Dr. David MacLean can see his work in nightmarish terms: he is on a boat going down a river. Suddenly he sees people overboard, begging to be saved. Faster than he can pull them to safety, more people along the shore tumble into the dangerous current. The boat soon is surrounded by outstretched hands and faces pleading for rescue.

This growing cry for help is what faces health care professionals all over the world, says MacLean, director of Heart Health Nova Scotia. The situation, he adds, is unlikely to change until we find out why people get sick and what can be done to keep them healthy. "We have to go upriver and find out why they're falling in in the first place. That's prevention."

And prevention is what Heart Health Nova Scotia is all about. As its director, MacLean's job is to beat back the high wave of heart disease in the province and teach people to steer clear of the undertow.

A New Direction

One of the smallest of Canada's 10 provinces, Nova Scotia nonetheless has one of the country's highest rates of cardiovascular disease. Nationally, the male death rate in 1996 was 319 per 100,000. In Nova Scotia that figure was 365 per 100,000. For women the numbers were 185 and 199, respectively. A survey conducted in 1986 by MacLean prior to the launch of the Heart Health program revealed that more than two-thirds of Nova Scotians had one or more modifiable risk factors for heart disease. These include: high blood pressure, high blood cholesterol, regular cigarette smoking, overweight, and sedentary lifestyle.

Heart Health Nova Scotia began in 1989 as a five-year demonstration project to help Nova Scotians reduce their risk of cardiovascular disease--Canada's leading cause of death and disability--and make healthier choices for themselves and their families. The program, the only one of its kind in Canada, has proven so successful it's been extended for another five years.

The key to the success of Heart Health Nova Scotia is twofold, says MacLean. First, the program is down to earth, developing practical activities and projects that people can easily incorporate into their busy lives. Second, the program does not operate in isolation from the people. By involving them in the planning and design of solutions, it provides them with a sense of "ownership" and is clearly community based. "Quite simply," says program coordinator Jane Farquharson with a smile, "we're user-friendly."

A 1995 survey was conducted by the program in partnership with the Nova Scotia Department of Public Health. It surveyed 3,227 men and women age 18 and over, and found that some improvements had occurred: the rate of high blood pressure dropped from 26% to 22% in the last decade; more than half the population now has a cholesterol count within the healthy range; the percentage of sedentary people dropped; and fewer people age 18-34 now smoke. More people are free of risk factors and fewer have two major risk factors. However, upwards of 70% of Nova Scotian adults continue to have at least one risk factor for heart disease.

Changing patterns of behavior is complex. It also takes time. Yet Heart Health's philosophy is that cardiovascular health is of such vital importance to overall good health that by targeting this area, other important health gains can be scored in Nova Scotia.

Heart Health encourages the creation of partnerships and coalitions among community groups, schools, industry, local health care professionals, and others to promote healthy lifestyle changes that will be long lasting. At the outset the research team focused on five areas: public education, professional education, food for health, working with heart, and community action for heart health inequities.

Educating Ourselves

The Heart Health team worked closely with a number of urban and rural communities to determine the health concerns of local residents. Then they joined forces to put programs in place that would respond to those concerns and help forge a community spirit of awareness. "The most efficient way to help people stay healthy is to teach them skills they can use in their own life after the project is gone," explains Farquharson. In Hants Shore, for example, residents came together to discuss their eating and exercise patterns--then they did something healthy about both.

Project coordinator Susan Sanford first spoke with 120 of the community residents to help them identify their needs. One need was for regular exercise. The small rural community of 3,000, about a 90-minute drive from Halifax, Nova Scotia's capital city, is fairly isolated. There are no workout gyms or jogging tracks. But now, thanks to donations from local landowners and the hard work of many volunteers, there are walking trails that meander up hills, hug the shore of the Atlantic Ocean, and dip into scenic wooded areas.

In addition, the women of Hants Shore came together over a hot cup of tea to chat about nutrition. Gathered in large groups around the kitchen table, they shared with one another how they shop for food, what they eat, and how they might make family meal patterns more wholesome. Another group of mothers and their small children also met in Sanford's kitchen to learn how to prepare heart-healthy meals. The guiding thought during this klatch was that the best way to be a healthy adult is to start out as a healthy child.

Key to the success of the Hants Shore activities was the high level of active citizen involvement and participation in every aspect of the Heart Health model. "The community approach enables everyone to work together and support one another," says Elinor Sanford, a local resident who hosted one of the kitchen chat groups.

