Africa: The Burden of CVD and Hypertension and
World Heart Federation Involvement
Africa’s lesser known killer
Despite infectious diseases still being one of the major and most urgent public
health concerns of the continent, cardiovascular disease is increasingly being
identified in the literature and by public health institutions as an emerging threat.
In 2001, the World Health Report reported that CVD alone accounted for 9.2% of
the total deaths in Africa in 2000 compared with 8.15% in 19901. It should also
be noted that the average age of death from CVD is at least 10 years younger in
low-income settings than in developed countries, thus hitting adults in their most
productive years2. For example, in South Africa, 41% of deaths due to CVD
occur in adults between 35 and 64 years old, compared to 12% in the United
States3. The WHO has reported that the number of disability adjusted life years
lost to CVD in sub-Saharan Africa rose from 5.3 million for men and 6.3 million for
women in 1990 to 6.5 million and 6.9 million in 2000, and could rise to 8.1 million
and 7.9 million in 20104.
This situation is notably due to the increase in CVD risk factors in the population,
likely linked to rapid changes in lifestyles:
 Tobacco represents an important risk factor for CVD in Africa due to the
prevalence of smoking on the continent, particularly among males: 50% of
males in Namibia smoke. 40% to 49% of the male population in Tanzania
and South Africa, and 30% to 39% in Zambia and Zimbabwe, smoke5.
 Among CVD risk factors, the one that appears from the literature to take the
lead in causing CVD is hypertension, which displays a clear upward trend.
According to the WHO, more than 20 million people have hypertension in
Africa, with a prevalence ranging from 25% to 35% in adults aged 25-64
years6. For comparison purposes, 24.5 million people (adults and children) in
Africa live with HIV/AIDS according to the 2006 UNAIDS report7. Although
these figures come from two different sources and thus must be used
cautiously, they help illustrate the under-recognised extent of hypertension in
the adult population.
1
WHO Regional Office for Africa (WHO/AFRO), The Health of the People: The
African Regional Health Report (2006). WHO Geneva 2006
2
Ibid
3
Leeder, S., et al, A race against time: the challenge of cardiovascular disease in developing economies.
The Earth Institute, Colombia University , 2004
4
WHO, World health report 2002. Reducing risks, promoting healthy life (2002). WHO Geneva, 2002
5
WHO, The Tobacco Atlas. WHO Geneva, 2002
6
WHO Regional Office for Africa (WHO/AFRO), The Health of the People: The
African Regional Health Report (2006). WHO Geneva 2006
7
UNAIDS, Report on the global AIDS epidemic 2006. UNAIDS 2006
Tackling both tobacco control and hypertension should thus constitute the
cornerstones of public health programs designed to address the burden of CVD
in Africa.
The changing face of hypertension in Africa
The data available for hypertension prevalence in Africa, although limited,
consistently indicates an increase in the rapidly expanding urban populations: a
study carried out in 1985 on the urban migrants newly settled in Nairobi showed
that their move form rural areas to an urban setting was associated with a rise in
blood pressure. This was notably explained by a marked change in diet of the
new arrivals in Nairobi, with higher salt and calorie intake and a reduced
potassium intake8. This trend is predicted to increase as fewer and fewer
Africans live in truly rural conditions, with a growing proportion becoming
urbanized or semi-urbanized9. A recent study in Ghana has shown that the
prevalence of hypertension in urban Accra reached 27.3%10.
However, and more surprisingly, the increasing prevalence of hypertension is
also reaching rural areas. It is true that while rural African populations suffer less
from hypertension than their urban counterparts, their remote locations and
traditional lifestyles do not seem to protect them anymore. This rise of
hypertension in rural Africa might partly be explained by the fact that more and
more rural settings are in fact becoming “semi-urbanized” and are moving away
from the tribal lifestyle that still exists in parts of Africa11. A recent study carried
out in collaboration between the Harvard School of Public Health, The Colombia
Earth Institute and the Millennium Villages Project analyzed hypertension
prevalence in three rural villages in Rwanda, Malawi and Tanzania, and found
out that 22.8%, 15.9% and 26.8% respectively of the inhabitants were affected,
rates that are far from being negligible12. A study performed in 2004 in 12
villages in Ashanti, Ghana, showed the hypertension prevalence to be of 28.7%
overall13.
