Down with high blood pressure [full issue]

down with high blood pressure WORLD HEALTH THE MAGAZINE OF THE WORLD HEALTH ORGANIZATION • FEBRUARY-MARCH 1978 • USA $ 1.60 Hypertension, or high blood pressure, is a silent, secret threat to the health of people around the world. Presenting no symptoms in its early stages, hyperten- sion often passes unnoticed. However, its complications are among the most im- portant causes of death and incapacity in many parts of the world. As blood pres- sure rises, so does the risk of stroke and coronary heart diseases. As blood pres- sure goes up, life expectancy goes down. Yet, though this is common know- ledge in the health profession and the means to control this condition exist, the largest part of the population at risk is not being helped. In a recent survey of European and North American adults, 10 to 15 per cent were found to be hyper- tensive; nevertheless, only half of the cases were known to the health profes- sion and of those only 30 per cent at most were under treatment. Moreover, of those under treatment only a minority had had their blood pressure brought down to a safe level. This is the situation in countries with highly developed medi- cal services. Prevalence of hypertension in developing countries seems to be about as high and the numbers who are treated far less. Because the problem of hypertension is worldwide and because the means are available to tackle it if the community can be mobilized, WHO has chosen hyper- tension as the theme for World Health Day-7 April-1978. A network of collaborating centres has been established by WHO to study the feasibility of community control for hypertension. This includes detection, treatment and follow-up of patients. Dif- ferent methods of control are compared, WORLD HEALTH DAY 1978 down with high blood pressure BY DR HALFDAN MAHLER Director-General of the World Health Organization 2 a a a AP a a a a a a a a a a a a a a a a • a as a a a a a a , 4.6 It's never too early to check on blood pressure. The diet and life-styles of youth will affect the health of the heart in later years. (Photo WHO/M. Jacot) and WHO is making a particular effort to develop approaches that can be easily adapted to the socio-economic condi- tions of developing countries. Certain broad principles have already emerged. Where the community has shown a strong will to combat the prob- lem, there have been some striking suc- cesses : in one such programme it is esti- mated that thousands of lives are saved each year through hypertension control using a variety of means. The fight to control hypertension should not be seen as a dramatic one- time-only campaign but rather as something that will become a normal and permanent part of existing health services. Control of this community health problem goes beyond the medical services. It needs the continuous support of the public, often spearheaded by non- governmental organizations. Teachers, public officials, the mass media and the entire community must be enlisted to help detect the large number of persons at risk who are unaware of their condi- tion. Nurses, doctors, members of the family must all be ready to help the person at risk to seek treatment and then encourage him to stick to it. In many cases a better life style with a view to improving diet and increasing exercise should be encouraged. With this broad appeal to health pro- fessionals, the public and non-govern- mental organizations, WHO hopes to en- list communities everywhere in the fight against hypertension. ■ WORLD OFF LIACAOOF OF TOL WOOF° XfAVIN °ROAM/F.0N FFOROMIV MARCH T978 USA 60 • • dawn with high blood pressure Cover designed by Peter Davies. Contents Down with high blood pressure by H. Mahler 2 Prompt treatment pays by J.I.S. Robertson 4 The silent killer by T. Sellers .. 8 On the right lines by S. Hatano 12 Hypertension in a quiet land by N. Willard . . . 16 The African experience by 0. 0. Akinkugbe 20 24 28 Priority problem by Z. Pisa and T. Strasser . . . 34 News Page 36 Young World Health 38 World Health appears in Arabic, English, French, German, Italian, Per- sian, Portuguese, Russian and Spanish. Articles and photographs not copy- righted may be reproduced provided credit is given to the World Health Organization. Signed articles do not necessarily reflect WHO's views. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland. Living longer by J. Bland Effective control by A. Froment prompt treatment pays BY J.I.S. ROBERTSON For years an academic bat- tle raged about just what hypertension was. Some maintained that high blood pressure was a disease in itself. Hypertensives were distinct from other people. There might be a gene responsible but, in any case, hyperten- sives were a class apart. Those who held the opposing view maintained that high blood pressure was simply the upper end of a scale on which were distributed all the degrees of pressure. Some people were very hypertensive, others had quite low blood pressure and all of the rest the majority—were located somewhere along a line that ran from one extreme to the other. There was no such thing as a distinct cut-off point between healthy people and those who suffered from hypertensive disease. This battle of ideas was no academic question but was indeed crucial to what it meant to screen for and treat hyper- tension. In recent years the second view has been generally accepted. There is no genuine dividing line that separates "normal" from "hypertension"; any def- inition of what is high blood pressure is therefore entirely arbitrary. What is referred to clinically as "essential hyper- tension" is really a blood pressure level distinctly above average and without evi- dent cause. High blood pressure carries an in- creased chance of stroke, coronary heart disease, heart or kidney failure. The higher the pressure, the greater the risk. Since it seems more and more evident that high blood pressure is caused by multiple factors, it follows that the search for a single, correctable cause will be unrewarding. This has proved to be the case. The great majority of thok whose blood pressure is high suffer from hypertension without evident cause. Their therapy must consist, therefore, in lowering arterial pressure through the use of non-specific anti-hypertensive drugs. Among a small proportion of patients, however, hypertension does have an identifiable cause and this possibility should be considered first by physicians. The younger the prospective patient, the BRIEF GLOSSARY Angina (pectoris): Chest pain, usually caused by a malfunction of the heart, brought on by effort or excitement. Arteriosclerosis: A thickening and loss of elasticity of artery walls which impedesthe flow of blood. It is usually caused by atherosclerosis. Atherosclerosis: Lesions and fatty deposits on the inside of arteries that narrow artery walls and thus block the flow of blood. Blood pressure: The pressure of the blood on the walls of the arteries, dependent on the energy of the heart action. Cerebral haemorrhage: Bleeding in the brain caused by rupture of arteries. Commonly known as stroke, it is frequently caused by hyper- tension. Cerebral thrombosis: Also com- monly known as stroke, it results from a clotting within an artery of the brain that reduces the blood flow to part of the brain. Coronary (or ischaemic) heart disease: An insufficient supply of blood to the heart muscles, in most cases caused by a thickening of the coronary arteries. Hypertension: Commonly known as high blood pressure, it is an abnormal rise of arterial blood pres- sure, which when normal is below 140 mmHg as the heart contracts (maximum or systolic) and below 90 mmHg as the heart dilates (mini- mum or diastolic) (mmHg being the pressure measured in millimetres of mercury). Essential hypertension: The most common form of high blood pressure, it is hypertension of unknown origin. Secondary hypertension: Hyper- tension where the cause is known. Renal hypertension, as a result of kidney disease, is the most common form. Heart attack: A commonly used term for myocardial infarct. Infarction or myocardial infarct: Death of a portion of the heart to which blood supply has been cut off owing to the blocking of an artery. Stroke: Sudden paralysis of part of the body when blood supply is cut off to a part of the brain. more assiduously should such a cause be sought. There are two reasons for this : an underlying abnormality is more likely to be found in a young person; and if such a factor is not identified, the patient is faced with the prospect of taking non- specific drug therapy for a lifetime. Some specific causes of hypertension have been identified. Oral contracep- tives, for example, can cause a marked rise in blood pressure in some women and a slight increase in most. This possi- bility should never be overlooked in a young woman with high blood pressure. The Pill certainly worsens hypertension and it is illogical to treat raised blood pressure while continuing oral con- traceptives. Sometimes merely stopping the Pill brings blood pressure down to acceptable levels. A variety of congenital kidney and adrenal gland conditions can cause high blood pressure; fortunately many can be dealt with by surgery. However, it must be emphasized again that hypertension with an identifiable cause is rare. Although high blood pressure carries an increased chance of the patient suffer- ing a stroke, coronary heart disease, heart failure or kidney failure, it does not necessarily follow that reducing it by the use of drugs will also reduce the inci- dence of these complications. This is a possibility that must be tested and proved. The first proofs were demonstrated in cases with severely raised levels. With very high levels, particularly if the pres- sure has risen rapidly, a complication known as "malignant phase hyperten- sion" may occur. Put simply, this means that small arteries in many parts of the body begin to disintegrate because of the very high intra-arterial pressure imposed on them. These changes can be seen when tissue is examined under the microscope and there may be damage to the retina and the kidneys. As the term indicates, "malignant hypertension" is invariably fatal if untreated. Residents of a Bombay suburb gather in the courtyard for a routine check-up during a community survey on high blood pressure. (Photo WHO/A. S. Kochar) 4

In these severe cases, no elaborate controlled trials were needed to show how important it was to reduce blood pressure. With appropriate therapy, heart failure declined, the advance of kidney failure was halted and, in many cases, lesions of the retina healed com- pletely. Malignant hypertension, though a medical emergency, can be cured if therapy begins soon enough, before the occurrence of kidney failure or a catas- trophic stroke. But while the value of treating severe hypertension seems obvious, controlled trials aimed at showing the benefits of treating milder cases ran into several problems. Because the incidence of com- plications is lower, any advantages of therapy will take longer to demonstrate statistically. With fewer complications, there comes a point where the side effects and inconveniences of drug therapy out- weigh the possible benefits. Moreover, since the number of potential patients needing treatment is much larger, the costs of treatment and follow-up increase considerably. The Mild Hypertension Liaison Committee, sponsored jointly by WHO and the International Society and Federation of Cardiology, is now coordi- nating and exchanging information about studies that are in progress in Australia, Europe, the United Kingdom and the USA. While lowering the blood pressure reduces strokes, heart failure and malig- nant hypertension, no comparable reduction in coronary heart disease has been observed. Indeed, some reports sug- gest that the incidence of myocardial infarction has apparently increased fol- lowing anti-hypertensive therapy. This may simply mean that more patients are surviving to develop coronary attacks, but there is also a possibility that some drugs used to bring down blood pressure may predispose to, or worsen, coronary heart disease. For this reason the introduction of beta-adrenergic blocking agents to treat hypertension has excited interest. These drugs definitely lower blood pressure, and have also been shown to reduce mortality when administered long-term after a myocardial infarction. Beta blockers may therefore be able to lower the incidence both of strokes and myo- cardial infarction. A number of trials are under way at the moment to find out, and the first prospects look extremely encouraging. There may be considerable benefits from treating mild hypertension. As we have seen, even a slight elevation of arterial pressure carries a distinct risk of stroke and heart attack—two of the major causes of death or premature dis- ability in the world. If blood pressure reduction can minimize these events, this would constitute a medical advance of the first magnitude. The size of the prob- lem, however, is huge. A survey made in Renfrew, Scotland, found that in the age group 45-64 years, 15 per cent had a diastolic pressure over 100mmHg, 25 per cent above 95mmHg and 40 per cent above 90mmHg. There is some cardio- vascular risk at all these levels, and there- fore a possibility that treatment could minimize this risk. If this treatment is of benefit, how can we best go about screening a population for hypertension? Most surveys have shown that when a special screening pro- gramme is set up, about 80 per cent of the target population will attend when sent for. In comparison, a study of gener- al medical practices in central Scotland revealed that roughly 80 per cent of a Above: An elderly woman has her blood tested for blood sugar, uric acid and cholesterol levels in the course of a hypertension study made by the Philippine Heart Centre for Asia. (Photo WHO/J. Abcede) Right: Overweight heart patients exercising at an Israeli hospital. "Weight-watchers" are well advised to watch their blood pressure too. (Photo WHO/P. Larsen). doctor's listed patients will see him for one reason or another over a three-year period. Thus if the opportunity was taken at these visits to check the blood pressure, this would be an effective method of screening, and convenient for both patient and doctor. A health education and publicity cam- paign is required to alert both the general public and the medical profession to the dangers of hypertension and to the ad- vantages of prompt treatment. ■ 6 A_ " 1 ..