This year, World Hypertension Day locates itself within the greatest health threat to human wellness in recent decades – the COVID-19 pandemic. It does so with the expected socioeconomic impact that the crisis is likely to have on all us; none of us are immune to the indirect effects of COVID-19. The pandemic also offers important lessons to be learnt, and to positively change the way we see our own health landscape in Barbados.
Hypertension kills directly and indirectly
High blood pressure has traditionally been described as a “silent killer”. This is largely due to the insidious approach of catastrophic events, such as heart attacks and stroke. The biggest driver for this is the “asymptomatic carrier” of uncontrolled blood pressure. Contrasting with the current public health emergency, this type of asymptomatic “carrier” of disease, although not contagious, is destined to an almost certain premature cardiovascular event. The biggest barrier to fighting high blood pressure is knowledge; people need to know their blood pressure numbers to be aware they have it.
The current phenomenon of hypertension predisposing to worse outcomes in COVID-19 is, however, not surprising. Most people, when faced with an infection, will try to mount a credible defense – the immune response. The infection and the response may impact almost every organ in the body – this is referred to as sepsis. A heart damaged from long term “exposure” to high blood pressure is less efficient and may therefore struggle to achieve the appropriate cardiac output required to sustain life. People living with high blood pressure therefore, start off at a disadvantage, but may still survive the sepsis of COVID-19, although they are less likely to do so successfully.
Regardless of the mechanism of assault, high blood pressure’s role in increasing the risk of death in COVID-19 is predictable. The fact that more than 50 per cent of adults with high blood pressure in some low- to middle-income countries are unaware of this is hazardous. The viral enemy therefore places this asymptomatic “carrier” at risk of an unguarded poor outcome.
Public health measures can change the disease environment
A strategic national public health response has been the major determinant of containing the COVID-19 tsunami wave. This called for a consortium of technical experts, connected by a common goal to reduce the impact of COVID-19 on the population, in a targeted effort to “flatten the curve”. The economy of the response can not be overlooked. There are financial, social, political and health compromises that must occur to effect this population response. Countries that have done this well have saved thousands of lives. There is also contemporaneous evidence that those countries which have sluggishly reacted still remain in catchup mode, and almost helplessly observe a growing count of death and disability.
The COVID-19 response has brought an entire country to a standstill, and, even with some strong voices in economic support of a premature reopening of lockdown, this has fallen on the very reluctant ears (and eyes!) of our society at large. Public health has taken precedence. The “lockdown” policy was created to ensure the healthiest environment to prevent viral spread. It makes sense.
The high blood pressure phenomenon is by no means a dramatic pandemic. There are no clocked figures on a CNN screenshot showing the number of people with hypertension, or number of deaths from heart attacks and strokes. Yet the disease burden is chronic, escalating, and driven by strong social and political determinants of health.
How have we secured the healthiest environment to reduce this “spread”? The high blood pressure environment has been created with socially not-so-distant access to fast, unhealthy food, reduced physical activity, and the emergence of a salty nation. The inability to achieve “safe” school environments now fosters the creation of the next generation for population susceptibility, with high rates of childhood obesity and earlier onset of high blood pressure. To put things in perspective, the six-feet social distance is very analogous to a six-steps intervention to reduce the risk of high blood pressure – a shorter distance significantly increases risk in both cases.
A “Six-Step” plan includes:
1. Access to healthy foods
2. Increased physical activity
3. Smoking cessation
4. Reduction in excessive consumption of alcohol
5. Reducing added sodium (salt) to food
6. Elimination of trans-fats from diets.
These risk factors for high blood pressure and other non-communicable diseases now need to be encouraged, easily facilitated, and policed by our government. The social determinants of health are the same drivers influencing RISK for both the constant hypertension epidemic in our region and the novel pandemic of COVID-19.
What can we learn from COVID-19?
COVID-19 will construct a paradigm shift in the way we live our best lives ever. The post COVID-19 world will likely see closer attention paid to the one quality that we have ignored in our highly technological sophisticated world – the interdependency of humanity.
There are six COVID-19 legacies which I believe we should carefully chronicle, and learn from, in our fight against the resident epidemic of high blood pressure:
Leadership counts – the world’s pandemic history from the 1918 Spanish Flu forecasted that strong decisive leadership will better equip a country to address national health threats. Failure to do so effectively, whether delayed or anemic, has the potential to cause loss of lives and social disruption. A national blood pressure reduction approach, therefore, needs the strongest political acknowledgement and decisive plan of action.
Recognition of the threat – high blood pressure must be recognized by both citizens and governments as posing a socioeconomic and health threat to the nation. The severity of this should not be diluted, but rather integrated into a national health and wellness protection plan.
Acceptance of the science – science must be seen as factually credible and not simply an alternative view of fake news. This allows for easy acceptance of similar disease models for high blood pressure deaths to flatten this curve as well!
Public Health interventions may be more important than tertiary care. As simple as social distancing, cough etiquette and hand washing initially appeared to be, they remain, by far, our only defense against COVID-19. So too are public health interventions to restrict the sale of sugar-sweetened beverages, with restrictions on sodium content etc., on high blood pressure. The “bigger picture view” of such interventions must be that they are simple, slower acting, and wider reaching than any drug treatment at an individual level.
Balancing human health with the economy continues to be a delicate game. The public health measures for COVID-19 heralded cries of a “devastating economic wave” from prolonged lockdowns – the medicine was thought to be more lethal than the disease! The same is true for any high blood pressure population intervention. Heart attacks and strokes carry an alarming cost to society as well. They do so outside of the health sector and continue to cripple workforces due to premature death and disabilities.
Increased testing to pick up asymptomatic “carriers” can be considered one of cornerstones of the population measures to reduce the infection rate of COVID-19. The potential of this group of well-looking individuals to rapidly infect an entire population is an easy concept for health authorities to grasp, and to action. The asymptomatic carrier of high blood pressure is also lethal at a population level, although not contagious. This individual receives the social investments of health care, access to higher education, and other public services, only to succumb to the devastating effects of premature cardiovascular events. People living with hypertension need mass testing as well. Screening is as cheap, convenient and as reliable as a blood pressure device, but the effort requires similarly robust “testing” as seen recently in curtailing spread.
I wish the nation, the region and our new world the very strongest hope for success in our battle against high blood pressure. As we navigate a novel health crisis, not seen before in our lifetime, my hope is that the memories of the hardship and pain we currently may feel, will build resilience and we move forward with a well-rehearsed COVID-19 legacy.
Happy World Hypertension Day 2020!!
Dr Kenneth Connell is the president of the Barbados Heart and Stroke Foundation.