In 2016, an estimated 1 million people died of HIV/AIDS, 445,000 people died of malaria, and 1.7 million died of tuberculosis.
Nearly 18 million died of heart disease. And more than three-quarters of those deaths occurred in the developing world.
If you ask someone to list the most lethal global health problems facing the world today, something as mundane as heart disease doesn’t typically top the list. Yet there it sits, responsible for one-third of all global deaths.
What’s more, in poor countries, those deaths are happening earlier. In wealthy regions like the US and Europe, heart disease tends to burden the elderly (only 15 to 20 percent of deaths from heart disease are under 70). But in poor countries today, more than half of people who die from heart disease are under 70 — some of them well under. Those people are also the poorest in those countries; wealthier people have access to preventive medicine and lifestyles that keep the disease at bay. And the problem is only projected to get worse: In Africa, deaths from chronic diseases, almost half of which are from heart disease, are forecast to increase by a third in less than a decade.
Heart disease, which is still thought of as a lifestyle disease of wealthy Americans who are eating more, exercising less, and living longer, is now very much a disease of the world’s poorest.
Getting the problem under control is going to be hard, especially if action remains as sluggish as it has been. Less than 1 percent of the $35 billion spent each year on health development assistance went to preventing heart disease, and that number has barely budged since 2000. HIV/AIDS, on the other hand, which represents 4 percent of the global disease burden, received 29 percent of global funds.
The world is changing: People are living longer than ever before, and for the first time in history, more people live in cities than in rural areas, making lifestyles more sedentary and the environment worse. Fast food is saturating every corner of the globe, meaning not just that McDonald’s is more ubiquitous but that cheap, fried starches are the most affordable way for people to feed themselves.
But perceptions of what kills poor people around the world have been slow to change. Most of the attention and funding for global health has gone to infectious diseases like HIV/AIDS, malaria, and even Ebola. Yet the nature of global disease is changing fast, and it’s changing fastest in poor countries. And neglecting the fact that heart disease is a major killer of the world’s poor means missing out on the opportunity to save millions of lives with simple interventions.
What makes heart disease so deadly
Heart disease is technically a subset of cardiovascular disease, but the two are often used interchangeably to refer to a handful of conditions that affect the heart. The deadliest involve narrowed or blocked blood vessels or arteries that can lead to heart attack or stroke, which cause the vast majority of global deaths from heart disease.
Heart disease is actually very treatable and, more importantly, preventable — if caught early. It can be prevented, and even reversed, with lifestyle changes like eating more fruits and vegetables and less sugar, quitting smoking, consuming less alcohol, and getting more physical activity. In addition, there are medications to lower blood pressure and cholesterol that are relatively inexpensive.
Once heart disease advances, things get more complicated and expensive — although it is still treatable with procedures like stent insertion to expand arteries or heart bypass surgery for when arteries are blocked.
But the countries that are experiencing the fastest increase in noncommunicable diseases — which include heart disease as well as other chronic diseases like cancer and diabetes — are the ones with health care systems that are least prepared to deal with it.
The changes are also happening very fast: In 1990, chronic disease caused about a quarter of deaths and disabilities in poor countries. By 2040, they are expected to be responsible for 80 percent in some countries. Part of this is a good thing: Fewer people are dying of infectious diseases like HIV and malaria, and hence the proportion of deaths from heart disease goes up. But the shift from infectious to noncommunicable disease is happening three to four times faster than it happened in wealthy nations, leaving health systems struggling to catch up.
Theoretically, eliminating behavioral contributors to heart disease, like smoking or eating fatty foods, is the best public health intervention against heart disease — but that’s a lot easier said than done.
The reason is that changing people’s behavior is really difficult, especially when it comes to health. Moreover, focusing on behavioral changes obscures how much the deck is stacked against people, particularly the poor. In some countries around the world, soda is cheaper than bottled water, making it a growing mainstay in the diets of adults and children alike in poor countries. Air pollution is worst in the world’s poorest cities: Living in a place like Mexico City is equivalent to smoking 6.5 cigarettes a day, and living in New Delhi, India, is equivalent to smoking 25 a day.
Liberalized trade has opened up markets in poor countries, making unhealthy food cheaper. In South Africa, eating healthier costs 69 percent more. Globally, big tobacco and international fast-food chains wield enormous political and economic power that is altering lifestyles and, in turn, influencing public health.
Taken together, these factors are pretty overwhelming, which makes heart disease seem a lot harder to combat than its infectious counterparts. That may be part of why there is still so much focus on combating infectious disease: We know how to do it. Distributing mosquito nets to rural villages in Africa has clearly been shown to reduce infant mortality and overall infection rates. Promoting condom use has clearly been effective in reducing rates of HIV/AIDS infection.
But while fighting heart disease is hard, it really may not be as hard as other global health challenges we’ve successfully met. As Thomas J. Bollyky, the author of Plagues and the Paradox of Progress: Why the World Is Getting Healthier in Worrisome Ways, pointed out to me, getting over 21 million people on antiretroviral (ARV) treatment for HIV wasn’t easy either. HIV treatment involves taking a cocktail of medications every day for the rest of a patient’s life. The medications have side effects, such as fatigue and nausea, and have to be taken with adequate nutrition, which is particularly difficult in some places in rural Africa. Despite all of this, new HIV infection rates have almost been cut in half since 1996 — in no small part because so many people are on ARVs that, if taken correctly, make it almost impossible to pass on the disease.
