Hypertension in Central America. The darkest side of poverty
GINNER O. RIZO-RIVERA
Hospital Victoria Motta. (67) Jinotega-Nicaragua. E-mail
Recibido el 26-FEB-2019 – ACEPTADO después de revisión el 21-MARZO-2019.
There are no conflicts of interest to disclose.
Noncommunicable diseases have become vitally significant in developing countries, even more than communicable diseases. One of the most striking examples of this change is that noncommunicable diseases outweigh infectious diseases as the main causes of mortality in these developing countries. An example of these noncommunicable diseases is hypertension, which has been declared responsible for one of the world's public health crises. Central America, as a region, suffers even more than the rest of America its consequences. In the development of this article we try to understand and explain the causes of this greater susceptibility.
Noncommunicable diseases. Hypertension. Public health.
Undoubtedly, noncommunicable diseases currently have become very significant in developing countries in comparison to communicable ones. One of the most remarkable examples of this change is that noncommunicable diseases, such as cardiovascular diseases, hypertension, cancer, diabetes and COPD among others, have overcome infectious diseases as the main causes of mortality in these countries, as in the world in general [1,2]; i.e. poor individuals currently die because of the same causes as rich people.
Hypertension is a lethal, silent and invisible disease leading to death yearly for approximately 9 million people in the world, so it has been declared the cause of a worldwide public health crisis .
Central America as a region, suffers even more than the rest of the continent, the consequences of hypertension, a true public health crisis. This in general, is due to several factors:
Less development in comparison to the rest of the continent .
Less support by developed countries to control noncommunicable diseases in comparison to the support to fight communicable diseases.
High prevalence of the disease.
A healing view of medicine in the region (lack of preventive medicine view in the region).
High financial costs to control these diseases.
High human costs of the disease generated by temporary disability or due to the sequelae.
Variable quality of the drugs used.
1. Less development in comparison to the rest of the continent
To assess the development of a country we may use 2 indicators as a guide: human development index (HDI) and (nominal) gross domestic product (GDP) per capita.
HDI is a summarized measure for human development; it measures the advancement reached by a country in three basic dimensions of human development: enjoying a long and healthy life, access to education and a decent standard of living. It is used to differentiate if a country is developed, developing or underdeveloped, and also to measure the impact by economic policies on quality of life. According to the 2018 report on these indicators, in a world list, the best positioned Latin American country is Chile ranking 44, and in Central America, Costa Rica ranking 66. The worst ones in Latin America are Guatemala (ranking 127) and Honduras (ranking 133).
If we use the 2018 nominal GDP per capita as guide, a distinctly financial indicator, in a list of the continent of America, the best positioned Latin American country is Uruguay (ranking 5) and the worst ones are Honduras (30) and Nicaragua (31).
Logically, less financial development will cause less availability of resources for policies addressed to the diagnosis and treatment of chronic diseases, in this case hypertension, in comparison to the support that highly developed countries may provide, such as Scandinavian countries. This will express in less disease control and more consequences for the health of its inhabitants, as shown by hypertension control data in both regions[5,6]. It is obvious that support will vary depending on the state policies of each country.
2. Less support for self-protection by developed countries
Developing countries (as in our region), depend to a high degree on the help by developed countries. Unfortunately, the help provided by these countries is addressed to other priorities, such as maternal and child programs, and diseases that may affect their own population in the long run (as for instance HIV, TB, dengue, etc.). As nobody gets infected by hypertension or diabetes, and we will neither export an epidemic of myocardial infarction, this is not their priority; but it has to be for us, because they are the leading causes of death in our countries.
3. High prevalence of the disease
Recently, the first epidemiological study of a population representative of the north of Nicaragua was carried out, following the guidelines of the World Health Organization and the American Heart Association; and we determined an absolute prevalence of hypertension of 28.1%, with a higher prevalence in women (32.6%) than in men (22.5%).
In Costa Rica, a somewhat higher absolute prevalence was observed, close to 31.5%, with more prevalence in women (35.4%) than in men (27.7%).
In Panama, in one of the most extensive trials conducted in Central America, McDonald et al, found an absolute prevalence of 29.6%, but with greater prevalence in men (34.2%) than in women (27.5%).
As it is possible to see, the prevalence of hypertension in the region is high, and as it is to be expected, the values are pretty similar in all Central American countries, something that makes sense as their populations share many characteristics.
