Heart disease, not HIV / AIDS or malaria, is the leading cause of death worldwide.

In 2016, about 1 million people died of HIV / AIDS, 445,000 were malaria patients and 1.7 million people were living with TB.

Nearly 18 million people have died from heart disease. And more than three quarters of these deaths occurred in developing countries.

If you ask someone to list the most deadly global health problems facing the world, something as commonplace as heart disease usually does not figure at the top of the list. Yet he is there, responsible for a third of deaths worldwide.

Moreover, in poor countries, these deaths occur earlier. In affluent areas like the United States and Europe, heart disease tends to weigh heavily on the elderly (only 15 to 20% of heart disease deaths are under 70 years of age). But in poor countries today, more than half of the people who die heart disease is less than 70 years old and some are much less. These people are also the poorest of these countries. more affluent people have access to preventive medicine and lifestyles that keep the disease at bay. And the problem should only worsen: in Africa, the number of deaths due to chronic diseases, nearly half of which are due to heart disease, is expected to increase by one-third in less than a decade.

Heart disease, which is still considered a lifestyle-related disease of wealthy Americans, who eat more, exercise less and live longer, are now diseases of the world's poorest.

It will be difficult to control the problem, especially if the action remains as slow as it has been. Less than 1 per cent of the $ 35 billion spent annually on health development assistance has been devoted to the prevention of heart disease, and this figure has barely changed since 2000. HIV / AIDS, on the other hand, accounts for 4 per cent of global burden of disease 29% of global funds.

The world is changing: people are living longer than ever, and for the first time in history, there are more urban than rural people, making lifestyles more sedentary and worsening the environment . Fast food is saturating all corners of the globe, which means not only is McDonald's more ubiquitous, but fried starchy foods are the most affordable way to eat.

But perceptions of what kills the poor in the world have been slow to change. The attention and funds devoted to global health have mainly concerned infectious diseases such as HIV / AIDS, malaria and even the Ebola virus. Yet, the nature of the disease in the world is changing rapidly, and more rapidly in poor countries. And neglecting the fact that heart disease is one of the leading causes of death among the world's poor means giving up the opportunity to save millions of lives with simple interventions.

What makes heart disease so deadly

Heart disease is technically a subset of cardiovascular disease, but both are often used interchangeably to refer to some conditions affecting the heart. The most deadly involve narrowed or blocked blood vessels or arteries that can lead to a heart attack or stroke, responsible for the vast majority of deaths from heart disease worldwide.

Heart disease is actually very treatable and, more importantly, preventable – if detected early. This can be prevented, and even reversed, with lifestyle changes such as eating more fruits and vegetables and less sugar, quitting, consuming less alcohol, and doing more physical activity. In addition, there are drugs to lower blood pressure and cholesterol that are relatively inexpensive.

Once heart disease progresses, things become more complicated and costly – even if procedures such as stent insertion to dilate the arteries or cardiac bypass still need to be treated, especially when the arteries are clogged.

But the countries that are experiencing the fastest increase in noncommunicable diseases – which include heart disease as well as other chronic diseases like cancer and diabetes – are those with health systems that are less prepared to deal with it.

The changes also occur very quickly: in 1990, chronic diseases caused about a quarter of deaths and disabilities in poor countries. By 2040, they should be responsible for 80% in some countries. This is partly a good thing: fewer people die from infectious diseases like HIV and malaria, and as a result the proportion of deaths from heart disease increases. But the shift from infectious diseases to noncommunicable diseases occurs three to four times faster than in rich countries, leaving health systems in trouble.

Theoretically, eliminating the behavioral factors contributing to heart disease, such as smoking or eating fatty foods, is the best public health intervention against heart disease – but this is much easier said than done.

The reason is that it is very difficult to change people's behavior, especially when it comes to health. Moreover, focusing on behavioral changes masks how heavy the game is against people, especially the poor. In some countries of the world, soda ash is cheaper than bottled water, making it an increasingly important staple in the nutrition of adults and children in poor countries. Air pollution is worse in the world's poorest cities: living in a city like Mexico City is equivalent to smoking 6.5 cigarettes a day, and living in New Delhi, India is equivalent to smoking 25 cigarettes a day.

Trade liberalization has opened the markets of poor countries, making unhealthy foods cheaper. In South Africa, eating healthier costs 69% more. Globally, major tobacco chains and international fast-food chains have enormous weight. political and economic power that changes lifestyles and, in turn, influences public health.

Taken together, these factors are quite overwhelming, making heart disease much more difficult to fight than their infectious counterparts. That may be part of why we continue to focus on the fight against infectious diseases: we know how to do that. It has been clearly demonstrated that the distribution of mosquito nets in rural villages in Africa reduces infant mortality and overall infection rates. Promoting condom use has clearly been effective in reducing HIV / AIDS infection rates.

However, while it is difficult to fight heart disease, it may not be as difficult as other global health problems we have encountered successfully. Like Thomas J. Bollyky, the author of The wounds and the paradox of progress: Why the world is becoming healthier in worrying ways, pointed out to me, getting more than 21 million people on antiretroviral (ARV) treatment for HIV was not easy either. HIV treatment involves taking a cocktail of medications daily for the rest of the patient's life. Medications have side effects, such as fatigue and nausea, and must be taken with adequate nutrition, which is particularly difficult in some places in rural Africa. Even so, new HIV infection rates have almost halved since 1996 – largely because so many people are taking ARVs that, taken correctly, make it almost impossible to transmit the disease.

