Hypertension treatment and control in sub-Saharan Africa

Editor—Cooper et al call for the inclusion of antihypertensive treatment among health priorities in sub-Saharan Africa.1 Assuming that the patient needs one drug to control his or her blood pressure and that compliance is good, they estimate that one death could be prevented at a cost of $1800 (£1130). Some patients need two or more drugs to control their hypertension, and compliance rates for chronic diseases in Africa are low for many reasons, including poverty, lack of access to health services, mobility of the population, and a lack of understanding of the nature of chronic disease. In the Republic of Congo patients arrive at a health centre to be cured. A doctor who can only control an illness is often seen as having failed, and the patient will then either try a new doctor or consult the local healer. The Centre Medical Evangelique runs an externally funded project for patients with epilepsy. The cost of the treatment is only $18-$24 (£11.70-£15.10) a year, and most patients see a considerable change in their condition. The programme is mobile to facilitate access. Despite this the average non-attendance at any consultation is about 40%. This figure is likely to be higher for a similar programme of antihypertensive treatment, because the patient often experiences no improvement in symptoms and may have side effects from the medicine prescribed. I think that Cooper et al’s figure of $1800 per life saved is optimistic. Even if accurate it means that antihypertensive treatment cannot rank alongside the provision of clean water, vaccination, and oral rehydration in terms of lives saved per unit cost. So what should be done for hypertension in sub-Saharan Africa? I believe we should treat patients with symptoms or complications, or both, as they are more likely to be compliant with treatment. We should also treat those who want to be treated and who understand the importance of continuing treatment. Doctors and other interested parties need to disseminate information to their communities about the nature and risks of hypertension. Finally, the authors do not mention the value of dietary salt restriction. This is cheap and particularly effective in African populations.2 Measures such as this would have a greater impact on the prevalence of hypertension in the African continent.