Quick, what is the leading acute cause of death in world’s poorest nations? How about the second most common acute cause of death? The truth may startle you. Pneumonia as the leading acute cause of death is no surprise. But number two is coronary artery disease. No, not HIV, not diarrhea, not even malaria. It is simply arterial athersclerosis. And least you believe this an outlier, consider the fact that stroke – another manifestation of athersclerosis – is the fifth leading acute cause of death in the poorest nations.
Such straightforward epidemiology challenges one of the most popular misconceptions in the field of global health: the notion that infectious diseases – particularly the Big Three: tuberculosis, malaria and HIV – are the greatest plagues afflicting the world’s most vulnerable peoples. The fact of the matter, conversely, is that non-infectious, chronic maladies severely burden those living in extreme poverty, and that such maladies worsen their poverty through both health care costs and lost wages connected with lost work.
Healthcare leaders of bear the responsibility of translating these truths into effective interventions. Such interventions begin with recalling the role of risk factors. Whether coronary artery or cerebrovascular disease, whether in North America or southern Asia, the antecedents are hypertension, diabetes mellitus, tobaccoism, hyperlipidemia, and unhealthy diet. And, regardless of one’s nation or latitude, the chief therapeutic aim is reducing the Big Five Risk Factors.
But how can we facilitate control of hypertension, diabetes mellitus, tobaccoism, hyperlipidemia, and unhealthy diet in communities with meager healthcare resources? Management of episodic infections can be difficult enough, while the logistics of providing continuity care for chronic diseases can seem unattainable.
For me, the issue was epitomized in the case of an African pastor, Valencio. At the time, I was living at the Kalukembe Hospital in Angola. Valencio presented with frontal headache and a blood pressure of 220/140. I supplied him with a thiazide diuretic and asked him to return in two weeks. When he presented again the clinic staff tried to send Pastor Valencio away because he stated that he felt no discomfort. When I succeeded in speaking with Valencio he was incredulous at the thought of continuing to take medication. “Malaria treatment is only 5 days, so why should I take blood pressure pills week after week?”
We can help control chronic diseases in low-resource settings by developing straightforward management protocols and through assuring an adequate supply of basic medications. But most important is often simply assuring that both staff and patients understand the nature and importance of these conditions. ‘Chronic disease requires chronic treatment,’ I often explain, and, ‘Patients without symptoms may need continued treatment to prevent symptoms from appearing,’ I urge. We must educate people at all levels to appreciate that arterial atherosclerosis is a greater threat than the Big Three Infections, and urge them to direct efforts toward reducing the Big Five Risk Factors.