8
Poulter NR, et al, Determinants of blood pressure changes due to urbanization: a longitudinal study
(1985). J Hypertens Suppl. 1985; 3 (suppl 3): S375-377.
9
Opie, L., Seedat, Y., Hypertension in Sub-Saharan African populations (2005). Circulation, 2005;
112.3562:3568
10
Amoah AGB., Hypertension in Ghana: a cross-sectional community prevalence study in Greater Accra.
Ethn Dis. 2003; 13:310-315.
11
Opie, L., Seedat, Y., Hypertension in Sub-Saharan African populations (2005). Circulation, 2005;
112.3562:3568
12
Stewart S., et al, The epidemiologic and nutrition transition: prevalence and correlates of hypertension in
rural East Africa
13
Cappuccio, F., et al, Prevalence, detection, management and control of hypertension in Ashanti, West
Africa (2004). Hypertension, 2004; 43: 1017
A public health challenge for Africa
The growing prevalence of hypertension in rural settings in Africa is of further
concern as detection rates are lower in those areas compared to urban settings.
Hence, even if the rural populations suffer from less hypertension than their
urban counterparts, they are often not detected and treated.
The study carried out in Ashanti revealed that detection, treatment and control
rates were higher in semi-urban areas (25.7%, 14.3%, 3.4%) than in rural villages
(16.4%, 6.9%, 1.7%)14.
In its 2006 report on Africa, the WHO underlined that detection, treatment and
control of hypertension is poor overall in Africa, and that the situation is
particularly bad in rural areas15. The advantage of rural populations who suffer
less from hypertension is thus offset by this lack of detection, a problem made
even more acute by the fact that hypertension is rising in rural settings as well.
The challenge to manage hypertension in Africa thus lies in prevention, detection
and treatment, with a focus to be given to both urban and rural settings in order
to avoid the further development of a silent hypertension epidemic. As far as
prevention is concerned, this should focus on reduction of salt intake and a
greater awareness of the implications of obesity16, the latter being most prevalent
in urban areas. From a public health point of view, a major challenge will
certainly lie in convincing governments and funding institutions of the priority
hypertension deserves given the competition for scarce resources and in the light
of the other problems the continent has to face, such as AIDS, malaria, neglected
tropical diseases, hunger and warfare.
World Heart Federation involvement in Africa
Since 2001, the World Heart Federation has been actively involved in building
capacity in Africa to address the rising burden of CVD. This is being
accomplished through the creation and development of the African Heart
Network and national Heart Foundations; through targeted support to the Pan
African Society of Cardiology (PASCAR); through the development of a PanAfrican approach to the prevention of Rheumatic Fever/Rheumatic Heart
Disease; and through its Twin Centers fellowship program.
The African Heart Network was created as a platform to grow the number of Heart
Foundations in Africa, to bring them together for training purposes, to exchange
best practices and to develop common initiatives aimed at preventing CVD on the
continent. The growth of the African Heart Network has been tremendous. Four
14
Ibid
WHO, The Health of the People: African Regional Report (2006). WHO Geneva
16
Opie, L., Seedat, Y., Hypertension in Sub-Saharan African populations (2005). Circulation, 2005;
112.3562:3568
15
years ago, of the 53 countries in Africa, only three had active Heart Foundations.
Today there are 12 Heart Foundations that have joined the African Heart Network
(current members are Cameroon, Congo Brazzaville, Democratic Republic of
Congo, Ghana, Ivory Coast, Kenya, Mozambique, Nigeria, Rwanda, South Africa,
Sudan, Tunisia) and more are being created and have applied to join. These
organizations are beginning to play a leading role in the prevention and control of
CVD by bringing prevention into the mainstream of public awareness, policy
development, health services, community action, training and education.
The Pan-African Society of Cardiology (PASCAR) is increasingly active and has
recently organized the successful First All Africa Conference on Heart Disease,
Diabetes and Stroke, which took place in Nairobi, Kenya on 13-16 May 2007.
