Rheumatic heart disease in developing countries.

439 O 30 or 40 years ago, rheumatic fever was a common topic in the Journal. A PubMed search for articles on rheumatic fever published between 1967 and 1976 returned 55 New England Journal of Medicine articles — fewer than for endocarditis (77) but more than for stroke and syphilis (24 entries each). A similar PubMed search for the decade 1997 through 2006 yielded just eight entries for rheumatic fever. This trend holds for all Medlineindexed journals: an average of 516 articles on rheumatic fever per year from 1967 through 1976, but only 172 per year from 1997 through 2006. Most observers would probably consider this decrease to be a reasonable reflection of the waning incidence of the disease. After all, in the mid20th century, children with rheumatic fever occupied many of the beds in pediatric wards in industrialized countries — indeed, entire hospitals were dedicated to the treatment of, and rehabilitation from, rheumatic fever. But in the latter half of the 20th century, rheumatic fever receded as an important health problem in almost all wealthy countries. Today, most physicians in these countries are unlikely ever to see a case of acute rheumatic fever, and their experience with rheumatic heart disease will be limited to heart-valve lesions in older patients who had rheumatic fever in their youth. The reality, however, is that the decrease in publications reflects only the waning burden of disease among the less than 20% of the world’s population living in highincome countries. For everyone else, rheumatic fever and rheumatic heart disease are bigger problems than ever. It was estimated recently that worldwide 15.6 million people have rheumatic heart disease and that there are 470,000 new cases of rheumatic fever and 233,000 deaths attributable to rheumatic fever or rheumatic heart disease each year.1 These are conservative estimates — the actual figures are likely to be substantially higher. Almost all these cases and deaths occur in developing countries. How did rheumatic fever become rare in wealthy countries? Medical science can take some of the credit, thanks largely to the use of penicillin for primary prevention, but most of the reduction is attributable to improved living conditions, which have resulted in less overcrowding and better hygiene, with consequent reductions in transmission of group A streptococci. In other words, rheumatic fever is a disease of poverty. That it is in many ways the epitome of diseases of poverty and social injustice is exemplified by the situations in Australia and New Zealand. In these countries, which boast living standards that are among the best in the world, there are indigenous populations, Rheumatic Heart Disease in Developing Countries