Editorial
Tackling the burden of stroke with primordial prevention
Worldwide, stroke is the second leading cause of death
and the third leading cause of death and disability
com­ bined, which makes World Stroke Day 2022
(Oct 29) a crucial opportunity to call on global, regional,
and national decision makers to act on risk factors,
primary and secondary prevention, treatment, and
rehabilitation. However, to have a tenable effect on the
future burden of stroke, public health campaigns also
need to focus on an even earlier stage—ie, primordial
prevention. In The Lancet Neurology Anniversary Lecture,
Carol Brayne states that, for brain health, targeting
individual-level interventions “ignores the magnitude of
influence that commercial influences, social environment,
and material circumstances have on options, oppor­
tunities, and behaviours”. Addressing the social and
com­mer­cial determinants of neurological health is an
essential component for tackling the burden of stroke
that should not be overlooked.
A strategy encompassing primordial prevention intends
to stop risk factors for disease developing at all, whereas
with primary prevention the goal is to modify existing
risk factors to prevent development of disease. Thus,
primordial prevention aims to change “the sociocultural
conditions that lead to risk factor development”.
Examples of sociocultural conditions that should be
changed as part of a primordial prevention approach
to stroke include those that tackle pollution, unhealthy
diets, and lack of physical activity. Interventions to change
these factors—eg, through regulation of food prices or
development of healthy environments that promote
exer­ cise—will require commitments from national
governments and international organisations.
In Europe, initiating government action on stroke is the
focus of the European Stroke Action Plan (SAP-E), which
is a collaboration between the Stroke Alliance for Europe
and the European Stroke Organisation. One of four key
targets of the SAP-E encompasses both primordial and
primary prevention. The target is to implement national
strategies for “public health interventions promoting
and facilitating a healthy lifestyle, and reducing
environmental, socioeconomic, and educational factors
that increase the risk of stroke”. However, even though
the SAP-E was established in 2018, scant progress has
been made on this target in most European countries,
where implementing basic stroke care remains a primary
www.thelancet.com/neurology Vol 21 December 2022 1061
focus. Another of the four targets of the SAP-E intends
to provide a clear road map for governments to produce
national plans for stroke, which will establish a pathway
from primary prevention through to rehabilitation and
life after stroke. National coordinators are working to
Jim West/Science Photo Library
formulate the stroke plans by 2030, but this work has
become challenging since the beginning of the COVID-19
pandemic in 2020, because non-communicable diseases
have fallen down the list of political priorities.
Support to set up national stroke plans in Europe should See Anniversary Lecture
page 1151
now be garnered from the European Commission (EC)
For Global Burden of Disease
and its Healthier Together initiative, which was launched 2019 data see Articles
in December 2021. Over the 5-year period from 2022 to Lancet Neurol 2021; 20: 795–820
For more on global primary
2027, Healthier Together aims to support countries in
stroke prevention see
the European Union to identify and implement policies Health Policy
Lancet Public Health 2022;
to reduce the burden of major non-communicable 7: e74–85
disorders. The initiative includes five strands, of which For more on primordial
mental health and neurological disorders is one, prevention see Series Lancet
2018; 392: 1269–78
and within this strand is an initiative to support the
For more on the SAP-E see
reduction of health inequalities. At a meeting held on Editorial Lancet Neurol 2020;
Oct 5, the EC Directorate-General for Health and Food 19: 963
For more on Healthier Together
Safety announced that the strand of mental health and see https://health.ec.europa.eu/
neurological disorders will receive funding proposals in non-communicable-diseases/
healthier-together-eu-non-
2023–24. European governments can use this funding communicable-diseases-
to take action on stroke, as a key cause of disease burden initiative_en
in the European population, and primordial prevention For more on the implications of
public health policies see
should be included in this process. https://www.fph.org.uk/
Political interventions to change the sociocultural media/1972/fph-
nannystatedebate-report-final.
conditions that establish risk factors for stroke—eg, by pdf
increasing taxes on tobacco, limiting traffic in urban For more on WHO European
Healthy Cities see https://www.
areas, or modifying foods to lower salt content— who.int/europe/groups/who-
might be perceived as unacceptable curtailments of european-healthy-cities-
network/about
personal freedoms. Yet, these interventions also target
overall population health, reduce health inequalities,
and include vulnerable and disadvantaged groups.
These sorts of intervention have been successfully
implemented. For example, in India, indoor air pollution
has been substantially reduced by a government policy
to subsidise cooking gas. Moreover, global tobacco
control, and WHO’s Healthy Cities project in Europe,
are key prevention initiatives that have become widely
adopted. But more primordial prevention strategies are
needed, and safeguarding the neurological health of
the population should be among the highest priorities.
■ The Lancet Neurology