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Equally troubling, it is not just the elderly who are being hit by cardiovascular disease. In India, nearly 50% of CVD-related deaths occur below the age of 70, compared with just 22% in the West. That trend is particularly alarming because of its potential impact on one of the region's fastest-growing economies. In 2000, for example, the country lost more than five times as many years of economically productive life to CVD than did the U.S., where most of those killed by heart disease are above retirement age. "That's why the impact heart disease will have on India down the road is going to be much greater than in America," predicts Dr. Uday Saxena, chief scientific officer of a leading Indian pharmaceutical company, Dr. Reddy's Laboratories. "It'll have huge economic consequences."
The unusual susceptibility of South Asians to heart disease can be traced to lifestyle issues, diet, rapid urbanization and possible underlying genetic causes. Dr. Naresh Trehan, executive director and chief surgeon of Escorts, says the common denominator is an increasingly sedentary lifestyle. "No matter what our diets were before, the physical demands on our life were high," says Trehan. "Now, the pendulum has swung in the opposite direction, and we refuse to do anything. If we Indians could drive to the bathroom, then we would do that. People simply refuse to move." And, just as happened decades ago in North America and Western Europe, India is undergoing a demographic shift in cardiovascular disease from the wealthy to the lower classes, thanks in part to the wider availability of rich food and the advent of mass transit. "Heart disease in this country has gone mainstream," says Professor K. Srinath Reddy, head of the cardiology department at the All India Institute of Medical Sciences.
Many scientists argue that changes in diet and exercise do not fully explain India's coronary calamity—that there must also be a genetic cause. "We Indians have genes that make us predisposed to heart disease," asserts Saxena of Dr. Reddy's Laboratories. Studies published in medical journals, including one in the Lancet in 2000, indicate that South Asians have elevated levels of artery-clogging blood chemicals, including LDL cholesterol and triglycerides, while also suffering from a deficiency in HDL cholesterol, which helps clear fatty buildups from blood vessels. In addition, South Asians tend to gain weight in the abdominal region; people who carry fat around their waists are at greater risk of heart disease, researchers say. There may be an environmental factor at work, too, according to Reddy. Indian babies are often born underweight, due to their mothers' poor diet during pregnancy. That "also predisposes Indians to increased risk of diabetes and heart attacks in adulthood," Reddy says.
Statistics alone suggest that South Asians seem more naturally vulnerable to heart disease than other ethnic groups—the 2000 Lancet study showed that, even after adjusting for all known risk factors, South Asians in Canada appeared to have a higher rate of heart disease than Europeans or Chinese living there. Some doctors think that this vulnerability can be explained by the "thrifty-gene" theory, which holds that South Asians adapted over many generations to the region's frequent famines. "People were eating half meals or a meal a day and there was not enough richness in the food, so the body adapted itself to get maximum mileage out of what it got," says Escorts' Trehan. Now that many South Asians are faced with a very recent overabundance of food, their bodies are having difficulty making a metabolic U-turn. The result is high insulin intolerance, with accompanying raised levels of diabetes and obesity. "The gene is still acting in the old way and conserving," Trehan says. "It may take a generation or two for the gene to adapt to the surplus food state."
But the thrifty-gene theory remains hypothetical, as Dr. Salim Yusuf of McMaster University in Canada points out, not least because the culprit gene itself has yet to be identified in our DNA. One of the world's foremost epidemiologists of cardiovascular disease, Yusuf once championed the idea that ethnicity was a significant determinant of heart disease, but his recent research has convinced him otherwise. "By and large, the differences in heart-disease rates are because of different lifestyles," he says. "About 80% of the risk can be accounted for by known risk factors like smoking or obesity or blood pressure and the way we live and eat, which leaves very little room for genetic risk factors." Even the common idea that family history is a decisive risk factor, Yusuf says, overlooks the fact that families tend to have similar lifestyles and are exposed to the same environment. Studies have shown that when Japanese emigrate from Japan, where their rates of heart disease are very low, and move to the West, those rates quickly rise to the Western norm. South Asians, moreover, are hardly alone in coping with centuries of famine, as the Chinese can attest. "It's not as if South Asians have more of a thrifty gene, and Chinese don't," says Yusuf. "Mankind's genes as a whole evolved across all ethnic groups similarly." He adds that his theory means no one is doomed by uncontrollable factors—and that it's feasible to protect yourself by modifying your lifestyle.
That's an overdue lesson for citizens of Asia's most populous country. In absolute numbers, China's total deaths due to cardiovascular disease, including stroke, have already caught up with America's. According to Dr. Gu Dongfeng, a top cardiologist at Beijing's Fu Wai Hospital, the force behind China's rising epidemic is a rash of unhealthy habits connected to the country's rapid economic development. "Ten years ago our hospital had four cars" assigned to it, he says. "That was it. Everyone rode bikes. You only need to look at our parking lot to understand what's happening." Indeed, the lot is so jammed with cars that it takes more than half an hour to enter the hospital's gates.
Americans may be among the fattest people on the planet, but mainlanders are losing their right to be smug. The incidence of overweight Chinese men and women rose 137% and 95%, respectively, from the early 1980s to the late 1990s, according to a survey conducted by a national task force. If this trend continues, by 2025 37% of men and 40% of women could be overweight. Most dangerous of all, however, is China's atrocious smoking rate, which hovers above 60% in men. Smoking is widely accepted as the No. 1 risk factor for heart disease. Nicotine raises blood pressure, damages blood vessels and multiplies the effect of cholesterol, worsening the fatty buildups that lead directly to heart attacks. "Just one cigarette can have a measurable effect on your artery walls," says Professor John Sanderson, head of cardiology at the Chinese University of Hong Kong.
Unless there are wholesale changes, Dr. Wan Feng will be a very busy man in the years ahead. One of China's leading heart surgeons and chairman of the department of cardiac surgery at Beijing's People's University, Wan is a pioneer in so-called "beating-heart" bypass surgery, a technique that allows doctors to operate on a patient's heart without shutting it down. (In normal bypass surgery, the patient is hooked up to a heart-lung machine.) Beating-heart surgery is less invasive and can reduce the risk of complications, including stroke, that can occur with bypass surgery. It also removes the need for expensive heart-lung machines and reduces costly follow-up care, making it an attractive approach for China's many financially strapped hospitals, which often lack the resources to diagnose and treat even standard medical problems.
After observing the procedure at a U.S. medical conference in 1996, Wan decided to try it back home in China. "The procedure would not only be cheaper, it would be easier to do," Wan recalls thinking. Short on equipment, he used a fork sheathed in rubber tubing to keep his first patient's heart still during the operation. The surgery was a success, prompting Wan to begin traveling around the country in his spare time, offering the procedure (minus the fork) on a private basis as a way to help reduce China's enormous shortfall in cardiac surgery. Wan estimates that the 70,000 open-heart surgeries performed every year in China represent just 1-2% of the total currently needed. The fees he receives for his traveling surgery exceed his regular salary of $362 a month, but Wan says his real motivation is to let people around China, not just those living in Beijing or Shanghai, "understand that they have options if they get sick." The surgeon laughs as he remembers a consultation he once did for a middle-aged engineer from the city of Shijiazhuang in Hebei province. "The man sent me a letter," Wan recalls. "He said, 'Can we really do bypass surgery in China? I've seen on television that Russia's President had a bypass operation, but do we really have that technology here?'"