MONICA'S quarter century

Following the seminal conference in Bethesda, USA in 1978 on the Decline in Coronary Heart Disease Mortality [1], organized by the National Heart, Lung and Blood Institute (NHLBI), the Cardiovascular Diseases Unit at the World Health Organization convened a series of meetings of medical researchers to plan a collaborative study of the mechanism of changing trends. These meetings resulted in the World Health Organization MONICA Project (derived from ‘Multinational MONItoring of Trends and Determinants in CArdiovascular disease’) [2]. Twenty-five years later, in late September 2003, the closing act of this global study, held at the World Health Organization Headquarters in Geneva, attended by some of its founding fathers, was the launch of an omnibus book, accounting for what MONICA had done in the interim. This MONICA Monograph and Multimedia Sourcebook [3] should appeal to everyone interested in cardiovascular diseases, in risk factors, in primary and secondary prevention and in public health and health policies. At its peak, in the decade from the middle 1980s to the mid-1990s MONICA encompassed 38 populations in 21 countries across four continents. MONICA requirements for cardiovascular disease, risk factor and medical-care monitoring were tedious and expensive, and placed participation beyond the reach of most developing countries: Africa and South America were not represented. But MONICA in the words of Dag Thelle ‘an outsider looking in’ in one of the prefaces to the Monograph ‘ignited vivid interest around the world, disseminating both the concepts and the disciplined practice of cardiovascular epidemiology’ [3]. As the book demonstrates, MONICA concentrated on basic disease, risk factor, and medical care measurements. It produced this elementary material to the highest possible quality standards, in the process making an unanswerable case for initiating local and national control and prevention policies in many countries, and challenging governments to improve the range and quality of routinely collected data [4–9]. These same data, through MONICA's careful standardization, were used collaboratively for sophisticated hypothesis testing [10–13], involving the development of new statistical techniques [14–16]. ‘Core’ MONICA population surveys of classic risk factors were often used to add on studies of ‘optional’ newer candidate factors, so that MONICA investigators figured in the study of both the new and the old. It is therefore no surprise that collaborative MONICA publications and those from individual centres appear in journals ranging from public health and health promotion, to clinical cardiology and stroke, and thence to prestige high-impact journals publishing biomedical discoveries. It is because MONICA publications are so scattered in time and place that the Monograph will be so valuable [3]. Richly illustrated in full colour, this book explains the background and history of the project, how it was organized and the rationale for all the procedures. Each population centre has a page in which the principal investigator describes how it contributed, what made it special, the local interests and publications. Abstracts of all the collaborative papers are reproduced and the final third of the book consists of 80 graphics of the MONICA collaborative results along with detailed explanatory notes. The Monograph describes how MONICA adopted the information technology revolution to complete its programme - the Monograph is no exception. Within it are two CD-ROMs, which make it a Multimedia Sourcebook. They contain the protocol and manuals for the study, the quality assessment reports on each subject area and the data books themselves, so that full MONICA findings are available to the reader and researcher. The graphics are made available again on the CD-ROM as downloadable slide presentations with a spoken commentary. Finally a 20% random subset of the MONICA database is reproduced for those wishing to carry out their own analyses. (The full database is currently accessible only to MONICA investigators and through the continuing MONICA Steering Committee). The book has been designed to attract a wide readership of anyone interested in heart disease, stroke, lifestyle and risk factors, public health policy, epidemiology and prevention, ranging from the general public to journalists, medical specialists, students and teachers. Generous sponsorship from a variety of sources has made it affordable as a potential student textbook. In the words of the Editor, Hugh Tunstall-Pedoe of the University of Dundee in Scotland, who was Rapporteur of the WHO MONICA Project and coordinated the 70 contributors: ‘See how, by sharing our objectives and standardizing our methods, we have been able to draw conclusions for the public good from the variety of experiences of our different populations. The Monograph illustrates the value of international collaboration in understanding and controlling chronic diseases and their causes, and in the dissemination of sound scientific methods. The success of the Monograph will be judged by how much it stimulates health workers and administrators in different countries to think like epidemiologists - on a world scale - and to collaborate in tackling other similar challenges to world health' [3].

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