By Shiva Sajja, The Walker School, Marietta, Georgia, USA
The World Health Organization (WHO) recognizes the global need to combat cardiovascular disease. In 2013, they set out to reduce the prevalence of high blood pressure by 25% and to get at least 50% of eligible people on medication. Another part of their plan was to provide these people with counseling on their condition in order to prevent as many heart attacks and strokes as possible by 2025 (WHO, 2021). In 2016, the WHO and United States CDC partnered and launched the Global Hearts Initiative. This initiative aimed to control tobacco use by raising taxes on tobacco products and promoting physical activity by providing access to places to walk, cycle, and other forms of physical activity. Additionally, efforts were made to reduce salt consumption by reformulating food products and establish accurate labeling standards. It also set out to eliminate industrially produced trans fat from the global food supply by replacing it with healthier fats and oils (WHO, 2016).
In order to help with management of cardiovascular disease at the primary care level, the Hearts Technical Package was established to provide healthy lifestyle counseling. It consists of evidence-based protocols, access to essential medicines and technology, and risk based management. Its purpose was to give a strategic approach to battle cardiovascular disease in all countries (WHO, 2020). In 2017, the partnership grew to include the Global Health Advocacy Incubator, Johns Hopkins Bloomberg School of Public Health, The Pan American Health Organization, and Resolve to Save Lives. Because of this effort, eighteen low to middle income countries have benefited and three million people were treated through patient-centered care and put on protocol-based hypertension medication (WHO, 2021). Despite this global approach, in 2019 an estimated 17.9 million people died due to cardiovascular disease. This is 32% of all global deaths (WHO, 2021) and a huge global burden. Figure 1 demonstrates how cardiovascular disease is the leading cause of death globally. By 2030, the WHO expects this to rise to more than 23 million deaths annually (Banks, 2022). Despite these global efforts, the world is headed in the wrong direction in our fight against cardiovascular disease. But why is this?
Figure 1: Burden of disease by cause, (Ritchie, 2019).
Obesity and an elevated body mass index (BMI) puts one at risk for cardiovascular disease, making it a global concern. Most of the world consumes a fatty diet, rich in sugar and salt. Whole, fresh food is consumed far less than cheaper, processed food. Compared to previous generations, today’s lifestyle is more sedentary. But obesity is not just a problem for adults; it also affects children. Shockingly, in 2020, 39 million children under the age of 5 were classified as overweight or obese (WHO, 2021). This is not solely a problem for high income countries, even low income populations deal with obesity. In Africa, the amount of children under the age of 5 who are obese have increased 24% in the last 22 years. Asia has similar problems with childhood obesity. In 2019, around 50% of obese children in the world lived in Asia (WHO, 2021). Obesity is part of the problem keeping the cardiovascular disease burden alive today.
Low to middle income countries impact the increased prevalence of cardiovascular disease. Figure 2 demonstrates the death rate from cardiovascular disease globally. The figure shows how low to middle class countries have increased rates of death. As countries modernize, people give up rural, farming jobs for more sedentary, urban jobs (Banks, 2022). In some third world countries where people aren’t as educated about cardiovascular disease, they may not understand that disease progression can be silent. In general, it is hard for people to view cardiovascular disease as an emergency since symptoms or discomfort may not exist until it is too late and someone has a heart attack or stroke (Banks, 2022). This is also the same reason why patients often do not follow prescribed treatment regimens set by doctors for hypertension and atherosclerosis or other cardiovascular ailments. When a patient is struggling financially, it is hard for them to spend money on treatment they don’t immediately see the results of or feel better from. Noncompliance of prescribed medication is perpetuating the cardiovascular disease burden.
Figure 2: Death rate from Cardiovascular Disease, (Ritchie, 2019).
There are also ethno-cultural differences in how patients view science based guidelines, protocols and treatments. For example, some Chinese and South Asian patients tend to question Western medicine and its safety and efficacy (King-Shier, 2018). This is because they traditionally rely on herbal or natural treatment for an illness. Even in the Western world, ethnicity plays a part. Studies have shown that compliance in the usage of diabetic medication is lower in Mexican Americans and Vietnamese because alternative medicine falls more in line with their cultural traditions (McQuaid, Landier, 2018). Globally, we need to address this diversity in patients’ perception of set guidelines, protocols and medication in order to enhance compliance of more cardiac patients.
The COVID-19 pandemic has undoubtedly exacerbated the cardiovascular disease crisis, not only through direct heart and vascular damage caused by the virus but also due to its indirect impact on individuals' lifestyles and healthcare access. Extensive research has already highlighted the direct cardiac implications of COVID-19 infection. During COVID quarantine, lifestyles changed as people began to eat unhealthy, drink alcohol more and lacked in their daily activity regimen and exercise (American Heart Association, 2021). Patients missed doctors appointments for fear of contracting COVID so their chronic conditions like hypertension, coronary artery disease, and diabetes went largely unchecked and untreated (American Heart Association, 2021). People feared hospitals so they did not seek timely treatment when having heart attacks or strokes (American Heart Association, 2021). Timely treatment could have prevented future heart decline or even death. People with cardiovascular conditions are predisposed to serious complications from COVID, but in their effort not to contract the virus, they often made their chronic conditions worse.
Combating global cardiovascular disease was already such a monumental task for the WHO and its partners, and the emergence of the COVID-19 pandemic has further complicated matters. So, the real question is, where do we go from here? We need to target not just adults, but children as well. Teaching healthy living practices from an early age can normalize healthy habits and make them an intrinsic part of life. By instilling these habits early on, we can prevent the onset of heart disease, saving valuable resources that would otherwise be spent on combating it later in life (Gaziano, 2005). The strategies created by the WHO and CDC also need better and effective implementation. Many low- and middle-income countries are already battling problems like hunger and infections, and lack the necessary resources to tackle another pandemic (Banks, 2022). These countries often experience a shortage of cardiologists, medications, and procedures needed to give them even a fighting chance. Globally, we need to make our strategies affordable, cost effective, and easy to implement. Establishing strategies that address the ethno-cultural differences in patients’ perception of set guidelines and medications would be helpful with patient compliance. Unifying the world is not an easy task, but without it we will all pay the price with our resources, health, and future.