ONE COMPROMISED LEADERSHIP
Author: Chudomir Merdjanov
This work constitutes the concluding part of a full-length monograph on non-communicable disease prevention in Bulgaria. The project CINDI and its failure in the countries of Eastern Europe was already commented in a previous book from the same author — viz., "Merdjanov, Ch. Non-communicable Diseases and Smoking. Sofia, 1988".
Given the non-conformity status of epidemiology and allied health sciences in the former Communist Bloc, further evaluation of behavioral health interventions and their application in health policy seemed obsolete. WHO stopped the financing for CINDI and the capital resources were referred to the "Health for All" branch of the programme.
In this case, data collected for Bulgaria remained unreferenced and a large sample of 711 000 questionnaires were lost to follow-up. The work of Ch. Merdjanov is unauthorized, but done altogether on this particular information set.
The value of literature sources cited in the book — more than 1000 references in Cyrillic and Latin — are concomitant with scientific truth in the field of prevention and particularly with Multiple Risk Factor Intervention Trial (MRFIT).
However, health policy measures with respect to particular interventions are unheeded for the case of Bulgaria. We do not recommend this study for international comparisons and even because of the mere fact that its results are difficult to translate in meaningful English language.
This study comes to refute the paradigm that research is anything else than a community effort of self-bound participants or contributors, ditto.
NON-COMMUNICABLE DISEASE IN BULGARIA AND SMOKING
Non-communicable disease /i.e., cardiovascular, cancers, diabetes, etc./ have gained momentum in the field of epidemiology and in a comparatively short historical period - say, from about the 50s of the past century - have almost totally obliterated the burden of health and disease in human populations. Among the major risk factors of death in a modern society, smoking and tobacco consumption stands on a high level with other major preventable life-style habits - such as, alcohol consumption, occupational activity, habitual stress, etc. Scientifically proven is the fact, undoubtedly, that smoking is contributing a largest share of undiluted attributable risk for community health. This leaves many undecided opportunities for politicians and community leaders, per se.
Let us make the long story short and proceed for the case in Bulgaria. We have already referred to another monograph in our booklist, where some data on CINDI program in this country have been communicated - cf., Ivanov, L. Prophylaxis of Non-communicable Diseases. Sofia: Medicina i Fizkultura, 1988. Problematically, this study remained unreferenced in the international literature and I would like to say few words about it.
Originally, CINDI collaboration was conceived in 1984 and Bulgaria was an official member of the participant group. The principal investigators from the bulgarian side, however, developed a conflict with the political authorities of the Medical Academy - viz., at that time a singular decision-maker in that country. As a matter of fact, investigators couldn't fulfill criteria for inclusion in the study by the WHO collaborative committee. This resulted in for several consequences and for reasons of both internal and external validity problems. Firstly, a bulgarian survey questionnaire was designed by a national model, covering the requirements of the national census survey of year 1986. Secondly, a WHO questionnaire was ignored by the bulgarian health authorities and personally from Acad. Atanas Maleev /i.e., the latter being undisputed leader for a long period of time, since and because of his personal relative kinship with the country's Premier Todor Zhivkov/.
As a matter of fact, a survey was held privately with a design related to the national census criteria. A questionnaire was printed on the premises of the National Statistical Institute /NSI/ and distributed at a little added cost value among a sample of four regions in the country. We have already mentioned this and shouldn't reiterate more technical details. Further data can be obtained from the census manuals with particular reference point in year 1986. Albeit, the author of this lines have seen those 711 000 questionnaires de vizu and has been acquainted with the principal investigators on a friendly basis. One of them /i.e., Ass. Prof. Pencho Balabanov was diseased and died in 1997. The other one and author of this particular monograph /i.e., Prof. Chudomir Merdjanov from the non-communicable disease branch of the survey/ has been retired from work, however, a full length monograph on the findings of the unreferenced CINDI study in Bulgaria was written as unauthorized monograph.
This is so far a preliminary note on the history of non-communicable disease /NCD/ in this country. We proceed with some short review on the findings of the smoking substrata of the survey - namely, 586 852 persons (263 786 male + 323 066 female from 15 to 69 years of age). Smoking status is acknowledged as: 1) non-smokers; 2) former smokers and now quitted; 3) active smokers in three categories - namely, from 1 to 10 cigarettes daily, from 11 to 20 cigarettes daily and 20 + cigarettes daily. The book contains a lengthy appendix, where additional data is presented on time trends, absolute numbers of study population in cross-tables, occupational status in 14 categories according a social registry, regression modeling with quadratic and cubic terms on predicting risk, etc. Altogether, this is an interesting survey and even from the viewpoint of an disengaged scientific reading. My notion is, that even today some 20 years later, this study has remained a paragon for bulgarian epidemiological literature. We refrain, however, from any international comparisons and generalizations.
Addendum: We have been dealing by now with some national connotations of the smoking problem. Strictly speaking, this subject has received special attention in the international literature. It is not only, because, smoking has acquired a status for the most dangerous "killer" of the 20th century epidemiology. An undisputed fact is that, since prevention requires a strong political agenda for concerted action at all community levels and smoking has been instrumental for modeling those preventive programs. Simultaneously, smoking as a risk factor has helped to develop a theory for chronic disease epidemiology itself and these are some first publications from U. S. Department of Health, Education and Welfare /USDHEW/ as reports of the Surgeon General. We wish to present those publications, starting from year 1964 and continuing up-to-now.
Copyright © 2008 by the author.