- • ' = - - -- - . r . - . ,---..;,. .1, .... - • - .4 -':" 'r."1*".y. ,. , '''''' -. ...- - , . . .0 . •. - . --4 the silent killer Blacks living in low-income areas of the USA are alarmingly susceptible; it could be that inner- city stress forms a major factor in hypertension BY TO SELLERS An enigma of medicine in the United States today is the appalling rate of high blood pressure suffered by blacks. One distinguished black physician, Dr Charles S. Ireland, Director of the Howard University Hos- pital in Washington, D. C., has called hypertension "the most serious health problem of blacks in America today". He cites studies which show that a quar- ter of the 25 million Americans who have the disease are black; high blood pres- sure kills black adult males at more than 15 times the rate for whites, and kills black females at 17 times the rate for white females. Do blacks have a genetic predisposi- tion to high blood pressure? Is diet a factor? What about emotional stress caused by poverty or by problems asso- ciated with living in a white-dominated society? All these factors seem to be involved in hypertension to some degree. There is no clear-cut scientific evidence which points to a single most important reason for the black experience with this disease. However, economic and psychosocial factors seem to play a larger role in high blood pressure than was previously believed. Dr Ireland quotes evidence which points to dietary factors, including eating too much salt, but adds that he is convinced, along with many other medi- cal men, that "a major cause of high blood pressure among blacks is the stress of living in a hostile environment, where achieving financial stability and family solidarity is so difficult". Blacks in low-income areas are alarm- ingly susceptible to the disease. A study by scientists at the University of Michi- gan found that blacks tested in "high stress" neighbourhoods of Detroit were more likely to have high blood pressure than blacks in middle-class neighbour- hoods. Among blacks who felt to be "trapped" in urban ghettos, some very high readings were recorded. On the whole, blacks have a higher incidence of hypertension than whites, according to Dr Herbert G. Langford of the University of Mississippi Medical Center in Jackson. But he adds : "Blood pressure also seems to reflect socio-eco- nomic differences. When we measured the blood pressures in high school students in Jackson and Hinds County, Mississippi, we found high readings in both black and white students. A large part of the hypertension problem may be deeply tagged to the socio-economic situ- ation and, on the whole, blacks are poor- er than whites. In the city, the poorer the family, the higher was the student's blood pressure." Blacks living in the South are harder hit by this disease than those in the North. In Atlanta, metropolis of the Southeast, Dr Neil Shulman runs a hypertension control centre for the Emory University School of Medicine, and describes as "an epidemic" the prev- alence of high blood pressure in the vicinity of his clinic. "If this were polio or the 'Legion- naires' Disease' that killed 29 people in Philadelphia in 1976, you would be hear- ing a lot more about it", Dr Shulman said. "High blood pressure isn't dramat- ic and it hasn't received the front-page other diseases have. But the death and suffering it causes are dramatic enough. A lot of people aren't aware of what an enormous problem this is." Field workers from the Atlanta clinic recently found a 32-year-old black man who had a blood pressure of 200 over 150—almost twice as high as it should have been. "We get a case like this about once a week", Dr Shulman noted. The man was almost certainly headed for a medical catastrophe : a heart attack, a stroke, or kidney failure. Yet he felt well and was not aware he was ill until his blood pressure was checked. He was persuaded to come to the clinic for treat- ment, and his pressure is now being controlled by medications. "He was one of the lucky ones", Dr Shulman said. "Nearly one third of the adult blacks in Atlanta's inner-city popu- lation are victims of high blood pressure, and a lot of them don't know it and don't get it treated." Each year, thousands of men and women are brought into Atlanta's largest hospital—Grady Memorial—after suf- fering hypertension-related disasters. Many die : others become lifelong inva- lids. A majority of these patients at Grady Hospital are indigent blacks, and a tragic proportion of them are struck down early in their prime years—in the 30s and 40s. High blood pressure is called "the silent killer" because it strikes without warning. Usually a person does not feel ill with this disease. It creeps up on its victims and lurks in the circulatory sys- tem until a weak place develops. Then suddenly a blood vessel in the brain ...As important as diet is obesity. Doctors in the USA have found a correlation between obesity and hypertension in some patients... (Photo Len Sirman ©) 8 '.t. 4 bursts, causing a stroke; or the pressure causes severe damage to heart, kidneys, or eyes. "The big problem with hypertension is not finding a way to control it", Dr Shul- man said. "We have a number of good drugs that will do that. Our main concern is to identify the people who need treatment, get them on medication and keep them there for long periods, maybe for the rest of their lives." The fact that many hypertensives have no symptoms lulls them into a treacher- ous sense of security. They fail to realize that a time bomb is ticking in their bodies, and they have never bothered to learn how easy it would be to defuse that bomb. When is blood pressure too high? Some US insurance companies use a blood pressure of 140 over 90 mmHg as the borderline between elevated and nor- mal readings. Applicants with an average below 140/90 will generally be eligible for standard insurance if there is no history of hypertension and there are no other ratable risk factors. On the other hand, an average in excess of 140/90 generally means that an extra premium will be assessed. Hypertensive blacks, in addi- tion to their other problems, often find it difficult to buy enough life insurance to protect their families adequately. What causes high blood pressure? In about 90 per cent of the cases, medical science just doesn't know for sure. It can only make educated guesses. A family history of the disease may mean that a person has inherited a tendency for it. Yet genetic susceptibility has not been shown to be the predominant reason for the black hypertension problem in the USA. On the other hand, dietary factors have been linked with elevated blood pressure in some people. Too much salt intake, for example, causes the blood pressure to rise temporarily in many people, and many American blacks sub- sist largely on diets containing heavy amounts of salt, saturated fats, and cholesterol. Just half a block from Emory University's hypertension clinic in Atlanta, a Municipal Market caters to a predominately black clientele by offer- ing "soul foods" such as pork ribs, ham hocks, and salt-encrusted fatback bacon. Another point of concern, which goes along with diet, is obesity. Blacks tend to have this problem more than whites, and doctors have found a correlation be- tween obesity and hypertension in some patients. But after looking at all the suspected physiological or non-psycho- logical reasons, medical investigators a're not satisfied that they are sufficient to explain the "epidemic" of high blood pressure among urban blacks. Above: ...High blood pressure thrives in a class society such as modern industrial nations have created, and a programme to prevent the disease will require fundamental social change ... Right: ...Many American blacks subsist largely on diets containing heavy amounts of salt, saturated fats and cholesterol... such as pork ribs, ham hocks and fatback bacon... (Photos WHO/C. Blackwell) Dr Richard Cooper, a New York car- diologist, believes that hypertension varies greatly in different parts of the world, and that this difference can be attributed to environmental rather than genetic causes. Racial or ethnic groups who migrate to other countries often have changes in the average level of blood pressure; he cites studies showing that native African groups have predominate- ly normal readings, in sharp contrast to black Afro-Americans whose blood pres- sures have been found in some cities to be as high as 40 to 60 per cent above normal. High blood pressure thrives in a class society such as modern industrial nations have created, Dr Cooper argues, and a programme to prevent the disease will require fundamental social change. He is not optimistic that such changes are 10 forthcoming. "The National Institutes of Health are not likely to fund a grant to eliminate racism and class oppression from the south side of Chicago", he comments. Dr Charles L. Curry, a black physician in Washington, D. C., adds : "It's impos- sible to imagine the depth of feeling experienced by many blacks to unspoken prejudice, be it real or imagined. Perhaps the occasional violent outburst in our cities is an overt expression of this feel- ing-state, while hypertension is a form of inward violence to one's self." Psychological factors are known to affect disease, but the field is loaded with questions. So far, no one has come up with the money or the method to prove scientifically that inner-city stress is a major factor in hypertension. Competent physicians often take opposing sides on the question. But among those who work most intimately with the problem, there is little room for doubt. One such person is Gail McCray, a black woman who is a field coordinator for Dr Shulman's hypertension pro- gramme in Atlanta. "We see a lot of people living in poorly heated, rat-infest- ed houses that may or may not have electricity and often don't have any food in them", she says. "Stress is a day-to- day kind of thing for these people; they're constantly in a strain about their living conditions, their jobs, their very survival. I've been in places where we had to take the blood pressures by can- dlelight or by sunlight coming through the door. We see a lot of alcoholism, and when people drink too much they don't pay much attention to their health. "One of our goals is to get people to restrict their salt intake. It's hard to get older people to change when their taste buds have been conditioned for most of their lives to foods that contain a lot of salt. But we show them how to use substitutes—lemon juice or garlic pow- der, for example—and occasionally we throw a `no-salt party' with various dishes that are salt-free or low in salt. Now we're trying to take this message to the younger school children so they'll be warned at an early age to avoid heavy salt intake." In a four-year period, Atlanta's Pro- ject Control screened more than 10,000 households for hypertension, took an estimated 40,000 to 50,000 blood pres- sures, and found about 30 per cent of the inner-city population it serves had ele- vated readings. Emory University is one of 14 US medical centres participating in the national programme, which is supported financially by the National Heart, Lung and Blood Institute, a federal health agency. The programme is aimed at determining how effectively a large-scale detection and follow-up project can reduce the number of deaths and serious illnesses from high blood pressure. A second Emory project is looking at high blood pressure in young women. In par- ticular, it is designed to evaluate the effects on blood pressure of estrogen- containing oral contraceptives. Dr Shulman feels that high blood pres- sure should be regarded as a public health problem on the scale of tuberculo- sis and venereal diseases. "We need to get our local public health departments involved in both the screening and treat- ment of hypertensive patients", he says. Patients should be able to walk into local neighbourhood clinics, have their blood pressures checked and receive medication to keep their pressures under control. Further solutions to the problem may lie in research, and one helpful develop- ment would be a longer-lasting drug. "I'd like to see a pill or an injection which might be taken once a week or once a month instead of the daily medi- cation which is now available", Dr Shul- man explains. "It would also be helpful if research scientists could identify with certainty the causes of hypertension; the