each
racial/ethnic and area income group; however residents of the
lowest area income quartile had higher in-patient mortality rates
than residents of the highest area income group in five of the 10
years evaluated.
6
In 2008, Hispanic men and women were less likely to
receive blood pressure measurements compared with their
white counterparts. Furthermore, although vaccination for
pneumococcal pneumonia is a cost-effective strategy for reducing
illness, death and disparities associated with pneumonia and
influenza, blacks and Asians were less likely than whites,
and Hispanics were less likely than non-Hispanics to receive
immunization, among the elderly who reported ever receiving
pneumococcal vaccination.
Similarly, among hospital patients, age 50 years and above
with pneumonia who received influenza immunisation status
assessment or provision, black, Hispanic, American Indians/
Alaskan natives (AI/AN) and Asian patients were less likely
than white patients to receive influenza immunisation status
assessment or provision. Also, among long-term nursing home
residents, black, AI/AN, multiple-race and Hispanic residents
were less likely than white residents to receive both influenza and
pneumococcal immunisation.
From 2003 to 2010, the percentage of people with current
asthma who reported taking preventative asthma medicine daily
or almost daily fell from 29.6 to 26.5%. In five of eight years,
blacks compared with whites, and poor and low-income people
compared with high-income people, were less likely to take daily
preventative asthma medicine.
New and evolving insights
The above noted trends occur in an era where new insights are
reshaping our understanding of the complexities of disease
mechanisms, while prompting us to contemplate transformative
ways to prevent and pre-empt the burden of HLBS conditions.
In the wake of recent reports, the intimate and intricate interplay
between social and biological systems in the pathobiology of
HLBS conditions is increasingly appreciated.
In the context of obesity, a central risk factor in the domain of
HLBS disorders, the report by Christakis and Fowler evokes the
notion of the social contagion of disease.
7
They demonstrated
that obesity appears to spread though social ties, and therefore
network phenomena may be relevant to the biological and
behavioural trait of obesity. Simply stated, a socio-ecological
construct underpins trends in disease evolution, which implies
that it matters where we live, learn, work and play, and that
culture, religion, war, food desserts and unhealthy diets all play
into the determinants of HLBS conditions. The philosophy of
social contagion of disease has profound implications for disease
intervention, because if we are to successfully tackle inequities in
HLBS conditions, we have to embrace the understanding that we
are dealing with a complex multi-level problem that warrants a
systems science intervention approach.
8,9
The mechanisms by which socio-behavioural and biological
factors interact in the pathobiologyof disease are now increasingly
palpable and not just a figment inspired by epidemiological
studies. Recent evidence suggests a relationship between long-
term dietary patterns and gut microbial enterotypes,
10
that
a link exists between intestinal microbial metabolism and
cardiovascular risk,
11
and that the microbiota of the gut is
a potentially novel target for atherosclerosis prevention and
treatment.
12
In addition to the emerging evidence for the impact
of diet on human health via modulation of the composition
of gut microbiome, we are reminded that complex genetic
interplay attend disease mechanisms, and therefore can inform
our approaches for risk prediction, pharmacogenomics and new
therapies, particularly in the context of genomic-based medicine
strategies to reduce health inequities.
13,14
Challenges and opportunities
The above insights should inspire the deployment of systems
science in search of major proximal targets in the socio-
ecological model that could lead to a transformative impact
on HLBS conditions. Despite the challenge of austere budgets
for biomedical research, we remain committed to making a
transformative impact by maintaining a balanced portfolio
to reflect the strategic goals of the NHLBI, which include
promoting the understanding of human health and disease,
translating basic research into preventative and therapeutic
interventions, and developing a biomedical workforce with the
requisite set of skills for advancing HLBS research. There also
exists the challenge of maintaining a balance between achieving
these goals and encouraging creativity. These challenges converge
to significantly impact on our decisions and approaches for
tackling health inequities at home or abroad to advance the
unfinished business of maximising the public health impact.
In the focus on addressing health inequities, we often fail to
recognise the extraordinary resilience and resourcefulness of
people working to improve health in high-risk communities.
As we work collectively to overcome the challenge of reducing
global health inequities, we should recall the admonition of
Theodore Roosevelt: ‘Do what you can, with what you have,
where you are’. This is an opportune moment in history to
tap in to the resilience and resourcefulness of this ‘beloved’
global community in order to create a collective future in which
population health systems serve to promote the health of the
entire human family, and we bend the curves of health inequities
at the domestic and global level.
The optimum approach for addressing this question is to
catalyse systems science, which will entail the employment
of community health knowledge networks; a diverse pool of
cross-disciplinary investigators; and leveraging NHLBI study
platforms such as health systems clinical or population-based
cohorts to optimise the prediction, pre-emption and treatment
of HBLS conditions using new tools and platforms. Herein,
outstanding possibilities attend the confluence of advances
in genomics research and technology, imaging, informatics,
computational modelling, stem cell research, nanotechnology
and bioengineering, and collaborative knowledge-intervention
networks. These new tools and platforms provide impetus for us
to consider transformative questions.
What if we could develop new paradigms for citizen-enabled
community health and next-generation cardiovascular disease