At the beginning of the 20th Century Cardiovascular Diseases (CVD) were responsible for less than 10 per cent of deaths world-wide. Today they account for 30 per cent of the total global mortality. The matter of serious concern is that 80 per cent of this mortality now takes place in the developing countries, and 70 per cent of this in South Asian region. According to World Health Organisation (WHO) in 2001, CVD was the No 1 cause of death world-wide and it remains so to this date. As the developing countries are trying to draw the benefits of socio-economic development they are becoming increasingly victim to an insidious by product of so called modernisation. While diseases related to unsafe water, poor sanitation, unprotected sex and malnutrition still abound the growing burden of diseases related to tobacco, hypertension, Diabetes, hypercholesterolaemia and obesity is posing a serious threat to the socio-economic progress. South Asia comprises of India, Pakistan, Bangladesh, Nepal, and Maldives. More than half of the population lives below the poverty line in this region. In Urban setting cause of death is extrapolated from Death certificates issued by the Hospitals, while in rural setting the surveys of cause of the death provide the necessary information. Limited epidemiological data also exists from various quarters in the region. The international agencies including WHO have a clear idea about the extent of the CV Disease burden in South Asia. Studies conducted on South Asian migrants in the West show that they have higher CV mortality as compared to the reference native population. In 2003 the prevalence of Coronary Heart Disease (CHD) in India was 3-4% in rural areas and 8-10% in urban areas. This amount to 29.8 million affected (14.1 in rural & 15.7 million in urban areas). This is an population based cross sectional studies which is comparable to 31.8 million affected derived from extrapolation of the global burden of disease study. These numbers are likely to be underestimated, as they do not account for those with silent Myocardial Infarction or symptomatic CHD. Deaths from CHD in India rose from 1.17 million in 1990 to 1.59 million in 2000 and are expected to rise to 2.03 million by 2010. CVD accounted for 7% deaths in Nepal & 40% in Maldives in 1998. The National Health Survey of Pakistan (1990-94) has revealed that circulatory diseases account for 12% of the total mortality with over 100,000 deaths annually. In addition to the high rate of CHD mortality the other alarming features is the younger age of the individuals falling victim to the CHD in South Asia. As a result our region suffers from a tremendous loss of productive working years due to CV deaths. An estimated 9.2 million productive years lost in India alone in 2000. This will increase to 17.9 million productive working years by 2030. Currently mortality morbidity and disability related to major non-communicable disease (Hypertension, Diabetes Mellitus, Hyperlipidemia, Obesity & Smoking) account for 60% of all deaths & 47% of the global burden of the disease. It is projected that 89 million will die of CV disease in our region in the next ten years. 60 millions such deaths are likely to take place in India alone. The major contributors to this mortality and morbidity are: 1. HYPERTENSION: Hypertension is the commonest chronic disease in South Asia. Globally 20% population is affected. Hypertension is prevalent 20-40% among urban and 12-17% among rural adults. Similarly, the 1990-1994 National Health Survey of Pakistan revealed that one third of the Pakistani population over the age of 45 years had hypertension and 18% of the subjects over the age of 15 fall into Hypertensive range. There are an estimated 14 million Hypertensives in Pakistan. Hypertension is especially common in urban obese females. Similar trends are found in Bangladesh. 2. DIABETES MELLITUS: The prevalence of diabetes and its adverse health effects has risen more rapidly in South Asia than in any other region of the world. India has a higher number of people with diabetes than any other country, with estimates ranging from 19.4 million in 1995 to 32.7 million in 2000. In Bangladesh, the prevalence of diabetes in urban areas is double that in rural areas (8% v 4%). The International Diabetes Federation (IDF) gives an estimate of 12% prevalence in Pakistan, with a total of 8.8 million people with diabetes in 2002. In Sri Lanka the 1999 census report records diabetes prevalence as 8% in rural areas and 12% in urban areas; equivalent current rates for Nepal have been reported as 3% and 15% respectively. Projections for 2020, based on modelled estimates by WHO, shows a marked escalation of diabetes related burden in South Asia. The number of people with diabetes is expected to rise by 195% in India during 1995-2025 to reach 57.2 million in 2025. Pakistan is expected to have about 14.5 million people with diabetes by that year, becoming the 5th largest Diabetic nation of the world. 3. DYSLIPIDAEMIA: The relationship of Hypercholestrolaemia with the incidence of CHD is well established. The south Indian population suffers from what is best called Dyslipidaemia. The distinctive Dyslipidaemic pattern of reduced concentrations of high-density lipoprotein (HDL) cholesterol and high concentrations of triglycerides characterise the metabolic profile, and abdominal obesity characterises the phenotype of the urban adult in South Asia. The low levels of HDL cholesterol result in dangerously high ratios of total cholesterol to HDL cholesterol, even at concentrations of total cholesterol that would be considered acceptable in Western populations. That total to HDL cholesterol ratios of 4.5 exist in 73% of urban men and 54% of urban women and in 52% of both rural men and rural women; these men and women have total cholesterol values in the range of 4.7 mmol/1 to 5.2mmol/1. 4. CIGARETTE SMOKING: In 2002, a national survey of tobacco use reported that the Indian subcontinent, second only to China in both the production and consumption of tobacco products, had an alarming rate of current tobacco use of 56 per cent among Indian men ages 12-60 yr. In a survey of sixth and eighth graders attending school the prevalence of tobacco use (any history of use or current use) was 2-3 times higher among sixth graders compared with eighth graders, suggesting a concerning new wave of smoking among India's youth that forebodes serious future public health consequences for the Indian subcontinent. Similar trends are present in Pakistan & Bangladesh. Unfortunately the poor & the young are especially vulnerable to this menace. 5. PHYSICAL ACTIVITY: A recent hospital based cases control study from two urban centres in India suggested that daily moderate intensity physical activity (e.g., the equivalent of brisk walking 35-40 min per day) is associated with a 55 per cent lower risk for CHD. It has been seen that the prevalence of leisure time physical activity was substantially lower among South Asians (6.1% of control arm patients) compared with the rest of the world (21.6%). Cultural norms, such as the perceived impropriety of women's engaging in leisure time physical-activity especially in Muslim communities may be in part responsible for these low rates of physical activity. Most of these countries lack parks, open spaces & grounds in their urban settlements. Unfortunately whatever such facilities existed during the period of British Raj have not seen any expansion despite enormous rise in population. On the contrary there are examples that existing parks have been replaced with residential blocks. 6. CHRONIC KIDNEY DISEASE: Concomitant with the rise in the prevalence of diabetes and hypertension is an increase in the prevalence of chronic kidney disease, also recognised as an independent risk factor for CHD. A study from Pakistan reported a prevalence of 15-20 per cent of impaired Kidney function among people of 40 years of age or older. Data from India suggest a prevalence of chronic kidney disease of 0.8-1.4 per cent in urban areas. These are likely to be significant underestimate given the absence of registry in India and low rates of screening for chronic kidney disease in this region. To summarise, the exact data as compared to the West is not available in South Asia and therefore precise magnitude of the problems cannot be estimated but the available evidence suggest that the burden of CVD is rising. The health burdens of non-communicable diseases are high in South Asia, though there are differences among countries and within urban and rural communities of each country, depending on the level of developmental and epidemiological transition. Many of these disease burdens occur in the productive life period and will, therefore, adversely affect workforce productivity and economic development. The main obstacles to deal with this challenge include illiteracy, extreme poverty, lack of political will, myths, taboos and the widening gap between the rich and the poor. Unless revolutionary steps are taken at various levels the tide against this epidemic cannot be turned. Writer is the President Pakistan Hypertension League.