problem would then become a matter of eliminating such causes or protecting the population against them." ■ 11 On the right lines Regular medical checks among the staff of Japan National Railways have led to a sharp decrease in the incidence of high blood pressure and of strokes BY SHUICHI HATANO Smoothly controlling the train as it races along the foothills of Mount Fuji at a speed of about 118 miles an hour, Mr Kawasaki barely glances up at the mountain still covered with snow. He feels well and secure, having just passed his health check with flying colours. The train is heading for Nagoya, passing now through hills covered with green tea plants as he main- tains his calm watch on the track ahead. The Tokaido Super Express is in good hands. Running quietly and punctually while keeping up a high average speed, it has become a tourist attraction in itself. Japan National Railways (JNR) oper- ates a nation-wide network of 246 lines covering more than 13,000 miles of track, and passenger security is high on its list of priorities. But security applies not only to the passengers but to all the men and women who make the railway work. JNR is a large employer with 250,000 employees aged 40 and over who must submit to annual health checks. In particular, the hand at the controls or on the switch must not falter. The medical check-ups cover the usual ground of blood tests, body weight and medical history. Every five years the em- ployees get a particularly thorough ex- amination that includes chest X-rays, electrocardiography, blood cell count and much else. Anyone found with high blood pressure must then undergo a second physical examination which will include measuring the blood pressure again, testing for sugar protein in the urine, and an electrocardiogram. If the blood pressure remains high or any organ damage is discovered, the person is advised to seek medical help immed- iately. Drivers of trains must have a detailed cardiovascular examination and take tests for sight and hearing every two years. If abnormalities show up, the per- son is transferred to less exacting duties. In Japan we have found that, like body weight and height, each individual has his own blood pressure which places him somewhere along a bell curve of frequen- cies running from very high to low. Most people, by definition find themselves well in the middle. There are, therefore, no clear or abso- lute cut-off points between what is nor- mal and what is high blood pressure. High blood pressure itself is not disease but some degree of variation from the average, except for the small number of persons whose hypertension is a symp- tom of glandular, renal or other patho- logical conditions. In 1959 a WHO Expert Committee out- lined diagnostic criteria for hypertension and these criteria have been widely ac- cepted internationally. They provide a common basis for describing patients and comparing the frequency of hyper- tension in different countries. But it must be emphasized that the cut-off points between "normal" and "high" blood pressure are always somewhat arbitrary. An individual's blood pressure fluctu- ates all the time to meet the changes required by the body in its daily activi- ties. The heart beat may be slow and regular as he sits reading and then in- crease in speed and force as he summons up what is needed for strenuous physical efforts such as sports or hard manual labour. In a person with a heart trans- plant, such automatic adjustments no longer occur because the heart no longer has nerve connections with the rest of the body. In the rest of us, these adjustments occur instantaneously but unnoticed, hour by hour, around the clock. In fact, blood pressure changes rhyth- mically with each of our heart beats. When the heart pumps out blood, the pressure in the peripheral arteries that carry it off rises; the pressure drops when the heart relaxes after its effort. The greatest pressure at the height of the cardiac contraction is called systolic or maximum blood pressure, and the lowest pressure, when the heart pauses between contractions, is called diastolic or mini- mum pressure. Blood pressure is ex- pressed in millimetres by the height of a column of mercury. As the heart pumps, it may meet high resistance in the arteries because they are constricted or clogged. When it does, the heart must work harder and may become enlarged in order to meet this heavy workload; in the long run, it may fail. Increased tension in the arterial wall to contain the blood being pushed through at high pressure stimulates cell growth, which further thickens the wall and thus increases resistance to the flow. A vicious circle has been formed that keeps push- ing the blood pressure higher and higher. This is why high blood pressure is such an important risk factor in heart and arterial diseases. The most common complications resulting from hypertension are stroke and heart attack. In some cases the heart itself or the kidneys may be damaged. Therefore, even without complications, Running quietly and punctually, the high-speed Tokaido Super Express is itself a tourist at- traction. JNR's regular health checks ensure that the train is always in safe hands. ( Photo WHO! S. Hatano) 12

hypertension or high blood pressure should be considered as an early phase of a "hypertensive disease". Progress may be rapid, as in the case of malignant hypertension, or relatively quite slow; but even a mild degree of hypertension increases the likelihood of death from these complications. And high blood pressure carries an even greater risk when it appears in a young person. The shift to hypertension control in Japan was a logical next step after the major communicable diseases, particu- larly pulmonary tuberculosis, had been controlled. The staff, the infrastructure and the technology, as well as the techni- ques of mass screening and after-care, were already there. The new strategy meant employing them to meet the new menace of high blood pressure, once it was realized that stroke was a leading cause of death in Japan. Control of hypertension at Japan National Railways began with modest efforts at health education, detection and referral. But what was lacking was the involvement of screening teams in the provision of health care, and the lack of direct personal contact with those under treatment except during annual health examinations. As a result, neither blood pressure nor the prevalence of moderate hypertension declined among those in the age group 45-49. There was even a steady rise of mean blood pressure among those aged 40-44. Dr Y. Fukuda, who was in charge of cardiovascular disease control for the railway, feels that the younger group • may have been exposed for less time to control measures or that their rise in blood pressure may be specific to their generation. Young people in Japan today are taller and heavier than their parents. Since body weight and height are positively correlated with blood pres- sure, this may explain why blood pres- sure in the younger groups has been rising. It is also conjectured that rapid changes in life style and social values may exert some influence. Finally, the younger group contains those with the largest number of undetected cases since the age of 40 constitutes the point of entry into the blood pressure control scheme. As a result of firmer measures and greater attention to follow-up, the results improved. In the older group, fewer indi- viduals remained hypertensive and those with very high blood pressure were able to bring it down. The answer to the question of whether prevention pays must be yes. Within a few years Japan National Railways noted a sharp decline in those with marked high blood pressure, that is, those with a systolic pressure over 180. This was true of persons of all ages. A rapid reduction followed the first years of high blood pressure control in the sixties and, by 1973, enough data had been gathered to make meaningful com- parisons possible. Cerebral stroke had decreased notice- ably in the age groups 45-49 and 50-54. The incidence rate of cerebral infarction, however, did not change or even showed a slight increase—possibly as a result of physicians shifting their diagnosis from cerebral haemorrhage to cerebral infarc- tion. One fact stands out without qualifi- cations however: stroke—the number one killer in Japan—showed a decline in all age groups. In many countries, a decrease in stroke has been accompanied by an increase in 14 on the right lines Japan has long recognized that the lives of many people depend on the good health of those who drive and control the means of public transport. Passenger security is high on the list of priorities—and security applies not only to the passengers but to all the men and women who keep the national and suburban systems working. The hand at the controls or on the switch must not falter. ( Photo WHO/E. Schwab) ischaemic heart disease, and this was seen to a slight extent in JNR workers who are, on average, healthier and better-off than most other employees. The incidence of myocardial infarction increased slightly as well, though it remained less than that for stroke. So much for Japan National Railways. What about the rest of the population? Today annual health check-ups for those over 40, which include blood pressure measurements, are widely practised ex- cept in very small firms or isolated rural villages. They are compulsory in large firms and in homes for the aged. These checks are available for every citizen over 40 throughout Japan at community health centres. There is such a centre for every 100,000 people in the country. The national government also launch- ed a pilot programme to combat stroke in those parts of Japan where it was most common. Dr K. Isomura, working in Yachio village, in the rural highlands of central Japan, reported a decrease of brain stroke by one half and a decline of all kinds of stroke by one third, but an increase in angina and myocardial in- farction by nearly one half, particularly in women. This was after a 15-year health promotion scheme which included hypertension control. Bills for medical care which had been 30 per cent higher than those of neighbouring villages were now 30 per cent lower, representing an annual saving of 14,800 yen per resident in medical costs (240 yen = US$1). Apart from those places which under- took community control, Japan as a whole now shows a declining mortality from stroke in both men and women, without any significant increase in mor- tality from heart diseases. This repre- sents an important trend, since Japan had noted a sharp increase in mortality from stroke after World War II. The decline appears to have accelerated since around 1965 when effective anti-hyper- tensive drugs came into general use. An interesting study by Dr S. Kojima in Akita, where stroke occurred with notorious frequency, has shown that patients continuously under a physi- cian's care had an incidence of stroke of 7.4 per thousand each year, while those treated only intermittently had a rate almost double that; untreated subjects had a rate that reached 17.6. The lesson is that treatment of hypertension must be continuous. If the control had started earlier, the rate might have been brought down even further for those who received continuous care. Since cardiovascular diseases are caused by several factors, how can high risk individuals be detected in a general population? Dr Y. Komachi, during his own study in Akita, examined the risk profiles of patients who developed stroke during a five-year period. Hypertension was found at the outset in 88 per cent of those who later developed cerebral hae- morrhage and in 79 per cent who later developed cerebral thrombosis. Thus, a large majority of those who later developed stroke could have been found simply by taking their blood pressure. We find therefore that a community preventive approach is feasible and rewarding. Mr Kawasaki, at the controls of his speeding Super Express, drives his train through the orange groves on the Pacific coast, confident of his own health and that of all those who keep the rail- way going. One more safeguard has been added to the many others that keep the train securely on the rails. ■ 15 hypertension in a quiet land BY NEDD WILLARD It was absolutely quiet. Even the tiny leaves of the birch trees overhanging the water were still. Matti decided to finish picking mushrooms and find where the cows had wandered in the pine woods. It was a pleasant Tuesday morning in North Karelia, Finland, late in the summer and it would be hard to imagine a healthier looking or more peaceful spot. Yet North Karelia leads all other parts of Finland and Finland is among the lead- ing countries in the world in ... hyperten- sion. High blood pressure, high serum cholesterol and the resulting heart at- tacks and strokes make this pleasant land of lakes and forests a place where life expectancy can be tragically shor- tened at any minute. However it is also the place where the community has been mobilized to do something about the factors that can influence the heart. We can begin in Kuopio, a small town on round hills that end in a large blue lake where the Karelia Project has its headquarters. The team of investigators is young—its Director in his thirties— and most of the men and women who work with him are young social scien- tists, doctors, nurses and economists. "The main point to remember," Dr Pekka Puska, the Director, kept hammer- ing home, "is that it was