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CARDIOVASCULAR JOURNAL OF AFRICA • Volume 26, No 4, July/August 2015
194
AFRICA
price data, and mark-ups by distributers, pharmacies and
dispensing doctors.
Poverty is the main underlying factor for hypertension and
cardiovascular diseases.
8
There are 57 countries in SSA. Africa
has huge amounts of natural resources and is a source of natural
strategic minerals. It is not overpopulated compared to the Asian
continent yet economic conditions have deteriorated alarmingly
in recent years. This is due to corruption and maladministration.
Africa is the poorest continent and has the lowest per capita
income in the world. The effect of poverty and its impact on
health, particularly cardiovascular diseases, has been previously
described.
8
The number of poor people, defined as those making less
than one dollar a day, has increased substantially in both relative
and absolute terms. The absolute number of poor people has
grown five times more than the figure for Latin America and
twice that of South Asia. There is a critical shortage of doctors
and nurse midwives to achieve 80% coverage for deliveries by
skilled birth attendants, or for measles immunisation.
The staff shortages in SSA derive from a combination
of underproduction of qualified healthcare workers, internal
maladministration of professionals, and emigration of trained
workers. The shortage of health workers in SSA reached 4.3
million in 2006, including 2.4 million doctors, nurses and
midwives. It is more critical in rural areas as 38% of the world’s
nurses and less than 25% of doctors work in rural areas.
9
Obesity is associated with increased blood pressure levels in
blacks. In the South African Demographic and Health Survey
of 1998, the prevalence of obesity (body mass index
≥
30 kg/
m
2
was 30% in black females and 8% in black males.
4
It has
been suggested that in Africa, the rural diet is relatively healthy,
but with urbanisation, the diet is replaced with higher fat and
lower carbohydrate intake. Poverty and cultural factors hinder
the implementation of the DASH (Dietary Approach to Stop
Hypertension) high-fruit, high-vegetable, low-salt diet, which
was found to be very effective in African-Americans.
10
For most low- and middle-income countries, the major
obstacle to the control of blood pressure-related disease is the
absence of appropriate primary healthcare services. Strategies
for the prevention of cardiovascular disease (CVD) are to
prevent the acquisition or enhancement of CVD risk factors.
This is done by avoidance or decrease of the social, economic
and cultural factors that contribute to the development of
hypertension.
In primordial prevention, the main objective is to prevent
the acquisition or enhancement of CVD risk factors. This is
done by avoidance or decrease of the social, economic and
cultural determinants that contribute to the development of
hypertension. Primordial prevention relies on health policies that
create a congenial environment to promote healthy behaviour,
and population-wide education programmes. These in turn
depend on many factors, including the involvement of political
leaders and the mass media. Primordial prevention relies on
healthy behaviour and population-wide education programmes.
Primary prevention is to reduce or reverse the risk factors in
urban communities. This is done by reducing the risk factors
for hypertension through appropriate policies, or modifying
the risk factors in order to prevent or delay the development of
hypertension. Since a substantial number of adults have blood
pressure above the optimal level, even a small reduction in blood
pressure can produce a significant decrease in cardiovascular risk
in the population. At the individual level, primary prevention
of hypertension consists of adopting healthy lifestyles at an
early age. These should be non-pharmacological, population-
based and lifestyle-linked measures, such as salt restriction in
food, increased exercise, control of obesity, increased potassium
consumption in the form of fresh fruit and vegetables, reduced
alcohol intake, and stopping cigarette smoking.
There is a need to develop cost-effective methods for the
diagnosis of hypertension, and low-cost, saving measures such as
microscopic urine examination, and testing for urinary albumin
and glucose levels, and serum creatinine, potassium and glucose
levels. Coronary heart disease, while rising in incidence, is still
relatively uncommon in SSA. Because serum cholesterol levels
in blacks are lower than in whites and the Indian population
in SSA, it may not be necessary to routinely measure lipid
patterns in black hypertensive patients.
10
However, we need data
on the cost effectiveness of routine measuring of lipid patterns
in blacks, with the current stage of knowledge of elevation of
serum lipid levels in many individuals.
At a tertiary level, we need to avoid high-cost, low-yield
technologies such as routine echocardiography for hypertension,
and computerised resonance tomography and magnetic
tomography for reno-vascular hypertension.
8
While it
is important to use modern technology in medicine for the
treatment of hypertension, particular attention should be given
to cost-effectiveness and affordability, as many countries in
SSA have severe resource constraints.
9-11
In some countries, the
health budget per capita does not exceed US$10 per year and
this is completely insufficient to address the needs created by the
double burden of non-communicable and infectious diseases,
such as HIV/AIDS.
For most low- and middle-income countries in SSA, the
major obstacle is the absence of appropriate healthcare services.
In many regions, primary care provides only episodic care with
little record kept of previous visits. These services must be
adapted not only for the management of blood pressure-related
disease but also for the management of other serious diseases,
including HIV infection. Many of the clinics are poorly staffed
and lack adequate equipment and medication. It is the norm to
have large queues of patients waiting for many hours after entry
to a clinic, to be seen by nursing or medical personnel.
12
Conclusion
Treatment of hypertension in the poverty-stricken continent of
SSA presents a challenge that needs to be addressed urgently.
A similar plea has been made to the South African medical
fraternity.
13
The future approach to CVD prevention should be
aimed at societal change throughout the life of the individual,
and on large changes in multiple risk factors. There is a need to
solve the problem by working with goverments, the WHO and
other national and international organisations.
We must remember the wise words of our beloved Nelson
Mandela, ‘We must face the matter squarely, that where there
is something wrong in how we govern ourselves, it must be said
that the fault is not in the stars, but in ourselves. We know that
we have it in ourselves as Africans to change all this. We must
assert our will to do so; we must say there is no obstacle (large)
enough to stop us bringing about an African renaissance’.