There’s no reason we couldn’t make the same progress against heart disease.
Saving lives with pills and paperwork
Environmental and demographic changes are part of why heart disease has spun so far out of control. But a bigger reason — and the one that has made heart disease so deadly — is that poor countries don’t have the kind of preventive care that helps stop heart disease long before it’s advanced enough to result in a heart attack or a stroke.
“When you boil it down, the real narrative about noncommunicable diseases is, sadly, the same narrative that exists in other areas of global health: It’s driven by poverty and inequity and lack of access to the medical tools that exist in high-income countries,” says Bollyky.
Think about how many times you get your blood pressure taken: every time you go to the doctor, whether it’s for a regular checkup or for something more serious.
That’s because having high blood pressure puts you at risk for heart disease. And if you catch it early, as many Americans do now, blood pressure medication and lifestyle changes, like quitting smoking or exercising more, can nip the problem in the bud.
Deaths from heart disease in wealthy countries like the United States are a quarter of what they used to be in the 1980s. Half of that reduction is a result of preventive medicine, including screening people for risk factors like high cholesterol or high blood pressure and getting them on medications like ACE inhibitors and beta blockers — medications that are off-patent and inexpensive, in some cases costing less than $5 a month.
One study shows that managing heart attacks with low-cost drugs produces $25 in health and economic savings for every dollar of investment. Even aspirin, which costs a little over a dollar for a month’s supply, can reduce the risk of heart attack in people who have already had one and increase survival rates if taken right after a heart attack. It could save thousands of lives if it were always stocked in clinics across the developing world.
But while medications are cheap and effective, getting those medications to the people who need them can be difficult. And with many people in the developing world living on less than a few dollars a day, the cost can still be prohibitive. Almost half of Africans go without basic medicine or medical care, and some 10 percent of people in developing countries are getting preventive treatment for heart disease.
Pharmacies are few and far between in developing countries. Where they do exist, they frequently run out of medication. As Dr. Thomas Gaziano, who studies cost-effective interventions to heart disease and other noncommunicable diseases at Harvard University, said to me, people can’t stop by Walgreens or CVS on their way home from work or have their medications mailed to them. Getting medication often means taking a day off work to trek to the nearest pharmacy, which involves spending money on transportation and often waiting in a long line. Because medical supplies are irregular in the developing world, it isn’t uncommon for the medication you need to be out of stock by the time you get there.
Another issue is the lack of doctors and nurses to identify who needs these medications. The World Health Organization estimates that sub-Saharan Africa has a deficit of 1.8 million health workers, a number they project will rise to 4.3 million by 2035.
Those two factors — remote locations and overburdened health care systems in the developing world — are an argument for using community health care workers, an increasingly common strategy for poor countries to address the shortage of health care professionals.
These are people from the community who don’t have any formal medical training but who can provide health care information or distribute basic medical supplies. In fact, community health workers have been part of the success in getting HIV-positive Africans on ARV treatment and keeping them on it consistently. The advantage to using them is that they’re cheaper— sometimes they even work on a volunteer basis — and they can go directly to people’s houses, saving patients a costly and sometimes fruitless trip to the doctor.
The good thing about heart disease is that risk factors are relatively easy to spot. They include things like obesity or a history of diabetes. One study done in South Africa, Mexico, and Guatemala showed that community health workers using a set of questions on a piece of paper or a mobile phone app could visit patients in their home, ask the questions, and determine whether the patient is high-risk as effectively as a doctor or a nurse. Once patients were informed they were high-risk, 30 to 70 percent of them sought care at a health center, where a high percentage went on to receive appropriate care.
A growing number of countries are deploying community health workers in the fight against heart disease and other chronic ailments. South Africa, which has one of the fastest-growing rates of deaths from heart disease in the world, is restructuring its health care system and is planning to deploy 700,000 community health workers by 2030.
One more cost-effective intervention for heart disease, and one favored by the World Health Organization, is heavily taxing tobacco products. Cigarette smoking is a major cause of heart disease, and while smoking in the United States is going down, it is increasing in much of the developing world. In Africa, it has risen by 50 percent in 35 years.
Getting the political support for this kind of intervention is difficult, especially in poor countries whose governments are increasingly targeted by the tobacco lobby. But it might be worth a try: Studies have shown that making cigarettes more expensive through taxes leads to a clear and marked reduction in the number of smokers.
Heart disease is a disease of poverty, not luxury
Heart disease is still thought of as a disease of excess, rather than deprivation. That misconception is costing lives — and it will likely cost many more if things don’t change. Between 1990 and 2040, the countries that are estimated to have the greatest increase in deaths and disability from chronic disease are Bangladesh, Ethiopia, Myanmar, Iran, Indonesia, Pakistan, and India. Sub-Saharan African countries are also expected to see significant increases, and their health care systems are particularly ill-equipped to deal with these changes.
It’s also worth noting that the effort to combat heart disease could more than pay for itself. Effective management of high blood pressure alone could save $100 billion in health care costs per year.
It wasn’t that long ago that HIV/AIDS seemed as intractable and complicated as chronic diseases do now. HIV/AIDS is still a crisis — but it’s a crisis that the global community has had some success in tackling because we concentrated our efforts on it.
We need to devote that same energy and attention to heart disease. It has been driven by some pretty powerful factors — urbanization, big tobacco, and Burger King — but we also haven’t tried very hard to fight it, at least in the developing world. And that’s what needs to change.
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