Richard Smith: Four reasons why we may not be responding in the right way to hypertension in low and middle income countries

richard_smith_2014Should we be responding to hypertension in low and middle income countries? Of course we should. Hypertension kills 10 million people a year prematurely, and 80% of those deaths occur in low and middle income countries. Less than 5% of people with hypertension in those countries have their blood pressure well controlled, and yet we have cheap drugs that are highly effective in treating hypertension. But are we responding in the smartest way? This question came up at the Novartis Foundation London Dialogue on responding to hypertension in low and middle income countries, which was held this week. 

The dialogue heard about a whole range of innovative schemes to identify people with hypertension in low and middle income countries and treat them with drugs and by encouraging changes in lifestyle, but I could see four reasons why this might not be the right approach.

Firstly, perhaps we should be trying to prevent hypertension rather than identify and treat it. David Wood, a cardiologist and president elect of the World Heart Federation, pointed out that hypertension is not inevitable. Blood pressure rises progressively with age in people living Western styles but not in those who live as hunter gatherers lived. It’s our environment, probably particularly our food and lack of exercise, that cause hypertension. Perhaps much more emphasis should go on trying to prevent us developing hypertension rather than detecting and treating it.

Secondly, we treat hypertension to prevent heart attacks and strokes, but raised blood pressure is only one risk factor for these events. We should be treating total risk not just blood pressure. A young non-smoking woman with a normal BMI may have a higher blood pressure than an obese, smoking man in his 50s and yet be at much lower risk of a heart attack or stroke than him.

Thirdly, creating a programme to treat just hypertension may undermine health systems for managing all health problems. We saw this with programmes to respond to AIDS and tuberculosis: they were well funded and so took staff away from the usual health system. “I wish I had AIDS,” said a patient with diabetes in Cambodia where there were good services for patients infected with HIV but nothing for those with diabetes. Having a vertical rather than integrated programme may be a particular problem with hypertension because people do not have symptoms and often don’t understand why they need to be treated and why it must be lifelong. People have to be found, but they will come to primary care clinics with symptomatic health problems. Their hypertension could then be detected and managed along with other problems. Increasingly in low and middle income countries patients, as in high income countries, have multiple problems not just one.

Fourthly, perhaps it might be a better investment to create health rather than prevent disease. Jo Ivey Boufford described at the meeting programmes in New York City to make life better for older people. When asked what matters to them older people mention housing, transportation, outdoor spaces, social participation, respect and social inclusion, employment and civic engagement, communication and information, and community and health services. Health services are only one among eight domains. Those of us brought up within health (really disease) systems think of health in narrow terms—bluntly, the absence of measurable physical or mental dysfunction. But ordinary people have a broader—and more real—view of health, and it extends way beyond having a “normal” blood pressure.

Richard Smith was the editor of The BMJ until 2004.