the community who asked for help so that we were assured of full cooperation from the start." The road from Kuopio to Joensuu is uneventful but pleasant, with just a series of small farms and simple fir and birch forests. Joensuu itself represents the hub of North Karelia. The name in Finnish means mouth of the river, and it is where a vast lake meets a swift river amidst a constellation of lakes separated only by forest and islands. Upstairs in a modest building—neat, simple and modern as most things are here—the project has its offices. "We don't stand apart from the regular health services," the local project leader tells me as we go to see a few of the local town clinics in action. "On the contrary, we probably have had a lot to do with making them more vigorous and respon- sive to people's needs here." The clinic consists of only two rooms. As we came in, a nurse was talking to a woman of about 40 strapped to the blood pressure machine. The woman was obviously overweight, with a large soft white body poised over trim slender ankles. She was smiling but the nurse was not. "Your pressure is up again. It is far too high." "Oh, I am sorry," said the woman with real concern in her voice. "Did you take your pills each day?" the nurse persisted. "Oh, you see, there has been a cousin's wedding and I had to help and ... with so Above: The Karelia project goes into the field to gather firsthand information about living conditions that may lead to hyperten- sion. A young doctor talks to a logger on the site about his diet and way of life. Right: Much of the work in felling and transporting timber has been mechanized in Finland. However, in spite of mechanization the loggers lead an active life. (Photos WHO/N. Willard) many things on my mind ..." she stopped uncertainly, waiting for the nurse to sup- ply words. "You didn't." "I was meaning to. I had certainly intended to." We left as the nurse tried to convince her of a little more adherence to the schedule of drugs designed to bring her blood pressure down. But there was no coercion or heavy-handed attempt to lec- ture, only gentle disapproval and the persistence of advice from people who are trusted. "And I must admit," said the project leader, "that nurses are more effective in this than doctors. First of all because they see the patients more often, but really perhaps because less distance separates them from the patients. The patients feel more at ease with them and are unafraid to mention they have stopped taking treatment, for example." At the next clinic, the patient was a man, thin, a little drawn in features, with a history of high blood pressure. He was one of Finland's mysteries, a small active man with a job that required some amount of energy, stacking wood in a warehouse, yet who still had high blood pressure. The inexorable silver line on the blood pressure machine stopped at the same time as the huffing and puffing of the pump held in the nurse's hand. "Have you been taking your medica- tion?" "I certainly meant to ... in fact, up till a few weeks ago, I did religiously, but it slipped my mind." "Oh," said the nurse, quietly looking at the patient. That evening, on the wooden benches of the sauna by the lake, we discussed more about the project. "Don't get the idea that most people don't follow their treatment. They do. But there is a con- stant tendency to slip back and that is where the constant, gentle but constant, reminders of the health services come in. In fact, in a few days we will send you out with the public health nurse who visits those cases who can't make it to the clinic." 16 V It. hypertension in a quiet land Left: Weighing. cranberries in a crossroads country store. The manager has high blood pressure, but still does not feet the need to begin treatment. Resistance to treatment is a phenomenon common around the world; in North Karelia, nurses, doctors and the com- munity try to overcome it by gentle persuasion. Right : North Karelia is an overwhelmingly rural area where men and women work togeth- er. This couple are sharpening an axe before the work of splitting all the wood for the stove that will keep them warm during the king winter. (Photos WHO/N. Willard) ";' 111-71100: We pulled into a filling station along- side a huge truck piled with logs and waited for the forest workers to arrive. They arrived soon after we did and all of us began a long ride to the island where the work was going on. A high-pitched whine, such as you hear today in most forests of the world, told us we were getting near the site. A flat slam as a tree hit the ground indicated the nearest worker. Most of the men cutting wood were young, since the older ones gravi- tate to other jobs like hauling. An enor- mous machine, a monster with balloon tires bigger than a man, came jolting up over the soft terrain and, from a plat- form behind the driver, a crane reached out, lifted up a cut log, swung it aloft and placed it neatly alongside other logs on the back of an open platform. There was no high blood pressure among these loggers, though the man operating the machine that gathered logs was borderline. You could feel attention to safety in the operation. All the men wore helmets, and their earphones made sure they were not deafened with the constant noise of the operation. Even the man operating the machine had his ears and head protected. It was soon lunchtime and we checked on what the men were eating. There were bread, butter and sausage but also milk and fruit. We were happy to see that most were drinking fat-free or butter- milk. "And that represents a huge change around here," the young doctor from the project assured us. The loggers were invited to coffee at the nearest farmhouse and we joined them. The house was small, made of wood, with a small barn nearby. Only the farmer and his wife remained, as their children had all left for the city. We asked about hypertension and found that the farmer had been under treatment for years. "And I was fat in those days too. Now I have lost a lot of weight, take my pills every day (I make sure of that,' said his wife) and keep up my usual work." This farm on the island is remote and the couple rarely visits town. Their life is quiet with one tragic shadow, the death of the eldest son by drowning on a fishing expedition. Though they have wa- ter in the house, they still water their garden by hand during the summer, drawing it from a small stream that runs at the foot of the hill nearby. The doctor and I were standing in the garden later as the farmer's wife showed us what crops there were. The variety was small—carrots, beets, potatoes. "You must have a hard job getting peo- ple to change their diet when there is so little to choose from." "Yes, that is .a problem and one that the agriculturalists ought to look into." Another day, another doctor, another place. Juuka is a middle-sized village with a scattering of stores, one supermar- ket, and a clinic, all set in the middle of fairly prosperous country. "Most of the wealth here comes from farms, supple- mented by logging of course," I was told. "But agriculture is in a difficult way. So far it is mainly fat production in this part of the country. Also, most of our farms are small and hardly competitive. Yet we don't want everyone to move to the few large cities or to stop growing most of what we eat. That is why we go on subsidizing agriculture." From the window of the clinic I could see a brown horse browsing as we dis- cussed hypertension. In this community everyone was getting involved. The ladies' groups were trying to change diet- ary habits. The schools had already changed theirs. One thing was sure, as we found out repeatedly; there was no one so remote that he hadn't heard about the North Karelia Project, it was their pro- ject. I asked the doctor how people regard- ed heart attacks and heart problems in this district. "Well, when we examine someone in the prime of life, say 35-45 years of age, and ask if they have felt pain or constriction around their heart, they usually answer, 'not yet.' Heart attacks here have come to be considered 18 a normal part of life, but we are changing that. But you know we don't just look out for high blood pressure or heart problems, we check our people for anything that needs help. However, we are shifting emphasis away from the old killers like tuberculosis to new problems like this." A nurse stood alongside us on the small ferry that was being rapidly winch- ed across the lake to the island. "A few years ago they just had small boats and many a time I have spent a few weeks on the island as someone's guest just because I couldn't get back to the main- land. This water is lovely but it can be troublesome. And it caused the biggest tragedy of the island; two boatloads of young people collided on a stormy night and sank, drowning 13 people. That is a huge loss for an island community." On the island we turned to the left and began climbing a rocky dirt road up through the birches to the brow of the hill. "These people we are visiting can't make it to the clinic very easily," the nurse explained. "And they do like the company." We could see that, as we climbed out of the car and the woman ran to meet us. Her husband, scything oats in the field close by, put up his scythe and walked to the house. Soon we were all seated in the large warm kitchen drinking coffee ac- companied by bread, butter, cheese and sausage. To further quench thirst there were pitchers of fresh cranberry juice. In this house only the old mother had high blood pressure, and she had diabetes as well, but she looked solid and permanent as she sat there rocking on her chair. Further down the road, heading into the centre of the island, we found a woman alone. Her husband just died, a few weeks ago, of heart attack. She too had high blood pressure but what was most on her mind was giving up her farmhouse, as she intended, to move into the village. "Too far away, and too lone- ly here in winter," she said sadly. The wind outside was ruffling the leaves on the trees with a promise of cold weather as if to emphasize her remarks. It was a sad house. On the chimney piece stood photos of her family. Two of her children had been on the boat that sank and she had just been to bury her second hus- band. "I don't want any damn pills or treat- ment," blurted the heavy-set man who ran the crossroads store, after he finished weighing and buying cranberries from some farmers. "Sure I am overweight, but so is my brother and he doesn't have high blood pressure. So what has that to do with it? Listen, my high blood pres- sure comes from working seven days a week at this store, haggling with the farmers, never taking a vacation." As we left, the storekeeper said grud- gingly, "Well, Dr X., a big specialist comes here for vacation in the autumn. I may ask his advice." As we got in the car the doctor said : "Now you have seen someone who resists treatment." "He's a bachelor, isn't he?" "Yes." "Somehow it all goes together." On the ferry going back to the main- land, the nurse said "Would you like to talk to the ferryboat captain?" "Why?" "He is under treatment." So we climbed up the steep steel steps to the wheel- house, which in this case is a cabin with a small table of instruments measuring the speed and capacity of the winch that pulls the boat along. The captain didn't have much to say. He was a small pre- occupied-looking man but he was back on treatment after having given up for a while. "The pills made me sick. So I stopped." "Who got you to start again ?" "Well, I was too embarrassed to tell the doctor, but the nurse in Juuka found out and she gave me something else to take." We had no time for further questions since the boat had already bumped the dock, and other cars were waiting for the return trip, so we left. Farmers, shop- keepers, warehousemen, housewives, and ferryboat captains—I could begin to see why hypertension was a problem that concerned everybody here. In Kuopio, Dr Puska summed it up. "This is a programme to see if communi- ty control of cardiovascular disease can work in a rural area with an exceptional- ly high rate of mortality. Our main ob- jective was clear: to bring down cardio- vascular morbidity and mortality among the population. We laid heavy emphasis on primary prevention of disease. We tried to lower risk factors like serum cholesterol, smoking, and high blood pressure." "How well has it gone so far?" "We have been getting results. By the end of 1976 we had about 17,000 hyper- tensives on our registers, which repre- sents about nine per cent of the total population here. The number of hyper- tensives taking treatment among men in the high-risk group went up by four times, and the increase among women was also important. Stroke rates have dropped and so have case fatalities. More people have given up smoking and the number of young men drinking low- fat milk went up from 17 to 41 per cent." "So community control of hyperten- sion can work ?" "Yes, but only if you have the commu- nity working with you." ■ 19 the African experience The main thrust in countering hypertension lies in a community approach: Africa forms part of a world- wide scientific network which is seeking the answers BY O.O. AKINKUGBE In 1929 an article appeared in the Lancet describing a doctor's experience in Afri- ca. "No case of raised blood pressure was encountered", the author noted, in some 1,800 patients admitted over a two-year period in a hospital in south