Hypertension in Sub-Saharan Africa: What Physicians Can Do!

M'Buyamba-Kabangu et al.1 have provided American Journal of Hypertension readers with a compelling snapshot of how hypertension impacts health and health care in sub-Saharan Africa. Their story contains the scientific documentation that is essential if there is to be any hope of change. One can only be humbled by their commitment to both science and health care in settings that most of us can barely imagine, and with access to only a fraction of those resources we take for granted. Cardiovascular disease (CVD) is now the leading cause of death throughout the developing world. This twentieth century epidemic has completed its migration from the industrialized world to all of sub-Saharan Africa, including the Democratic Republic of the Congo. Moreover, in places such as the Congo, this modern scourge is compounded by its coexistence with the traditional communicable and deficiency deceases of poor nations and poor people. While malnutrition, infant infectious disease, and AIDS still blight young lives, now those who survive to middle age must anticipate the increasing likelihood of premature stroke, heart attack, and heart failure. As was previously the case in industrialized societies, CVDs first affect the more fortunate members of society before spreading throughout the socioeconomic ladder. Currently, the burden of CVD, in the developing world, falls disproportionately among persons at the peak of their economically productive life. The impact of hypertension on hospitalized patients examined by M'Buyamba-Kabangu et al. is only one, albeit important, dimension of the overall health and health care consequences of elevated blood pressure. More than 90% of the 401 sequential admissions with hypertension were admitted for acute medical conditions such as stroke, transient ischemic attacks, heart failure, and encephalopathy. Their mean age was 54 years, most were obese, and >20% had diabetes. In general, the entry status and clinical outcomes were, as expected, dismal. Entry blood pressure was high, most were untreated, and blood pressure was an important determinant of outcome. More than 20% did not survive hospitalization. The blood pressure dimension of this experience merits further consideration. Nearly three-fourths of these patients were aware of their condition—levels not very different from those found in many industrialized nations. Moreover, ~40% of the hypertensive patients were receiving antihypertensive care. Although these findings cannot be generalized beyond the participants in this study, and they probably overestimate prevalence of both awareness and treatment, they nevertheless provide clues that point to some hopeful prospects. The fact is that to some extent, and in Mbuji Mayi that might mean only among the very sickest members of the community, there is recognition by physicians and patients, that blood pressure has medical significance, and that it can and should be treated. The World Health Organization has described appropriate strategies for CVD prevention in different circumstances. Although efforts aimed at the general population are widely believed to offer the best hope for change in low-income countries, the data here suggest that physician provided and/or directed antihypertensive care can play an important role. Secondary prevention, which includes treatment of high blood pressure (or hyperlipidemia), is the most efficient and cost effective means to reduce disease burden—and to reduce hospital in-patient use. Blood pressure is easily measured and can begin the identification of that group with the highest global cardiovascular risk, and therefore the highest benefit to cost ratio. Targeting treatment to those who have had an event, have diabetes, and are at the highest level of blood pressure pays immediate dividends. Experience in Cuba suggests that societies with limited resources, by mobilization of physician extenders can, at low cost, achieve remarkable levels of blood pressure control.2,3 Antihypertensive therapy, where appropriate and feasible, can be enhanced by lipid lowering therapy. Physicians are doing those things at Mbuji Mayi now. At the same time, they are not best equipped to carry out other elements of an ideal CVD prevention program. Government action is the surest means to curtail smoking, and although physicians should advocate for antismoking taxes and regulations that work, they can't do it alone. Behavior modification would be nice and should be promoted, but the reality is that the technology necessary to achieve lasting change is unavailable. The size and composition of the high-risk group can be tailored by fixing the risk level to identify a treatment group commensurate with community resources. This secondary and tertiary prevention approach will have only a modest effect on the community's total burden of disease, because most disease actually occurs among those with only modest CVD risk. Nevertheless, this high-risk strategy is what physicians, along with their community extenders, do best. When they do it well, the results are visible and measurable. In short, blood pressure treatment is a good place to start. What is required is planning and coordinated action to optimize the knowledge and tools that already exist in the community. Doctors are respected leaders and know how to define goals and organize for their achievement. Implementation of a high-risk blood pressure treatment plan will demand commitment, sustained effort, and the support of civic leaders. Success in this physician centric effort will generate the tangible evidence and credibility to develop other, more comprehensive strategies for population wide CVD prevention. CVD is the leading cause of death in virtually all nations, and hypertension is its leading risk factor. National and international programs of a scale equal to the disease burden must ultimately be mounted if this challenge is to be met. Meanwhile, physicians, like our colleagues in the Congo, can take the first steps—and thus make a real difference.