Commentary: Health priorities for sub-Saharan Africa and the challenge of cardiovascular disorders

Commentaries are personal reflections on topics relevant to cardiovascular disease prevention contributed by members of ProCor's global community.

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This Commentary by Dr. Muna, a distinguished cardiologist from Cameroon, highlights a number of important points. First, he indicates the growing prevalence of cardiovascular disease in Sub-Saharan Africa and the special importance of hypertension. Second, he emphasizes the paucity of sound epidemiological data to guide health policy. And third, he questions the tendency in some quarters in the North to doubt the cost-effectiveness of primary cardiovascular prevention in poor countries. Dr. Muna's final words are worth repeating, "There should never be a justification for applying a lesser science or giving less value to human life on the basis of the socioeconomic context."

Bernard Lown, MD
Founder and Chair, ProCor

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Introduction
The control and prevention of infections and diarrheal diseases (including malnutrition, high infant and maternal mortality) has been the central theme and the point of focus for health planners and policy makers in the Sub Saharan African (SSA) region for the past 50 years, and to this day (1,2). Over 70% of the 500 million people in this region live in rural areas. Primary Health Care (PHC) is the main health care philosophy or policy in most of these countries. Prevention, education and information provide the cornerstones of the philosophy incorporated in the various components of PHC. Although PHC was initially designed to be a multi-component and comprehensive system of health care delivery adapted to these populations, it has recently been reduced to a policy of vaccination and the procurement and distribution of essential drugs.

The 47 countries that make up this are among the poorest in the world. Most of the wealth and money mass in these countries are controlled by less than 5% of the population, made up of salaried urban workers and the elite. Consequently, frequently quoted per capita income for these countries may not be relevant to rural populations where annual per capita income is largely below $150 per year. Despite the growing evidence on the importance of investing in health and its relationship to development, most of these African countries are still unable to make health care a priority budgetary item (attributions rarely exceed 4% of the national annual budget).

The increasing socioeconomic and geopolitical instability (in addition to other similar influences in a more global context) in several countries of this region is thought to have had a negative influence on the designation of health care as a budgetary priority. In most African countries of this region, the percentage of the total annual budgetary allocations towards health care have either remained the same or gradually decreased over the past 30 years. This has happened despite important increases (sometimes a doubling) in the population and subsequent demands for increased and specialized health care coverage over the same period.

The lack of reliable data and health statistics has made both the evaluation and the formulation of policy for these countries very difficult and a continuing challenge (3,4). In addition, available data is frequently not exploited. Such data may be used or cited out of context and frequently extrapolated beyond reasonable limits. Although infections and malnutrition still constitute the major component of the disease burden, there is accumulating and convincing evidence that chronic disorders in general and cardiovascular disorders in particular are increasingly important.

The growing importance of cardiovascular disorders
Over 20 years ago, a report showed that infections (30%), cardiovascular disorders (24%), and cancer (23%) were the leading cause of death among middle-aged men in a large urban hospital in one of the countries in the SSA region. Although specific data is still lacking, infections involving various cardiac structures and the pericardium, rheumatic fever and rheumatic heart disease and cardiomyopathies constitute frequent causes of cardiovascular deaths.

After about three decades of controversy (mainly due to the lack of reliable data), hypertension is increasingly being recognized as an important health issue in African populations (5). Rates in rural areas range between 5 and 10% and may frequently be in excess of 15% in most urban areas. These rates are still much lower than rates for populations of African origin living in developed countries.

Hypertension is also an important factor in stroke and congestive heart failure that are responsible for most cardiovascular deaths among adult black Africans. Recent hospital and community-based studies have suggested that cardiovascular mortality may be up to 15% and frequently in excess of 20% of total mortality (6).

Ongoing demographic changes (rural to urban migration, increasing longevity, etc.) in addition to important changes in life-style and nutrition, cultural and socioeconomic factors have certainly contributed to the current epidemiological transition to increasing cardiovascular morbidity and mortality among Africans. This transition has arrived much faster than Africans either anticipated or can cope with. An unfinished health care agenda that consisted of the prevention and treatment of infectious diseases has recently been complicated by "emerging" health issues due to the AIDS epidemic and tuberculosis. The transition is no longer from communicable to non-communicable diseases but rather a transition to communicable and non communicable diseases. Unfortunately policy makers and health care planners have been either slow to react to this transition or, they have not yet come to terms with its implications for the future.