Kenya. Further, "on no occasion was a diagnosis of arterio- sclerosis or chronic interstitial nephritis made". Much has changed since then. Today, nearly 50 years later, it has been generally accepted, as a result of extensive epidemiological studies in Afri- ca south of the equator, that hyperten- sion is the most common cardiovascular ailment in Africa and that one in four African patients with heart failure suffers from this condition. Earlier, perhaps, there was a lack of awareness of the problem in Africa. There may also have been differences due to the problems of measuring blood pressure itself, and the definition of hypertension. Getting a proper random sample, variation between observers, dif- ferences in arm circumference, age, sex and the circumstances in which the blood pressure was taken all make it difficult to compare the situation today with what it may once have been. But it is now clearly established that the majority of African communities have blood pressure patterns similar to those of economically advanced coun- tries and a similar prevalence of hyper- tension occurring mostly in persons over the age of forty. Studies from cardiovascular centres in Africa show that exact causes of hyper- tension can be determined in fewer than 20 per cent of all cases. The commonest cause is some form of kidney disease. Africa shows the same pattern as that of most parts of the world; its hyperten- sion is largely of the essential type whose cause or causes remain unknown. A sig- nificant proportion of those with hyper- tension, which we can arbitrarily define as 160/95 mmHg or above, show no out- ward signs of the disease nor are they aware of its potential dangers until com- plications become evident. This too is the classic picture of essential hypertension. Weak heart Heart failure, known to the layman as "weak heart", is easily the most common complication and responsible for much ill health that may go on for quite a long time. Next in frequency among the com- plications is renal failure which often causes death. Headaches are not symp- toms of hypertension, as is commonly believed, but are probably attributable to a state of anxiety that may resemble hypertension. Stroke or paralysis is usually a dramatic and distressing com- plication because it comes on suddenly and the patient often loses conscious- ness. Complications are just as common in women as in men, with the possible exception of renal failure, which is usual- ly associated with severe hypertension and occurs more frequently in young adult men. There are some peculiar and intriguing aspects of blood pressure in Africa that are worthy of closer consideration. In isolated pockets of population in East, Central and West Africa, for example, blood pressure does not rise with age. Although this has led to considerable speculation about such things as diet, the amount of salt people take, physical ac- tivity or absence of stress, an adequate explanation has yet to be found. Africans have been relatively immune so far to myocardial infarction, another complication of coronary heart disease. However, hypertensives may develop a mild degree of coronary atherosclerosis. Schistosomiasis, a parasitic disease, has been suspected of playing a role in the genesis of high blood pressure. Ad- mittedly it may play some role, and experimental studies with apes where kidney disease has been induced using the eggs of the schistosome parasite seem to confirm this. In addition, autopsies on young adults who died from a combina- tion of hypertension and kidney disease usually show evidence of schistosome infection. But recent work has yet to confirm that there is a direct cause-and- effect relationship. Treatment of hypertension often causes all signs of heart disease to disap- pear. Heart muscle disease is sometimes associated with hypertension and in such instances the blood pressure commonly returns to normal following treatment of heart failure with digitalis. A small group of patients seen in Africa suffer from severe hypertension, 240/160 mmHg or more, yet present little or no evidence of organ involvement. They live in "symbiosis" with their blood pressure for a number of years until complications set in—usually heart or kidney failure; then within days or weeks they go rapidly downhill. In these cases, It is now clearly established that the majority of African communities have blood pressure patterns similar to those of economically advanced countries. (Photo J. Mohr ©) 20 ~~ ° anti-hypertensive medication even in large doses does not seem to work. It is still not known why the medication does not work, nor why the target organs have been spared for so long. Although severe problems of sight in- volving the retina are uncommon in Afri- cans with high blood pressure, many suffer from varying degrees of mild reti- nal disturbance. Therefore, changes in the retina must be open to doubt as an index of the severity of hypertension. It would be imprudent, for example, to wait until malignant changes in the eyes appear before treating someone who suf- fers from severe hypertension. The mean arterial pressures, both sys- tolic and diastolic, of children in Africa are higher than those of children in the same age groups in North America, both black and white. This must be related to environmental changes but exactly what they are remains to be studied and eva- luated. The early recognition and control of hypertension in Africa will not be easy. Only a small percentage of the popula- tion have been screened and most of them live in urban areas. Yet African countries are predominantly rural and people living in cities account for only 15 to 20 per cent of the population. Of those who are screened and diagnosed as hav- ing high blood pressure, only a small proportion receive any form of treat- ment. Furthermore, less than a quarter of those treated fully recognize the impor- tance of regular, uninterrupted treat- ment. There are also problems of the cost of drugs, and of the insufficiency of medical personnel. Finally, for a disease in which a large number of affected persons show no obvious symptoms, we cannot usually rely on the patient seek- ing out medical attention. The main thrust in the field of hyper- tension must surely lie in a community approach to its study and management, as recognized by WHO. Five years ago a study was established with participating centres in 15 countries. Four of these centres are in Africa, two in Nigeria and one each in Ghana and Kenya. Efforts Above: Only a small percentage of the Afri- can population have been screened for hyper- tension—and most of them live in urban areas. (Photo WHO/R. da Silva) Right: In isolated areas of Africa, blood pres- sure does not rise with age; one line of specula- tion attributes this to the absence of stress. But an adequate explanation has yet to be found. (Photo WHO/P. Almasy) have been made to ensure that the data gathered by all the centres will be com- parable. Studies such as this should help provide answers to the most pressing questions before us such as whether mild symptomless hypertension is worth treat- ing on a community basis. Developing countries particularly want to know what are the operational implications for a rudimentary health care system in the management of high blood pressure. Africa is playing its part in a world- wide scientific network seeking answers to the worldwide problem of hyper- tension. ■ 22

-117011F L_LL,L1_11 AL_ so living longer High altitude affects the hypertension picture in several South American republics, but social and economic conditions are much more vital factors BY JOHN BLAND "Prolong your life: check your blood pressure" say the posters displayed around the hospitals of Lima. The same blunt mes- sage is echoed on the sides of the little fleet of green and white vans which tour the Peruvian capital offering free blood pressure tests : "Check your arterial pres- sure NOW". A badge on each van shows the map of Peru inset in a stylized heart. Like most countries of South America, Peru takes the hearts of its citizens seriously. In the words of Dr Augusto Mispireta, who heads the Cardiology Service of the Lima Children's Hospital, "Cardiovascular diseases, and particu- larly systemic arterial hypertension, con- stitute the greatest cause of illness, dis- ablement and death among adults. Today these diseases have reached epi- demic levels in most communities and present a huge challenge for the physi- cian and for public health in general." A special feature common to the republics lining the spiny Andean moun- tain chain is the fact that large numbers of their citizens live at high altitude, as much as 13,000 feet above sea-level, which leaves the newcomer from the flatlands gasping for oxygen. Has alti- tude any special effect on the incidence of hypertension? "Yes", says Dr Mis- pireta. "In our opinion there can be no doubt that the altitude—and therefore also the climate—is a factor to be consid- ered. At medium altitudes, there is more hypertension and more rheumatic fever than at sea-level here in Lima. "The curious thing is that those born in the Lake Titicaca area, 12,500 feet up, hardly ever seem to suffer from hyper- tension. Yet oddly enough, if they come down to live in Lima they suffer from the same prevalence rate as those who were born in Lima." But Dr Mispireta adds : "All the same, altitude is far from being the most im- portant factor. What matters much more is people's way of life, their economic Above: This little girl in a Quito hospital has rheumatic fever. Ecuador's drive to control hypertension in adults is comple- mented by a major programme to prevent rheumatic fever, which often has severe consequences for the heart. Right: La Paz fills to overflowing a dusty bowl in the high Andean plateau. Altitude above sea-level and the resultant lack of oxygen play a significant part in studies of the prevalence of high blood pressure in South America. (Photos WHO/D. Henrioud) situation, whether they live in crowded and impoverished communities." This verdict has been repeated again and again in other towns and cities of South America. In Quito, the capital of Ecuador, for instance, a random census was taken by investigators for the National Department of Cardiovascular Diseases, which works under the Minis- try of Public Health. First they picked six of the 56 sectors of the city, which perches on a shelf 9,000 feet up in the Andes, then drew lots to choose in turn blocks, houses and families; from each family one individual was also selected by lottery and these were then examined for arterial hypertension. The head of the Department, Dr Marcelo Moreano, explained what the results showed. "Out of 750,000 citizens of Quito we examined 1,380. This first contact showed that 10.6 per cent of the sample had elevated blood pressure. It also showed us that altitude was not the main factor but status in life—the family's economic situation. All the people we examined gave us a lot of details about their own families, and this will enable us to follow up our first survey. We plan five more such studies, which will involve looking into the social and economic factors, the level of educa- tion, the kind of work people do, and what health care they receive." The Quito study was actively comple- mented by the Ministry's Health Educa- tion section, which conveyed the message that it pays to check one's blood pressure by radio, closed-circuit television pro- grammes and other audio-visual means. Health workers visited sports clubs, working men's clubs, churches and fac- 24 • 1 A r CO ROLE AHORAu PRESION ARTER1 FLVACIO\ PERUI\A DE C ARDIOLOGIA W6I9 041 tories to spread the word. "And yet", confesses Dr Moreano, "our chief prob- lem turned out to be winning the collab- oration of the adult population." Too many people would rather not know the bad news that their arterial pressure is seriously or even dangerously high; or else they prove unwilling to do anything about it, even though treatment is mostly given free. However Dr Moreano has high hopes for the future : a second important pro- gramme of his Department concerns the prevention of rheumatic fever. Though not directly bearing on the incidence of hypertension, there can be no doubt that children affected by rheumatic fever will figure in later life among those who will have to pay special attention to the health of their hearts. An intensive study made among Qui- to's 66,000 schoolchildren aged from 5 to 14 years detected rheumatic fever in 6.3 children per thousand. "We have educat- ed everyone—health inspectors, head- masters, teachers and the parents—to watch for the symptoms and report them", said Dr Moreano. Positive cases receive a monthly penicillin injection, usually in their own homes. Out of this five-year pilot plan will come vital data which will help the Ecua- dorean authorities to deal with rheumat- ic fever on a national scale. But what is more, children and parents alike will have a new awareness of the need to maintain regular checks on their hearts, and their blood pressure. In the high Andes Some 1,250 miles to the south, the Bolivian capital of La Paz fills to over- flowing a dusty bowl in the high Andean plateau, with the great snowcapped mas- sif of Mount Illimani towering above. The National Thorax Institute stands conveniently alongside the Bolivian In- stitute of Altitude Biology, for the city lies at 11,800 feet above sea-level. Dr Luis Otero, Head of the Cardiolo- gy Department of the Thorax Institute, describes it as "a pilot centre, a clinic where people come voluntarily". Every Tuesday, Thursday and Saturday there is a consultation, and a sizeable queue forms of men, women and children who have either been referred to the Institute by health workers or have volunteered for a check-up. At present Bolivia has no complete prevalency figures for hyper- tension but Dr Otero comments : "Each year in the schools we detect a very high rate of rheumatic fever—something around nine out of every 1,000 children." New arrivals have their height and weight measured as well as their blood pressure. Most hypertension cases will move on to the little pharmacy for the drugs they need, which are dispensed free. A small number will spend some time in the hospital wards of the spick- and-span three-storey building, whose facilities also include a fully equipped theatre for surgical operations. 