Multiple sessions were dedicated to the early detection and management of
hypertension. The issue of sustainable hypertension control programs was
positioned as a high priority for Sub-Saharan Africa in both rural and urban
settings. The World Heart Federation was the major sponsor for the conference.
The high quality of the scientific sessions as well as the professional organization
of the conference was praised by all delegates. PASCAR is set to play a leading
scientific role in Africa notably through its new journal, “Cardiovascular Journal of
Africa” and the organization of a continent-wide conference every other year.
The World Heart Federation is committed to assisting PASCAR along this path.
Prevention of rheumatic fever/rheumatic heart disease in Africa: In Sub-Saharan
Africa, more than a million children suffer from rheumatic heart disease and few
get the medical care they need to survive and lead normal lives. Based on an
initiative developed in 2005 by the Pan African Society of Cardiology (PASCAR),
and drawing from its experience of rheumatic heart disease control in the South
Pacific islands, the World Heart Federation is working with its members to
implement a rheumatic heart disease control program in Africa. The approach is
called ASAP, drawn from the program’s four pillars: awareness-raising,
surveillance, advocacy and prevention.
Demonstration projects are underway in South Africa, Ghana, Ethiopia and Egypt
with the aim of developing models for comprehensive rheumatic disease control
at the national level. Also, in May 2007, the PASCAR/World Heart Federation
Workshop on the Control of Rheumatic Heart Disease in Africa was held in
Nairobi, Kenya, bringing together experts, interested clinicians and Ministry of
Health representatives from 10 African countries. The workshop provided
training in cost-effective strategies to reduce the burden of the disease among
children and young adults. This World Heart Federation/PASCAR commitment
was selected to be profiled by the Clinton Global Initiative in 2006.
The Twin Centers (TC) fellowship program aims to enhance the quality and
capacity of cardiology centers and hospitals in less advantaged countries or
regions. This is achieved using a fellowship program. Fellows are cardiologists
or physicians who receive post graduate training in a specified area of cardiology
in the best centers of the world.
The TC program promotes and strengthens the development of formal structural
links between the fellow and leading centers or institutions with established high
quality programs, encompassing outstanding preventive care, clinical cardiology,
research and training.
The World Heart Federation sponsors four fellows each year. As a condition of
receiving the fellowship, each person agrees to return to his/her country of origin
to assist in the development of appropriate cardiology services in their respective
countries. In 2007, two fellows have been chosen from Africa. This has been a
tendency over the past five years, with many of the fellows coming from Africa.
Between 2002 and 2006, eight fellows were African, and two of them trained in
South Africa.
Members in Africa (WHF, PASCAR and AHN members)
Continental organizations:
African Heart Network (AHN) (WHF Continental member)
Pan-African Society of Cardiology (PASCAR) (WHF Continental member)
International Forum for Hypertension Control and Cardiovascular Disease
Prevention in Africa (IFHA) (WHF International Associate member)
National organizations:
Algeria
Algerian Society of Cardiology
Cameroon
Cameroon Heart Foundation
Congo-Brazzaville
Un Cœur pour la Vie (foundation)
Egypt
Egyptian Society of Cardiology
Ghana
Ghanaian Heart Foundation
Ghana Society of Hypertension and Cardiology
Ivory Coast
Ivory Coast Heart Foundation
Kenya
Kenya Cardiac Society
Kenya Heart Foundation
Mauritius
Mauritius Heart Foundation
Lord Djamil Fareed, Kt (associate individual member)
Morocco
Moroccan Society of Cardiology
Mozambique
Heart Association of Mozambique
Nigeria
Nigerian Cardiac Society
Nigerian Heart Foundation
Rwanda
Rwanda Heart Foundation
Seychelles
Seychelles Heart and Stroke Foundation
South Africa
The South African Heart Association
Heart and Stroke Foundation South Africa
Sudan
Sudan Heart Institute
Tunisia
Tunisian Heart Foundation
Zimbabwe
Jephat Chifamba, MD (associate individual member)
Heart Foundations are currently being formed in Angola, Democratic Republic
of Congo and Uganda
*
*
*
*
29 May 2007