The paradox of health care reforms in sub-Saharan Africa
The ongoing demographic transition has given rise to large urban agglomerates in SSA. The expansion (in area and population) of these urban communities occurs at rates that are beyond the capacities and possibilities of local authorities to meet the challenges of such growth. The urban-rural interaction in SSA countries is quite complicated. In its simplest form, it is usually described as a rural to urban migration of the population. The introduction of unprecedented technologic advances in transportation and communication has led to a more complex phenomenon that makes traditional urban-rural distinctions irrelevant. Urban lifestyles are increasingly being imported into what may conventionally be considered as rural environments.

In large urban areas, there are many population groups that maintain lifestyles typical of a rural environment. It is generally assumed that urban communities have more health care facilities (more dispensaries and hospitals) and better access and health care coverage than rural areas. This has consequently led to the emphasis on PHC as being more applicable to rural areas in current reform processes on health care delivery in SSA.

The increase in the number of hospitals and the training of more specialized health care personnel coupled with the degrading economic environment and lack of matching resources to meet the increasing health care demands has resulted in an unprecedented crises in this sector. The Hospitals and other tertiary care institutions require resources and managerial expertise that are frequently not available. This has led to an increasingly disproportionate fraction of the health care budget being spent for the upkeep of these institutions at the expense of other parts of the health sector. The general medical services of these institutions are largely filled by patients with mostly chronic disorders such neoplastic and cardiovascular diseases, although the number of patients with AIDS and chronic infections such as tuberculosis is also on the rise. This phenomenon has led to a further escalation of health care costs and grave consequences on health care spending patterns and the execution of health care policy.

Cardiovascular disorders and health care priorities in sub-Saharan Africa
The 1993 World Bank Report (Investing in Health) suggested the closure of many of the tertiary health care structures in SSA for some of the reasons discussed above. Most of these poor countries depend on external funding (and financing) of almost all economic sectors for survival. Cost effectiveness is an important and the driving consideration in feasibility studies across almost all these sectors, and this frequently leaves the health sector at a disadvantage. The almost total lack of reliable data for the health sector in SSA countries further accentuates this disadvantage (4).

These cost considerations and the prioritization process (for scarce resources) have sometimes led to controversial recommendations even when available evidence suggests otherwise. In a recent analysis where non-communicable diseases were identified as an important cause of adult mortality in Africa, it was argued that drug treatment of hypertension (directly or indirectly responsible for over a third of all cardiovascular deaths) should not be attempted because of its prohibitive cost (7).

We, on the contrary, have presented an argument to encourage a policy (based on available epidemiological evidence) of drug treatment of hypertension in SSA (8). Using a "Number needed to treat" analysis we estimated that the cost of drugs needed to prevent one death would be much less than US$2000 in Africa while the same cost needed in the United States could range anywhere between US$14,000 and US$1 million.

What should it cost to save the life of a patient with hypertension in SSA? Firstly, the argument that the drug treatment of hypertension should not be attempted is based on the assumption that the $2000 figure is at least 50 times the "cost effective value" that is an arbitrary determination based on data that may not be relevant to SSA. Secondly, such an argument must necessarily incorporate the assumption that an African's life (or saving a life in SSA) was comparatively less valuable than that of some other human being.

Prioritization is an important element in management especially when resources are scarce. Policy must however be based on available evidence and such policy must provide a rational and practical approach (when the opportunities and possibilities are available) to solving problems. Hypertension is a public health problem in SSA and policy for both pharmacological and non-pharmacological (life-style modification) management must be developed for those in need and those that can apply such policy. Available evidence suggests that the treatment of hypertension in the context of an organized priority-based health system would result in significant reductions in mortality and improvements in adult health. There is no reason why such an approach should not be true for cardiovascular disorders in general.