4. Healing view of medicine in the region
There are different state and nongovernmental organizations that attempt to fight hypertension, but with virtually nil effects. It is very difficult to understand how the healing view of medicine still remains in numberless countries, including those in Central America, when evidence is more than overwhelmingly showing that the most significant health problems are solved with education, with health promotion and prevention, with state strategies addressed to health protection and not to its restoration. In the continent of America, the greatest achievements have been reached by countries focusing in this manner, as Canada and Cuba, and I think it should be mandatory for the health care systems of our countries to apply the North Karelia (Finland) project strategy, to get real results in health matters.
5. High financial costs for its control
In literature, the yearly cost of care for ambulatory hypertensive patients has been described as ranging from 57 to 450 US dollars, including lab tests and medications. The data from Villarreal et al, are quite more recent; they determined that in Mexico (a country very near our region), the yearly cost per insured hypertensive patient is equivalent to 13.95% of the budget appointed for health, and 0.71% of GDP, values that turn to 51.17% and 2.62% respectively in an extreme scenario, not to mention the exorbitant costs of the complications in a poorly controlled hypertensive individual, and the patients that do not have medical insurance, and those who do not contribute to the economy of the country. I think it is unnecessary to discuss the financial repercussions of diseases like this on the capital of developing countries, as those in Central America.
6. High human costs of the disease generated by its sequelae
Hypertension is a direct cause of temporary disability because of its acute decompensations, but it may also cause permanent disability because of the consequences of its complications (myocardial infarction, heart failure, strokes, etc.)
In Cuba, hypertension is included among the first causes of temporary disability and complete disability in the statistics of the Sistema de Peritaje Médico Laboral (Work Medicine Survey System). In year 2009, HTN was reported as the second cause of disability. We did not find studies reporting these data in our region.
It is very difficult to determine the real financial cost of hypertension in a country, whether by direct expenses (medications, medical care, hospitalization) and by indirect expenses (losses due to temporary or permanent disability to work).
In the US, US$ 300 are lost per person per year due to hypertension, because of absences and medical leaves. It produces yearly losses for the financial system of up to US$ 30,000 million per year. In 2006, 4.5 weeks of work were lost per 100 workers because of hypertension.
If health care systems of developed countries approach the financial losses caused by hypertension as a big problem to be solved, it is difficult to think of the real impact on financial systems of developing countries such as those in Central America, countries that need all their populations capable of working, and that need to decrease losses by absences or disabilities. We should remember that an individual that is active in terms of work and that undergoes a permanent disability (for instance, a stroke due to a hypertensive crisis) will cause a triple loss to the country, as his/her work input will be lost, as well as his/her financial contribution to the social insurance, and he/she will also become a financial load for the country and his/her relatives.
7. Variable quality of drugs
In spite of a well-intentioned policy of medications existing in Central America and the Dominican Republic, and of such policy being addressed to a universal right of access to medications, in the region there are three basic types of medications: 1- Original drugs; 2- Bioequivalent drugs; and 3- Those of unknown quality. The latter are drugs that do not have bioequivalence studies meeting the necessary requirements in comparison to original medications; therefore, the level of real effectiveness is unknown, but regrettably they are authorized to be sold in several countries of the region; further, as they are the cheapest ones, they are the ones most consumed by the population. State policies should be addressed to the use of bioequivalent generic medications, effectively responding to solve the problem for which they are prescribed, and to them also being affordable for most of the population.
Hypertension is causing a crisis in world public health. Most developed countries have identified and are promoting the main factors favoring the control of this disease. In spite of the efforts of different state and nongovernmental institutions to fight hypertension, Central America as a region that still suffers even more the consequences of this public health crisis in comparison to the rest of the continent, as less developed countries always have a darker side in their health care systems.
«Human Development Indices and Indicators2018Statistical Update» (PDF). Programa de las Naciones Unidas para el Desarrollo (en inglés). 14 de septiembre de 2018. Consultado el 15 de septiembre de 2018.
Fondo Monetario Internacional (FMI), Base de datos World Economic Outlook ("Perspectiva económica mundial"), 17 de abril de 2018.
Valladares M, Rodríguez N, Rizo G, Rodríguez M, Rivera RM, López I. (2017). Prevalencia de hipertensión arterial y factores de riesgo en la población adulta de San Rafael del Norte, Jinotega, Nicaragua. (Tesis doctoral inédita). Ministerio de Salud-Jinotega. Nicaragua.
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