26 living longer Left: "Check your arterial pressure now" says the sign on the side of the little fleet of vans which tour Lima offering free blood pressure tests. Peru takes the hearts of its citizens seriously. Right: Canto Grande suburb outside Lima, home of thousands of newly arrived migrants from the countryside, has no running water and depends for its water supplies on these roving tankers. Such crowded and im- poverished communities often show a higher proportion of hypertension cases than better- off urban districts. (Photos WHO/D. Henrioud) Dr Otero explains : "About 30 hyper- tension cases arrive during each of the consultations, and on average they in- clude six new cases. Hypertension ac- counts for about 12 per cent of the heart patients we have seen at the Institute since 1969. One of the aspects of our work we are particularly aware of is the high economic cost to the community at large that hypertension represents." In Peru, the health authorities in Lima proclaimed a "Heart Week" in 1975 and used it to good measure. Of the almost 40,000 people who had their blood pres- sures measured in that year, the "Week" accounted for over 21,000. Out of a total of 56,000 people who were checked in 1974 and 1975, 10.51 per cent were found to have high systolic blood pressure readings. Although the number of women ex- amined was greater than that of the men, fewer cases of hypertension were found among the women; the compa- rable percentages were 9.93 for women and 11.15 for men. The incidence in- creased with age. Cases of diastolic hypertension amounted to 11.51 per cent (10.9 per cent of the women and 12.18 per cent of the men). Unexpectedly high Dr Mispireta concludes that the hyper- tension rate in Peru is "unexpectedly high" and that this disease "constitutes one of the leading problems for public health in Peru. Almost 12 per cent of the population have definite hypertension and another 16 per cent are borderline cases, which means that 28 per cent of the Peruvian population face hyper- tension in one form or another." "These alarming figures match those determined by specialists in other coun- tries and force us to take a more aggres- sive attitude towards treating this 'silent killer'—so called because more than half of hypertension cases do not notice any symptoms." As in Ecuador, Peru's drive to control high blood pressure is closely linked with a major programme to prevent rheumat- ic fever. The efforts of specialists in seven different countries of South America are being coordinated by the Pan American Committee for the Study and Prevention of Rheumatic Fever, which has so far organized six annual meetings under the aegis of the Pan American Health Or- ganization, sister-agency of WHO. Just as with hypertension, the incidence of rheumatic fever is again proving to be related first and foremost to social and economic factors. And like their counter- parts in Ecuador, the programme organ- izers hope that, apart from the fruits that will be reaped among children who suffer from this crippling disease, there will also be a spin-off in the form of a corre- sponding interest in healthy hearts and comfortable blood pressures as the chil- dren come to adulthood. After all, for the great majority of human beings on our planet "Prolong your life" is a mes- sage that is hardly likely to be ignored. ■ 27 effective control Hypertension control in the community must start by introducing more sensible personal and health habits from childhood onwards so as to reduce risks BY ALAIN FROMENT Just because a medical con- dition deviates from the "norm", we don't feel the need to rush into action. We take steps to check, first of all, that the anomaly poses a threat, and then that practical means are available to rectify the situation. The serious consequences of hyperten- sion can hardly be doubted: chronic elevation of arterial pressure puts extra strain on the heart, thus increasing the risk of heart failure as well as damaging the arterial wall. Atherosclerosis may follow in turn with its various dreadful consequences—coronary conditions (an- gina pectoris, myocardial infarction, sudden death) and cerebrovascular dis- eases (often leading to paralysis). These consequences are particularly disastrous in Europe, where hypertension is ex- tremely common and affects one person in ten over the age of 50. Of course, all hypertension cases are not heading automatically for one of these calamities, and fortunately many people get away with it. But it would be wrong to conclude, just because one per- son or another cheerfully learns to live with high blood pressure, that this proves its innocuous nature. The situa- tion is like that of motorists who drive carelessly; they don't all have accidents, but the fact remains that they run greater risks than those who drive with care. This increased risk that hypertension en- tails has to be reduced by controlling the situation better in the community, just as we try to reduce the risk of an infectious disease by vaccinating large numbers of people who were not very likely to catch it anyway. We have known for years that the risks can be very considerably lessened by treatment, which can almost totally rule out heart failure and most strokes. It has less effect on coronary diseases since these are also influenced by other fac- tors, such as smoking or a high level of cholesterol in the blood, which must also be checked in order to bring about a major reduction in coronary risk. Above: An 18th century version of the human arterial system. Chronic elevation of arterial pressure puts extra strain on the heart. Right: "It is particularly desirable for a hypertension patient to adopt a diet which will help lower the serum cholesterol level." (Photo Bavaria- Verlag/O. Poss © ) Treatment is not a complex matter; in most cases it consists of taking quite a small daily dose of a drug which the human body usually tolerates quite well. These doses may sometimes have to be increased, particularly in cases of hyper- tension that are detected late in life or have been neglected for a long time. The follow-up to such treatment is also sim- ple; a medical check-up twice or three times a year is usually sufficient. So the problem of hypertension seems quite easy to solve. Yet all too often the hypertension patient is not treated effectively. Either he or she pays too little attention to the ailment (by neglecting it or forgetting it entirely), or else receives no drugs, or undergoes treatment that is ineffective or unsuitable. It is still difficult to explain this situa- tion satisfactorily. It would be all too easy to blame the patients, or the general practitioner who may not have been properly trained to deal with the prob- lem in practice. Before the age of modern drugs, highly competent specialists tried hard to investigate the mechanism of faulty blood pressure, in the hope of finding a therapeutic method that at that time did not exist. In so doing, they involuntarily helped to give hypertension too complex an image, so much so that doctors have generally used the same process ever since instead of seeking bet- ter ways of applying the curative means available to us at the present time. Simi- larly the pharmaceutical industry, to which we owe the discovery of some remarkable drugs for reducing high blood pressure, has paradoxically com- plicated the doctor's task by offering an increasing choice of products, while de- fending this practice with sophisticated 28 ~ ; arguments which reinforce the image of a tricky treatment full of pitfalls. What we have only recently begun to understand is that the doctor's relation- ship with his hypertensive patient is not only important for the latter's immediate well-being but can also considerably in- fluence the treatment. The ever-increas- ing part payed by technology in their profession leads many doctors to devote much of their time to modern research and hence to limit the time available for doctor–patient relations, which they view as so much time wasted. Contrary to what many people think, improving the control of hypertension in the community is less likely to result from sensational discoveries or advanced technology than from the simple use of already existing methods in a more human atmosphere of health care. Introducing a new course of treatment obviously implies that hypertension has been diagnosed. All that this requires is to measure the blood pressure— something that is undertaken anything but regularly. It should be taken about once a year, or certainly every two years, during adult life. This is done anyway in most cases during routine medical check- ups at work. The reading should not be taken at a time when some other illness might falsify the figures, and the result should be explained to the patient. The doctor's interpretation of the figures can lend itself to two conflicting errors. One consists of frightening a pa- tient by recording an occasional, never- to-be-repeated high reading. The other, more frequent, error is to ignore a high reading. Thus a pressure of 160/90 mmHg should not bring the response: "It's probably nervousness and nothing to worry about." Much better to say: "Hullo, your blood pressure is a bit too high today. Come back in a few days and we'll check again. Then if it is still high, we can take a few simple precautions and do something about it." It is in fact much more serious to neglect slightly raised pressures; because they are by far the most common, it is these that—despite their lower severity— cause the greatest number of tragedies. Even if we only apply the term hyperten- sion to cases where the pressure reaches or exceeds 160/95 mmHg, repeated read- ings in excess of 140/90 ought to be followed by strict medical advice of a preventive nature. We are not speaking here of particular cases where hypertension is due to toxic factors like oral contraceptives, or over- consumption of liquorice, since the treat- ment consists simply of suppressing such factors. In cases where the pressure is regularly high, let us look first and foremost at two factors which seem to have nothing to do with hypertension—tobacco and high serum cholesterol. Smoking and an ex- cess of cholesterol in the blood distinctly increase the risk of coronary disease; and the risks are much greater for a hyperten- sion sufferer than for someone with nor- mal blood pressure. So it is particularly desirable for a hypertension patient to stop smoking and to adopt a diet which will help lower the serum cholesterol , level. The advice given will certainly be followed more closely if the health professionals concerned can explain the situation clearly and simply, preferably setting an example themselves. Patients should be warned that these measures will have no direct effect on the blood pressure reading but are intended all the same to reduce the risk of complications, just as a motorist reduces the risk of an accident on a wet road by slowing 30 effective control A cut in the calorie intake, particularly as regards saturated fats, alcohol and sugar, is a must" for sufferers from high blood pressure. The patient should he warned off alcoholic or sweetened drinks, which are an important source of calories (left). And ordinary milk products or cream-enriched foods should be replaced by skimmed milk products. Some 75 per cent of the production at the Finnish cooperative dairy pictured here (right) consists of low fat content milk. ( Photos Len Sirman © and WHO/D. Hen- rioud) down—even if this does not dry the road ! Medical advice on avoiding obesity on the other hand does directly affect blood pressure, along with other factors. We know that being overweight not only encourages a higher arterial blood pres- sure but also a raised serum cholesterol level and the possible appearance of diabetes. A simple evaluation of corpu- lence can be made; it is very instructive to check on an individual's gain in weight since he or she stopped growing, that is, since the age of about 20. This weight gain is highly significant since it marks fatty deposits and therefore a pos- itive excess of weight. This is not to say that the patient has to return to the weight he was at the age of 20 ; even if this were desirable, it is usually just not possible and there is no point in setting unattainable goals. However if there is excess weight, an assessment has to be made of the daily physical losses as well as of eating habits; within the limits of a normal comfortable life, the patient has to try to correct the imbalance by some means that