Opportunities and future directions
Cardiovascular disorders are still considered a problem by many governments of the SSA region. The existing list of health priorities and the increasing list of "emerging" health priorities has, unfortunately led to a strengthening of this common misconception among policy makers and health care planners of this region. Although opportunities and possibilities for action exist, this has considerably delayed the considerations for cardiovascular prevention on the health care agenda. In addition to drug treatment of hypertension already mentioned, primary prevention (with education on limiting salt intake, sedentary lifestyle, and obesity as attributable risks) is largely a feasible strategy in some of these countries and in at least some population groups. Primary prevention (although feasible from a theoretical standpoint) may be less practical and secondary prevention with drug treatment (as is currently the case with rheumatic fever and rheumatic heart disease) may be a more reasonable option in other population groups.

Average total cholesterol levels remain generally low (and HDL-cholesterol levels are generally high) and the risk for coronary heart disease remains low for black Africans. Changes in cholesterol levels in some population groups (average levels in a Nigerian population rose from 140 mg/dl to 160 mg/dl between 1958 and 1980) suggest that there are also some opportunities for education and primary prevention. Similar considerations can be made for diabetes (with a prevalence that is generally less than 2%) and obesity. The tobacco industry and cigarette smoking constitute an area of growing concern in this region. Although smoking-related disorders are still not an important cause of mortality and morbidity, smoking rates may be as high as 40 % in some urban areas (6). Of more concern is the growing commercialization of tobacco and related products in this region and the rising smoking rates among children and women. Unless there is a global approach to anti-tobacco legislation, most of the poor countries in this region may not be able to avoid the consequences of a "tobacco epidemic". The "apparent" economic incentives and pressures from the tobacco industry (that is increasingly being forced through increasing anti-smoking legislation from developed countries) still present a dilemma for these poorer SSA countries who fail to appreciate the long-term consequences of tobacco commercialization and use on health. Paradoxically, the SSA region presents a unique and the best opportunity for primary (and possibly " primordial") prevention against such an epidemic. In conclusion, cardiovascular disease prevention can easily be incorporated in some of the components of PHC such as health education, food supply and proper nutrition as well as maternal and child care. A strategy, within the context of PHC, may involve social engineering (i.e., clean water, air and other environmental factors) social and lifestyle interventions (e.g., smoking, alcohol intake, salt intake, etc.) and population-based medical interventions (which could range from drug treatment of hypertension, streptococcal pharyngitis to the use of available vaccines for disease prevention). Funding (especially from external sources) health research in SSA continues to be important and commendable. However, building sustainable capacity for ongoing research (In its simplest form, this can be reduced to providing structures for proper management of health-related data that can consequently be used for the evaluation and formulation of policy.) in chronic diseases in general and cardiovascular diseases in particular may prove to be both timely and critical. Some of these poor SSA countries currently have the most cost-effective opportunities for the prevention and the control of cardiovascular disease. It may require responsible and evidence-based global leadership to bring these countries to realize and seize these opportunities. There should never be a justification for applying a lesser science or giving less value to human life on the basis of the socioeconomic context.

Citations:
1. Murray CJL, Lopez AD. Morbidity by cause for eight regions of the world: global burden of disease study. Lancet 1997; 349: 1269 - 76.
2. Feacham RG, Jamison DT, et al. Changing patterns of disease and mortality in sub-Saharan Africa. In:Feacham RG, Jamison DT, eds. Disease and mortality in sub-Saharan Africa. Washington, DC. World Bank. 1991; 3 - 27.
3. Cooper RS, Osotimehin B, Kaufman J, Forrester T. Adult mortality in Africa: What should we conclude in the absence of data? Lancet 1998; 351: 208 - 10.
4. Wolfers Ivan, Adjei S, and van der Drift R. Health research in the tropics. Lancet 1998; 351: 1652 - 54.
5. Cooper RS, Muna WFT, Kingue S, Osotimehin BO, Kadiri S, Rotomi CN, and Kaufman JS. The burden of hypertension in rural Africa: results from the International Collaborative Study on Hypertension in Blacks (ICSHIB). Tropical Cardiology, 1996; 22(87): 69-74.
6. Muna WFT. Cardiovascular disorders in Africa. World Health Statistic Quarterly, 1993; 46:125 - 33.
7. Feacham RGA, Kjellstron T, Murray CJL, Over M, Phillips MA, eds. The Health of Adults in the Developing World.

Advocacy & Policy
Date Posted: 9 July 1998