NEW YORK CITY – A leading killer, hypertension, receives barely a nod in many of the world’s health systems – even though it’s the key contributor to deaths from cardiovascular disease, which claims about 17.9 million lives annually and is the single largest cause of deaths in the world today.  Addressing this systemic neglect is critical to advancing universal health coverage, says the World Health Organization. 

WHO’s first-ever Global Hypertension Report, released Tuesday, calls for the dramatic scale up of prevention, treatment and diagnosis of a condition that affects one in three adults worldwide, but is adequately treated only in about one in every five cases.  

The report was one of two WHO publications released just in advance of a critical UN High Level Meeting on Universal Health Coverage, set for Thursday, 21 September. 

A second publication, the Global Monitoring Report co-authored with the World Bank, underlines the huge gap that still exists between the vision of UHC and the reality. Half of the world’s population lacks access to essential health services and 2 billion people face severe financial hardship due to out-of-pocket healthcare expenses. That reality is far short of the 2030 Sustainable Development Goal (SDG) of coverage for all.  

Without more attention to hypertension and other noncommunicable diseases, which today represent some 74% of premature mortality worldwide, progress on UHC will remain stalled, WHO officials have warned.

“Uncontrolled hypertension can lead to heart attack, stroke and premature death,” said WHO Director General Dr Tedros Adhanom Ghebreyesusm, speaking Tuesday at the launch of the report . “The loss of families and communities is not only personal, it also affects economies and development. In the Sustainable Development Goals, countries have committed to reducing premature mortality from noncommunicable diaseases by one-third by 2030. To get anywhere near that target, all countries must take urgent action on hypertension as part of their journey towards universal health coverage.”

Number of people living with hypertension has doubled

The number of people living with high blood pressure doubled between 1990 and 2019, from 650 million to 1.3 billion, the global hypertension report notes. But nearly one-half of people are entirely unaware of their condition, and only one out of five people actually receive adequate treatment. 

Moreover, the condition that was traditionally associated with the rich diets and sedentary lifestyles of high-income countries is making big inroads in developing regions – along with the encroachment of salt-laden processed foods on traditional diets and other lifestyle changes. 

In fact, more than three-quarters of adults with hypertension today are living in low- and middle-income countries, the report stated. 

“One in three people worldwide has hypertension, only one in two knows that they have it and only one in five globally are under control [of their condition],” said Bente Mikkelsen, director of WHO’s Department of Noncommunicable Diseases at a press briefing on Monday, just ahead of the report’s release.

Increased diagnosis and treatment could prevent 76 million premature deaths by 2050

Technically, the condition is defined as having a blood pressure measurement of more than 140/90 mmHG [millimeters of mercury] or taking hypertension medication, said Mikkelsen. 

However whenever blood pressure levels rise above 120/75 mmHG, risks begin to increase sharply, warned Tom Frieden, head of the US-based nonprofit Resolve to Save Lives, which has long supported WHO’s work on hypertension and cardiovascular disease.  

“Hypertension is the world’s leading killer,” he declared at the WHO briefing. “And in fact risks double with every 10 mmHG increase in blood pressure.”

Additionally, although the 1.3 billion estimate of people with the condition spans the ages of 30-79, it can occur at younger ages as well, he said.

Detecting and treating people at levels achieved in “high-performing” countries could prevent some 76 million premature deaths by 2050, along with 120 million strokes and nearly 100 million cases of heart attack and heart failure, the report concluded. 

Solutions are cheap and simple – or should be

But while diagnosis and effective medications are both simple and inexpensive, in principle, neither are routine services in primary health care systems in many low and middle income countries, the health experts noted. 

“The most deadly condition is also the most neglected,” declared Frieden.

He noted that the technology to detect hypertension, a simple handheld sphygmomanometer, is hardly new. More recently, battery-powered devices have made measurement even easier for lay people. 

“There is no excuse for any country not to measure blood pressure,” Frieden declared. “This is not an innovation that just happened, it’s an innovation that happened many years ago.” 

And he described it as “unethical” that many generic medications, which are inherently inexpensive, are subject to markups and price gouging in many developing countries – and thus unavailable to many people. 

