The political power of heart doctors: with the European Heart Health Charter towards a European policy on cardiovascular disease

The emergence of the European Society of Cardiology (ESC) in the health policy field is relatively recent. Although this organization took the initiative to create Joint European Guidelines for cardiovascular prevention already in 1994, it was not until 2002 that the ESC Board decided ‘to launch a common strategy for member states to reduce cardiovascular deaths by 40%’. This would not be possible without creating alliances to get political support. By tradition, doctors have been very successful in understanding mechanisms behind and treatment of established disease. However, although forfeited by some enthusiasts, a coordinated investment in the preservation of health has been limited. However, doctors are able to provide valuable knowledge on epidemiology and preventive measures that is not available elsewhere. Their knowledge, if shared with the right people, those who make decisions on the society we live in, will help make the right choices to improve their mission to prevent diseases and to save lives. This statement summarizes in a few words the shift that the ESC undertook since the beginning of the millennium, from a purely scientific and medical society to an organization fully involved in the public health policy-making process. There are several reasons behind this evolution, or perhaps revolution. One of them is that it is not always clear whether organizations such as the ESC should and are entitled to enter policy-making discussions. Experts in political sciences, and in particular civil society, can question the role of the ESC as part of the civil society [1–3]. One concept, however, on which they all agree, is the participative democracy triangle (Fig. 1), where the ESC can claim a role in the expertise angle, and as an opinion leader. After the controversy over the Santer Commission, which was forced to resign following the European Parliament's suspicions of budget mismanagement in March 1999, the European Institutions strove to make their decision-making processes more transparent. The European Commission published a White Paper on European Governance in 2000, which includes professional organizations in the definition it gives of civil society, along with workers unions, nongovernmental organizations and religious communities. That same year, the European Economic and Social Committee, an institution whose role is to be ‘a bridge between Europe and organized civil society’ adopted a series of criteria to define the notion of representativeness and legitimacy in civil society [4] (Table 1). The ESC clearly qualifies for every single one of them. There is no obstacle, in this context, for a professional organization such as the ESC to try to share their opinion and present their expertise in a way which will help policymakers understand the challenges of cardiology in general, and cardiovascular prevention in particular, so as to make the best possible decisions. The late emergence of the ESC in the European public health policy-making process is not only related to the recent awareness of a new role to play. Simply, public health is a new competence for the European Union [5]. It was only in 1992, with the Maastricht Treaty [6], that the stage was set for a European public health agenda, with article 129 giving provisions on public health and prevention of diseases. This role was reinforced by the Amsterdam Treaty [7] in 1997, article 152 of which stipulates that ‘a high level of human health protection shall be ensured in the definition and implementation of all community policies and activities’. European institutions have had to adapt accordingly. Originally, public health was under the remit of the European Commission's then Directorate General (DG) Employment, Industrial Relations and Social Affairs. An important improvement was the institution in 1999 of a single DG (DG SANCO from the French ‘Santé’, health and ‘consommateurs’, consumers) dedicated to public health, along with consumer issues [8]. The framework was then in place for a relationship to be established between the ESC and European policy makers. The participative democracy triangle. Representativeness criteria, as adopted by the European Economic and Social Committee (2001/C 193/21) Representativeness criteria, as adopted by the European Economic and Social Committee (2001/C 193/21) On the one hand, European cardiologists had given themselves the mission to ‘reduce the burden of cardiovascular disease in Europe’ and established that almost half of cardiovascular disease is preventable by adjustments in lifestyle, whether by adopting healthier diets, quitting smoking, or doing exercise. However, cardiologists cannot act alone with the European population. On the other hand, policymakers were all too conscious that more than half of the healthcare budget is spent on preventable diseases; the cost of heart disease alone represents 1% of European GDP. This turned out to be a good fit! The work in partnership with the European Commission officials, Ministries of Health at member state level on the occasions of their EU presidencies and Members of the European Parliament soon resulted in practical achievements that contributed to an increasingly