can be lastingly maintained. Generally speak- ing, doctors recommend an increase in daily physical activity (particularly walk- ing) and a cut in the calorie intake partic- ularly as regards saturated fats, alcohol and sugar. In practice this means a reduction in fatty foods added to the diet (butter, cooking oil, margerine) and the replacement as far as possible of fatty animal products by lean animal products (for instance, replacing beef and pork by fish or chicken, and ordinary milk prod- ucts or cream-enriched foods by skimmed milk products). In addition, the patient should be warned off sugar and alcoholic or sweetened drinks, which are an important source of calories. The individual should be assured that there is no substitute for personal effort, but medical advice should be adapted to the circumstances and the personality as well as to the benefits likely to accrue from following such advice. This is par- ticularly important for younger patients. It is easy enough to cut down salt consumption to three to five grams per day and this alone helps to reduce hyper- tension; it should be strongly recom- mended. More than half the salt con- sumed is usually added in the kitchen or at table. So whoever does the cooking should be advised to keep down the use of kitchen salt experience shows that people quickly get used to doing without it in most dishes—and should try to find the minimum amount needed for really insipid dishes. The salt-cellar should be banned from the table. Cooked meats and ordinary cheese are usually salted, and since they also contain undesirable fats they are better avoided; no doubt to cut them out altogether would be viewed as too drastic. In France at least, bread provides about 20 per cent of all the salt eaten, but it would be unwise to cut down on this since it forms the basis of a balanced diet. But it is worth suggesting that people try unsalted bread, which often proves acceptable. Finally, plenty of vegetables should be recommended, as they are rich in potassium. Drugs come into the picture when hypertension is clearly severe or when, in spite of all precautions, the cardiovascu- lar risk remains high, with blood pres- sure measurements regularly reaching or exceeding 170/105 mmHg. Other unde- sirable factors such as smoking or elevat- ed blood cholesterol have to be taken into account, even when the readings are less high. The choice of treatment will depend on the results of medical exami- 31 nation, but in standard cases most spe- cialists would probably recommend in- itial daily treatment with thiazide drugs, whose effect is much the same as cutting down on salt but which acts more drasti- cally. It is best to start the treatment with a weak dose and to increase it progres- sively according to its effectiveness. In 50 per cent of cases, diuretics are not sufficient and another product has to be added to obtain satisfactory control; alpha-methyl-dopa, beta-blockers or clonidine are usually recommended. This treatment has to be adapted to each individual and closely watched. It ought to be easily tolerated at first, and even doctors who are inclined to dismiss drug intolerance as a criticism of their action have a duty to warn the patient clearly about this possibility and ask him to report any trouble. A slight modifica- tion in the treatment often suffices to put matters right. Depending on the drugs selected, certain factors need a close watch, for instance the quantity of glu- cose in the blood of people predisposed to diabetes who are taking thiazide How to avoid hypertension Check your blood pressure regularly Stop smoking Watch your weight Take plenty of exercise Eat less salt diuretics, or the heart rate of people receiving beta-blockers. Generally speaking, there is no point in repeating medical check-ups at frequent intervals, and an annual examination is often quite sufficient. Eventually treatment should succeed in bringing down the arterial pressure to 140/90. Occasionally correct treatment fails to have the desired effect and special problems arise. But apart from long- standing or long neglected hypertension, the fact remains that many so-called resistant cases are the result of incorrect treatment. In some cases, there is a specific cause of hypertension, in particular a diseased kidney or superrenal gland. But it seems rare for hypertension to be cured by treating its cause, contrary to what physicians thought a few years ago. Elaborate investigations into a possible cause should therefore be reserved for particularly severe cases or those which resist treatment. Prevention of hypertension is often simply neglected, yet the available data 32 effective control Left: Cigarettes represent a distinctly in- creased risk of coronary disease a risk that is much greater for a hypertension sufferer than for someone with normal blood pressure. The wisest advice is: Stop smoking. ( Photo Len Sirman Right: Many lives are being saved by this ambulance specially equipped to deal with severe heart attack cases in Northern Ireland. But prevention is better than cure; the risks stemming from high blood pressure can be considerably reduced by treatment, which can almost totally rule out heart failure and most strokes. ( Photo WHO/Royal Victoria Hospital, Bel- fast) suggest that the possibilities are very promising. These raised hopes are all the more welcome because the traditional cu- rative approach to hypertension cannot be regarded as an entirely satisfactory solution. It cannot be over-emphasized that in practice the majority of hyper- tension cases go untreated. Furthermore it is hardly desirable to oblige millions of people to take drugs all their lives. In any case there can be no question of applying this treatment to borderline cases—those people whose systolic pressure is, say, between 140 or 150 and who therefore run an extra risk : so they are simply abandoned to their fate even though they will eventually constitute a large propor- tion of cardiovascular accidents. To sum up, everything points to the fact that arterial pressure depends largely on the life-style of the individual. Two facts are well established : firstly, hyper- tension is very rare among populations which eat salt in small quantities, and the same people do not even show that in- crease of pressure with age that is taken for granted in Europe. Conversely, hypertension is very frequent in coun- tries with a high salt consumption. Secondly, the more a person's weight rises, the greater is the risk of high blood pressure; this is particularly clear among young people but remains true in later life. We have to spread the message very widely, especially to young people, that the best precaution is a way of life in- volving' very moderate use of salt and plenty of physical exercise; while a regu- lar watch on weight should ensure that people stay as close as possible in their adult years to their weight at 20. In view of the family predisposition to hyperten- sion, this advice should particularly be put across to the patient's family. From all aspects it is good to recommend the same diet for all, with a view to a cure in one case and prevention in the rest. This will have the double advantage of simpli- fying the preparation of food while avoiding any upset in the family atmo- sphere by isolating the sufferer at the family table. Hypertension control in the communi- ty must depend on two-fold action : on the one hand preventive, starting with the introduction of more sensible health habits from childhood onwards so as to reduce the risks; on the other hand cura- tive, for those who have failed to avoid hypertension, based on a better applica- tion of the simple rules of detection and treatment. ■ 33 priority - problem Through a worldwide network of study centres, WHO is now examining the feasibility and effectiveness of a variety of community pro- grammes for the control of high blood pressure BY Z. PISA AND T. STRASSER flik Two crucial issues underlie the very complex problem of hypertension. On the one hand, research is needed into its origins and causes in order to open up new possibilities for preventing this condition. On the other hand, more experience is needed in ap- plying available knowledge to control the disease with the therapeutic and health care arsenal now at our disposal. Epidemiological analysis of the health care situation in various parts of the world during the early 1970s showed that knowledge then available was being ap- plied to only a fraction of the vast army of hypertensives. In fact, it became evi- dent that only half the hypertensive sub- jects in the general population were aware of their high blood pressure, only half of those aware were being treated, and only a few of those treated were considered to be treated adequately. This situation was typical for most of the world's developed countries, even though the risks of high blood pressure were recognized and although the bene- fits of lowering persistently elevated blood pressure were well known to the health profession from detailed clinical trials. From the viewpoint of the epidemiolo- gy of health care, hypertension thus pre- sented a double paradox: although blood pressure can easily be measured, hypertension often remained undiag- nosed; and although relatively simple and efficient treatment was available, the patient all too often remained untreated. Since the number of hypertensive sub- jects all over the world is enormous—as many as 15 to 20 per cent of middle-aged men and women are reported to have elevated blood pressures in practically every country—it became clear that this double paradox is one of the priority health care problems on the interna- tional scene. One possible way of coping with this problem is a systematic, well-designed and well-organized community-based approach to improving hypertension care. WHO laid the foundations for such a programme based on three fundamental components : education of the public, education of the health profession, and improvement of the services concerned with hypertension. All three components were amalgamated into a community control programme and WHO committed itself to exploring whether such pro- grammes are feasible under various social, economical, cultural, and health care situations. Like any other tool, community pro- grammes for the control of hypertension have to be tested in practice. WHO oper- ates a large cooperative project which is studying the feasibility and effectiveness 34 WHO'S HYPERTENSION STUDY A Worldwide Network "A bolder vision of the future is based on another scenario that prevention will eventually become the ultimate solution to the world problem of hypertension" Hypertension detection team at work in India. A standard method of compiling the data from such surveys has been suggested by WHO, but it is a flexible system and can be modified to suit local conditions. (Photo WHO/A. S. Kochar) of such programmes in a worldwide net- work of centres. These operate in Argen- tina, Brazil, Chile, Peru and Venezuela in South America; in Barbados and Cuba in the Caribbean; in Ghana, Nigeria and Senegal in Africa; in Czechoslovakia, Finland, France, the German Democratic Republic, Italy, Portugal, USSR and Yugoslavia on the European continent; in Israel in the Middle East; and in China, Japan and Mongolia, among the Asian countries. In order to collect reliable information on what is happening to the hyperten- sives in each community, individuals in whom high blood pressure has been diagnosed are being registered and sub- sequently followed up. At present almost 30,000 such people are included in this vast study. What are the findings? Although only interim results are yet available, it is clear by now that a reduction in the blood pressures of thousands of hypertensives can be achieved by a community-orient- ed programme. It has also become clear that a certain threshold level of health services has to be reached before a com- munity control programme can be made viable. It is equally clear that in different cultural and social settings various shades of approaches are needed. This is true even though the basic principles— early detection and consistent treatment, promoted by education of both the pub- lic and the health profession—are equal- ly valid in any country. There are some very encouraging results. In North Karelia, Finland, for instance, the proportion of hypertensives under treatment has very considerably increased since the community pro- gramme was started. At the same time the frequency of stroke has decreased in this community, and it is expected that similar results will be observed in the other centres. There are therefore sufficient grounds for reasonable optimism as regards the control of hypertension and the preven- tion of its complications within the pre- sent state of the art. There is no doubt that a systematic approach to hyperten- sion control in the community is a neces- sity. However, a bolder vision of the future is based on another scenario; that prevention will eventually become the ultimate solution to the world problem of hypertension. To attain this goal, however, the scientists have still a long road to travel. ■ 35 See 000 000 000 000 000 000 0041 000 *00 000000-.' 4100 000 0000e0 000 000 000 fbefl 0000800ee 000 000 000 eee 000 0.• elle 0 00 000 000 OOO O OO 000 411.0011e 0e0 000 000 00e 000 00. 0041 000 000 00• 000 •0• e•e 000 0 00000 000 000 Soo ... ....00 550 m oire :::••• •=.", A.