“It’s an immoral fact that we have off-patent medicines that are unavailable,” said Frieden, who revealed that he, himself, uses an inexpensive, generic blood pressure medication known as amlodipine. 

“I have hypertension. I am on it.  It’s not second rate in any way.

“But we have to put on record that, as of today, there is a huge access problem,” he observed, for drugs just like the one he is using. “It is almost catastrophic. These are very cheap molecules. But if you look at countries, you have markups, you have little regulation. And until medicines are free, the most vulnerable may have to choose between food and medicines.” 

Essential to UHC core package

Mikkelsen declared that “an essential package for hypertension should be core to any universal health coverage,” referring to the WHO HEARTS technical package for guidance. 

She pointed to the examples such as Canada, India and the Philippines, which have made hypertension diagnosis and treatment a standard procedure in primary health care. 

“We want to make it clear that it is possible for any country, low-income or high income country, to change the situation,” she added. 

In India and the Philippines, community-based and team based care has made all the difference, she said. 

“India has the largest HEARTS-based programme in the world,” added Frieden. “I’ve never seen anything as exciting and as important as the Indian health and wellness centers, which have very effective hypertension treatment.”

Yet while such Asian countries are making big progress, in Africa, hypertension treatment lags far behind.

“If in Canada six out of every 10 people with hypertension are very well treated, in Africa it’s only five or six people out of 100,” noted Mikkelsen. 

Even so, money is not the secret to success. The United States, which outspends most countries on healthcare, has far lower hypertension detection and treatment rates than its neighbor to the north, Mikkelsen and Frieden noted.  

Unhealthy diets, physical inactivity and air pollution 

Incorporating hypertension treatment into the traditional national and donor-supported programmes for HIV/AIDS ,TB, malaria and maternal health is one way to mainstream diagnosis and treatment, the experts noted. 

Collaborations with organizations such as The Global Fund have expanded along with the recognition that people living with diseases like HIV/AIDS also are at increased risk of hypertension – particularly as they age.  

Prevention of hypertension through diet, lifestyles and environmental factors is another key message, however, of the new WHO report and initiative. 

Levels of hypertension roughly correlate with salt and potassium intake, Frieden said – with salt increasing risks and potassium reducing them. 

However, barely 6% of countries have policies in place to combat excessive use of sodium in food products, he pointed out.  Excessive use of alcohol and tobacco are other factors – also still poorly regulated in many countries. 

‘We have imported an alien way of life’

Urbanization and the onslaught of cheap processed and ultra-processed foods marketed by global food chains  are changing diets and lifestyles in many low- and middle-income countries, increasing hypertension risks, noted Terrence Deyaisingh, Minister of Health, Republic of Trinidad and Tobago, at Tuesday’s launch event.

“We have, unfortunately, imported an alien way of life in what we eat. When we try to walk around, it’s like New York City. In the adoption of technology, children no longer play [outdoors],” he lamented. The country implemented a HEARTS-based programme of outreach to increase diagnosis and control, and is committeed to have 50% of people living with hypertension under treatment by 2050.

Lesser known is the fact that exposure to air pollution increases hypertension risks, as well.  The fine particles of pollutants absorbed into the bloodstream inflame and constrict the blood vessels, as well as increasing blood clotting, which can lead to a stroke. WHO estimates that 99% of people worldwide are exposed to unhealthy levels of air pollution. 

And overall, addressing such issues require a wider approach, beyond the individual and the health care system, Frieden noted.

“Encouraging people to have healthier diets is fine,” he said. “But it’s not really effective. You have to make the physical environment more conducive, so that you are more likely to walk or bicycle.”

Added Mikkelsen. “We don’t believe that we can totally delete the problem by prevention – rather we are looking into modifying the trajectory of hypertension. So I have to say that we need to continue to focus on treatment and control.” 

Image Credits: WHO Global Report on Hypertension/Natalie Naccache, E. Fletcher/HPW, WHO Global Hypertension Report, 2023, E. Fletcher/Health Policy Watch, WHO Global Hypertension report, Marco Verch/Flickr , WHO Global Hypertension Report , Jean-Etienne Minh-Duy.