Professional Education

The community approach was also central to a program put in place in three Nova Scotia centers. Physicians, public health nurses, pharmacists, dieticians, social workers, health educators, and fitness and recreation specialists were brought together to discuss specific heart-related cases. While these cases helped participants zero in on risk factors, they also helped them to think about the larger social context in which all health-related decisions are made. There is no point in saying, for example, that a patient must eat healthier if the patient cannot afford to buy fresh fruit and vegetables.

"These are the issues that health care professionals, governments, policy planners, and others are wrestling with. We provide some insight into the road ahead," says MacLean.

He adds that while it may seem natural for health professionals to meet and discuss mutual issues of concern, multidisciplinary case-based learning is actually still quite rare.

Food for Thought

The simple truth is, those who do not maintain a healthy, low-fat diet increase their risk of cardiovascular disease over time. What is not so simple is making intelligent choices off the supermarket shelf. Nutritional labeling has become a hot political issue in recent years. It has also piqued consumer interest in what exactly constitutes a "healthy" food product. Trying to decipher which ingredients and measurements are important sometimes requires a Ph.D. in nutrition, says MacLean.

Or an innovative program from Heart Health Nova Scotia.

Shopping for Health is a retail point-of-purchase program that ran in three grocery stores--two in Halifax, and one in Truro, an hour's drive to the north--over a 10-week period. Targeting women between the ages 25-39, the stores' management and staff received special training to help customers make informed choices. Taste-testing demonstrations were held onsite, where research shows 80% of all food choices are made. Information kiosks were set up to provide relevant, easy-to-read information on such topics as lower-fat and nutritionally balanced cooking, fat and fiber, and recipe suggestions. A toll-free telephone line was created so that customers and supermarket staff could call in nutrition questions to a licensed dietician. Grocery store tours enabled participants to request on-the-spot help in meal planning and in understanding the contents labeling.

Barbara Ryan, owner of Ryan's IGA Supermarket in Truro, enthusiastically threw her support behind the program. She continues to promote good nutrition in her store and among her customers: "It's the most logical place."

Working with Heart

Another logical place to incorporate promotion of a healthy heart is the workplace. Most people spend eight hours or more a day on the job, often eating at least one, if not two, meals there. Busy schedules often necessitate squeezing in time at the exercise gym either on the way to or from work, or during the lunch hour. The Heart Health team knew that if they were to increase awareness and knowledge about heart disease in the workplace, they would need a business partner. One such partner was Sears Canada, Inc., a large department store chain with branches throughout the country.

The first step in Sears' worksite program was called Heart Check, and it involved conducting a series of tests and evaluations on each employee to assess his or her overall health. Occupation health nurse Janet Radford then met individually with workers to discuss test results and provide them with tailor-made information about steps they could take to reduce their risk of heart disease. For many employees, one of those steps was regular exercise. But as Farquharson points out, it isn't easy for people, especially single parents with small children, to find the time or the place to exercise.

Sears provided both. As a result of the Heart Check exercise--and the high interest level of employees--the company set up an exercise room where employees could come to give their heart a good workout, tone up loose muscles, and generally feel better about themselves. "It's not enough to give knowledge and skills. You must change the norms and values of society," stresses Radford. That includes offering a work environment that encourages the adoption of healthier lifestyles.

Nutrition NOW

Individual change through community support has also been an integral part of the NOW project, launched in Glace Bay, Nova Scotia. NOW, which stands for Nutrition Outreach Worker Project, seeks to address the special challenges people of low income face in achieving and maintaining a healthy, high-nutrition lifestyle. Working through trained peer nutrition counselors, residents were motivated to become involved in activities that would lead them upriver toward cardiovascular health. Among these activities were two community health fairs, a support group for heart attack survivors, a school breakfast program, and the creation of a community newsletter.

Just the Beginning

Heart Health Nova Scotia is moving full steam ahead to make healthy choices the easier choice for Nova Scotians like those in Glace Bay. Local health experts agree that too many Nova Scotians still smoke, are overweight, inactive, and have many of the other risk factors favoring the development of chronic diseases like cardiovascular disease, cancer, diabetes, and chronic lung disease. Yet they are optimistic.

"Heart disease is the entry point into the community," says MacLean, "but it is part of a broader concept of chronic disease. We're not a single-disease entity. Our ultimate goal is to empower people to look after their overall health."

A secondary goal is to encourage the replication of the Heart Health spirit and its guiding principles into a variety of contexts around the world. "What is being done here is translatable to other communities," says MacLean. "It has to be."

Otherwise we will never get upriver.

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Donalee Moulton and Allan Kindervater are a freelance writer-photographer team based in Halifax, Nova Scotia, Canada.