important role for cardiovascular health on the European political agenda. The years 2000 and 2002 were marked by raising the awareness that cardiovascular disease was the biggest health threat in Europe, however, so far not fully acknowledged by the political community but in the need to be addressed. This was initiated by the European Heart Network (EHN) launching the Saint Valentine's declaration on 14 February 2000: ‘Every child born in the new millennium has the right to live until the age of at least 65 without suffering from avoidable cardiovascular disease’. Soon thereafter, a declaration from Spain, then presiding the European Union, on the initiative of the ESC, called for action from member states and the European Commission to tackle cardiovascular diseases. A series of partnerships with presidencies of the European Union, starting with Ireland in 2004 and including Luxembourg, Austria and Portugal helped maintain the momentum, as policymakers had to focus on cardiovascular health, with several conclusions of the European Council of Health ministries to promote heart health. The progress achieved over these years was crowned by the adoption, in the European Parliament in 2007, of a resolution on action to tackle cardiovascular disease [9]. It was in the year 2007 when the European Heart Health Charter [10] was officially launched in the European Parliament, chosen for its symbolic significance of the power of the European people. The Charter, an initiative of the ESC and the EHN, was created in partnership with the European Commission and WHO – Regional office for Europe. It was developed to meet the expectations of stakeholders, whether from the Ministries of Health, Heart Foundations or National Societies of Cardiology, who all in the 2005 Luxembourg declaration had expressed the strong need for a simple manifesto that they could all adhere to and contribute to in concertation. The text was adopted in July 2007 and signed by 14 professional organizations or nongovernmental organizations involved in the promotion of public health. European partners behind the Charter urged member states to adopt and implement it. Today, only 2 years later, the Charter has been translated into 23 languages and adopted by 30 countries across Europe. The success of the Charter clearly shows the political power of heart doctors when it comes to soliciting a clear commitment from health authorities towards a heart healthy environment. An important key to the success of the ESC is its alliance with other organizations strongly involved in promoting the understanding of cardiovascular diseases and cardiovascular disease prevention. This dates back to 1994 when a Joint Prevention Committee was formed by invitation of the ESC. The members are depicted in Table 2. This multisociety partnership has overseen the creation, dissemination and frequent updates of joint management guidelines in the field of cardiovascular prevention and followed their implementation through regular surveys, the European Action on Secondary And Primary Prevention by Intervention to Reduce Events (EUROASPIRE) programme. Another success factor is the mobilization of the medical community that the ESC and the EHN were able to accomplish through their member organizations at national levels. Across 30 countries in a wide Europe, the cardiology community mobilized itself to show local authorities the benefits of adopting the Charter. They urged policymakers, not only from the departments of health but also from other portfolios such as education and research, which were often involved in the official launches of the Charter, to create environments favourable to a heart-healthy population, whether it comes from making fruit and vegetables affordable and easily available or to building cycling lanes, promoting the use of risk assessment tools to primary care physicians, etc. The combined power of the ESC and EHN lies not only in providing adequate scientific information but also in federating its whole community around a single project aimed at changing policies in Europe, for better promotion of cardiovascular health. Finally, the success of the Charter, and its adoption by such a large number of European countries, was made possible, to some extent, through the EuroHeart project; EuroHeart is a 3-year project co-funded by the European Commission's Public Health Programme and led by the ESC and EHN, with the primary objective to determine areas of policies and public health interventions which can contribute to preventing avoidable deaths and disability across Europe. Within EuroHeart's Work Package 4, 18 countries have received support to have the European Heart Health Charter launched and adopted locally. Members of the Joint Prevention Committee Members of the Joint Prevention Committee The overwhelming adhesion of European countries to the Charter reveals that at a national level, there is a strong need for guidance from European Institutions to identify the health challenges of tomorrow and to guide them towards the best ways to tackle this in an effective manner. The ESC has now taken full measure of its responsibility and the role it can play to make sure that cardiovascular diseases are properly addressed by European institutions, by making it a priority within health programmes and legislation.