There is no reason why we can not make the same progress against heart disease.

Save lives with pills and paperwork

Lauren DeCicca / Getty Images

Environmental and demographic changes partly explain why heart disease has become uncontrollable. But one more important reason – and one that has made heart disease so lethal – is that poor countries do not have the kind of preventative care that stops heart disease long before it is advanced enough to cause a heart attack. heart attack or stroke.

"When you boil Unfortunately, the true story about noncommunicable diseases is, unfortunately, the same as in other areas of global health: it is poverty, inequality and lack of access to medical tools in high-income countries. " said Bollyky.

Think about the number of times your blood pressure is taken – every time you see a doctor, whether for a regular check-up or something more serious.

This is because high blood pressure puts one at risk for heart disease. And if you detect it early, as many Americans do now, high blood pressure medications and lifestyle changes, such as quitting or exercising, can stop the problem.

Deaths from heart disease in rich countries like the United States account for a quarter of what they were in the 1980s. Half of this reduction is the result of preventive medicine, including screening for risk factors such as as high cholesterol or high blood pressure and their combination with drugs such as ACE inhibitors and beta-blockers – unpatented and inexpensive drugs, sometimes less expensive than $ 5 per month.

A study shows that heart attack management with low-cost drugs produces $ 25 in health and economic savings for every dollar of investment. Even aspirin, which costs a little over a dollar for a month of stock can reduce the risk of heart attack in people who have had one and increase the survival rate if taken just after a heart attack. This could save thousands of lives if it was still stored in clinics around the developing world.

But, while drugs are inexpensive and effective, send them to the people who need them can be difficult. And with many people in developing countries living on less than a few dollars a day, the cost can still be prohibitive. Nearly half of Africans lack basic medicines or medical care, and about 10 percent of people in developing countries receive preventive treatment for heart disease.

Pharmacies are rare in developing countries. Where they exist, they often run out of drugs. As Dr. Thomas Gaziano, who is studying inexpensive interventions for heart disease and other noncommunicable diseases at Harvard University, said, people can not stop at Walgreens or a CVS to get in. at home after treatment or receive treatment by mail. Taking medication often means getting off work to get to the nearest pharmacy, which involves spending money on transportation and waiting often in line of waiting. As medical supplies are irregular in developing countries, it is not uncommon for the medicines you need to be out of stock by the time you get there.

Another problem is the lack of doctors and nurses to determine who needs these drugs. The World Health Organization estimates that sub-Saharan Africa has a deficit of 1.8 million health workers, which is expected to increase to 4.3 million by 2035.

These two factors – remote sites and overburdened health care systems in developing countries – argue for the use of community health workers, an increasingly common strategy used by poor countries to address shortages. health professionals.

These are people from the community who have no formal medical training but who can provide information on health care or distribute basic medical supplies. In fact, community health workers have contributed to the successful antiretroviral treatment of HIV-positive Africans and the maintenance of their treatment. The advantage of using them is that they cost less – sometimes even voluntarily – and can go directly to their loved ones, which means patients do not have to spend an expensive and sometimes sterile visit to the doctor. .

The good thing about heart disease is that risk factors are relatively easy to detect. They include things like obesity or a history of diabetes. A study in South Africa, Mexico and Guatemala found that community health workers using a series of questions on a piece of paper or a mobile phone application could visit patients at home, ask questions and determine if the patient was high. risk as effectively as a doctor or nurse. Once patients were informed that they were at high risk, 30 to 70% of them were treated at a health center, where a high percentage continued to receive proper care.

An increasing number of countries are deploying community health workers to fight heart disease and other chronic diseases. South Africa, which has one of the fastest growing heart disease death rates in the world, is restructuring its health system and plans to deploy 700,000 community health workers by 2030.

One more cost-effective intervention for heart disease, and that advocated by the World Health Organization, imposes heavy taxes on tobacco products. Smoking is a leading cause of heart disease and, while smoking is decreasing in the United States, it is increasing in most developing countries. In Africa, it has increased by 50% in 35 years.

Obtaining political support for this type of intervention is difficult, especially in poor countries whose governments more and more targeted by the tobacco lobby. However, it is worthwhile to try: studies have shown that making cigarettes more expensive through taxes has resulted in a net and marked reduction in the number of smokers.

Heart disease is a disease of poverty, not luxury

Heart disease is still considered a disease of excesses, rather than deprivation. This misconception costs life – and it will probably cost a lot more if things do not change. Between 1990 and 2040, Bangladesh, Ethiopia, Myanmar, Iran, Indonesia, Pakistan and India are the countries where the increase in the number of deaths and disabilities due to chronic diseases is the highest. important. Countries in sub-Saharan Africa are also expected to experience a significant increase and their health systems are particularly poorly equipped to cope with these changes.

It should also be noted that the effort to fight heart disease could be more than profitable. Effective management of high blood pressure alone could save $ 100 billion in health care costs per year.

Not so long ago, HIV / AIDS seemed as insoluble and complicated as chronic diseases today. HIV / AIDS is still a crisis – but it is a crisis that the global community has managed to cope successfully because we have focused our efforts there.

We must devote the same energy and attention to heart disease. He was led by fairly powerful factors – urbanization, big tobacco and Burger King – But we have not tried hard to fight it, at least in developing countries. And that's what needs to change.