— , -AO (Photo UNICEF/WHO) Poverty has many faces. Four UN strategies to attack poverty Four strategies aimed specif- ically at bettering the lives of the world's poorest people have emerged following in- creasing awareness in inter- national circles that UN's development efforts are not producing the desired results, especially where the most disadvantaged com- munities are concerned. WHO has realized that con- ventional health services, with their emphasis on hos- pital-based treatment and expensive medical technolo- gy, make hardly any impact on the rural poor. During the economic crisis of the early seventies, UNICEF noted that, despite international aid which enabled hard-hit countries to maintain their level of imports, develop- ment programmes and national services for children suffered badly. It came to the conclusion that there was need for alternative ap- proaches to meeting the basic needs of the children belonging to low income communities. A survey of current rural development activities of the UN system conducted under the aus- pices of the Administrative Committee on Coordination (ACC - consisting of the ex- ecutive heads of the UN and the specialized agencies) revealed that rural develop- ment projects had mainly benefited the higher income farmers in many cases, and in some even aggravated the problem of income distribu- tion. ILO has likewise drawn attention to the fallacy of equating increased produc- tion with a better deal for the poor and has attempted to pioneer a new employment- oriented approach to devel- opment. No-one doubts any longer that even such a remarkable breakthrough in food production as the so- called "green revolution" succeeded only in enriching the rich farmer, and virtually passed by the hungry mil- lions. The rising GNPs of nations offer no guarantee that the poor are faring any better. The four strategies that have resulted from this thinking are: the Primary Health Care strategy of WHO with which UNICEF, too, has been closely associated; the Basic Services for Children strategy of UNICEF; the Poverty- Oriented Rural Development strategy of the ACC; and the Basic Needs strategy of ILO which was first pro- posed by the World Employ- ment Conference in 1976. The strategies naturally reflect each organization's special field of interest, for instance, WHO's preoccupa- tion with health and disease, UNICEF's with the problems of children, ILO's with un- employment and poverty in general, and the ACC's concern to develop a com- mon UN approach to the problems of the rural poor. However, there are close similarities in approach. The goal is identical: to develop feasible solutions to the many-faced problem of poverty, which Member Governments may adapt in programmes devoted to bet- tering the lot of the poorest sections of their people. All the strategies require the close collaboration of people drawn from many disciplines and a multi-sectoral ap- proach, the emphasis on one or the other element of the development process— health, education, agricul- ture, industry, communica- tions, etc.—being deter- mined by specific local needs and the expressed will of the community. All are agreed that governments themselves are responsible for develop- ment, and that the participa- tion of the community in the planning, propagation and execution of development activities is essential. All development plans are envi- saged as part of the total na- tional effort and are drawn up realistically, taking fully into account the human and material resources of the community. The coordina- tion of the four strategies at the country level is ensured by a Resident Representative appointed by the UN Devel- opment Programme. Control of a measles outbreak in Nigeria The control of a measles out- break through a vaccination programme carried out with exemplary rapidity and thoroughness has been reported from Nigeria. The disease broke out among a community of around 34,000 people in Bendel State, in the south-western part of Nigeria, and attacked mainly infants and toddlers under three years. As soon as the presence of the disease had been recognized by the health authorities, it was decided to launch a mass measles vaccination cam- paign. The task was entrust- ed to the physician in charge of a pilot project of the Nigerian National Youth Ser- vices Corps' Rural Mobile Health Service which was operating in the area. Prep- arations for the campaign were completed within six days, and within a period of only 11 days teams using three vehicles and three jet injectors succeeded in vacci- nating 4,205 children — vir- tually 100 per cent of the target population. The following factors were seen to have contributed to the success of the operation. The physician in charge of the mobile project had, with the aid of school teachers and village chiefs, taken a census of the population so that the names, ages and other data about the inhabi- tants were already known. A medical field unit was made available to supplement the staff of the pilot project. The storage of the vaccine at the correct temperature was en- sured by utilizing the refri- gerator used for storing fish in the community. Informa- tion was disseminated to the mothers and village elders through an existing commu- nication system, and a loud- speaker was used by the physician to reinforce the message. Transport was available to bring people to the central village collecting points used by the vaccinat- ing teams. Children, particu- larly those known to have been exposed to the disease, were actively sought and brought to one of the vacci- nation centres. The epidemic has, however, brought to light the need to establish continuing surveil- lance of diseases like measles to ensure their prompt detection. In this case several weeks had passed before the outbreak was reported. It has also been realized that while a well-organized ad hoc mass campaign can effectively stop an epidemic, it entails the unnecessary expense of vaccinating a large number of children who have already had the disease and are im- mune to it. The ideal method is to undertake planned and continuing programmes of vaccination to prevent the possibility of such epidemics. Measles is one of the six target diseases under the Ex- panded Programme for Im- munization in which WHO is collaborating with a number of Member Countries. Major water supply study in Yugoslavia Yugoslavia has completed a major study of the water supply and waste disposal needs of its southern pro- vince of Kosovo, and pre- pared master plans to cover the entire province, which has a population of more than 1.2 million. Launched in 1974, the pro- ject was aimed at studying the practicability and esti- mating the cost of safe water supply, waste disposal and industrial pollution control systems in Kosovo, where in- 36 4141ffiglialaRtatimaraw- (Photo WHO/D. Henrioud) Water treatment plant that serves Pristina. tj'N RENE GOSCINNY, creator of the cartoon character Asterix, died November 1977, aged 51 ( Photo Keystone ©) PRESIDENT GAMAL AB- DEL NASSER of Egypt, died Sep- leather 1970, aged 52 "King of Rock" ELVIS PRESLEY, died August 1977, aged 42 ( Photos Len Simian ) KING GEORGE VI of the United King- dom, died February 1952, aged 56 Opera-singer MARIA CALLAS, died Sep- tember 1977, aged 53 ( Photos Len Sirmanc) dustrial and rural economies are both important. The studies prepared include master plans for community water supply and urban waste disposal, together with preliminary engineering fea- sibility studies, and final designs for water supply net- works to meet the needs of 12 major towns in Kosovo, including the capital, Pristi- na. Detailed designs for the sewerage, stormwater drain- age and waste treatment plant have been made for the economically important tour- ist town of Pec. Work has already begun in Pec on the construction of the main sewerage and stormwater collection systems. Twelve detailed water supply designs have been prepared for rural settlements with populations ranging from 500 to 4,000. The project was funded by UNDP and WHO acted as the executing agency through its European Re- gional Office in Copen- hagen. The Government del- egated responsibility for the work to the Institute for Town Planning in Pristina. Hydroprojekt Praha, an eng- ineering firm from Czechoslo- vakia, was appointed by WHO as consulting eng- ineers and worked closely with the Institute for Town Planning. An important element in all projects of technical cooper- ation is the training of national staff needed to im- plement the project pro- posals. This was achieved by associating a number of offi- cials from the Urban Affairs department of the provincial government and from the University of Pristina with the various project activities and enabling them to study water supply and waste dis- posal technologies in Cze- choslovakia. The UNDP contribution to the project was over $950,000 and the Govern- ment contributed the equi- valent of $710,000. To meet the needs of Kosovo by 1990, the master plans en- visage an outlay of $530 mil- lion for water supply and US$275 million for liquid waste disposal. For such large investments, funds will have to come from national as well as international sources. Rabies defeated by community effort Laredo, a small town in Texas, USA, was the scene of an intensive anti-rabies campaign last year, according to a report recently published by WHO. Launched in November 1976, when a dog was diag- nosed to be rabid, the cam- paign lasted eight months and succeeded in bringing under control a rabies epi- demic in which a total of 55 rabid dogs were identified in Laredo. The disease, was not diagnosed in any other animal. Anti-rabies treatment was given to 59 persons who were exposed to the disease during the outbreak. No human cases occurred. This was a new experience for the authorities and the people since no case of rabies had been reported in Laredo for 29 years. But the health officials at the local, county and state levels, the news media, practising veterinarians, the animal Pro- tection Society, and the gen- eral public all joined hands in a well-coordinated commu- nity effort to defeat the threat. Under the massive control programme, over 14,000 ani- mals (13,000 dogs and 1,000 cats) were vaccinated and over 1,700 stray dogs were destroyed. The campaign had to be coordinated with another across the USA's frontier with Mexico, where Laredo's twin city, Nuevo Laredo, recorded 25 cases of canine rabies. The control opera- tions in Nuevo Laredo in- cluded the vaccination of 15,135 dogs and destruction of 1,146 strays. HEARTS THAT FAILED Princes, potentates and peasants have fallen alike to the scourge of heart disease. Untold numbers of premature deaths might have been prevented if high blood pressure had been detected and treated early enough. On this page we recall a handful of the well-known figures who died "before their time". 9 heures 3 heures 7 heu O 21 heures 2 heures 6 heures 10 heures 14 heures 18 heures 2 2 heures 11 heures 15 heures 19heuras 23 heures 8heures 12 heures 16 heures 20keures 24heures 5heures PUMPING 24 HOURS NON-STOP If we could imagine the human heart plugged in tc an enormous reservoir of blood, it has been calculated that over a period of 24 hours it would fill to capacity a tanker-lorry capable of holding 10,000 litres. Our diagram shows hour by hour the amount of blood pumped by an average adult's heart. We are quite ac- customed to the idea of a mechanical pump filling up a tanker, or of the petrol-pump that is used many times a day to fill up the fuel-tanks. But think of such a pump throbbing away unceasingly for 24 hours a day, 365 days a year, and every year for a lifetime. So there is all the more reason for treating this vital pump of ours with care and having it checked out at regular intervals. OUR FOUR-STROKE MOTOR A The cardiovascular system is a closed-circuit arrangement for pumping fresh blood all round our body, and keeping it renewed with oxygen derived from the air that we breathe into our lungs. The heart plays the part of a four- stroke pump, forcing the blood outwards through the arteries. The first phase occurs as tired blood comes back from the body along the network of veins, re-entering the heart through the right auricle the small upper chamber, shown here as a black circle. B The second phase: while the right auricle fills with tired blood (shown in black), the same quantity of blood replenished with oxygen fills the left auricle (the chamber shown in red). C Thirdly—the diastole or relaxation phase of the heartbeat. Valves open to enable the auricles to empty into their respective ventricles (the large lower chambers). The blood flows passively at first but then the auricles contract to force the remaining blood into the ventricles. Tne valves then close on the full ventricles. D Fourth phase—the systole. Abruptly the ventricles contract. Valves open at the start of the pulmonary artery (leading to the lungs) and of :he aorta (leading to the main arteries), and blood is firmly pumped out of the heart. The right ventricle (in black) forces a quantity of veinous blood—still not oxygenated —towards the pulmonary artery and the lungs. E Simultaneously the left ventricle expels the same volume of blood, this time replenished with oxygen, by way of the aorta to all organs of the body. F The blood circulation to and from the lungs calls for special explanation. The veinous blood expelled from the right ventricle is forced towards the lungs through the pulmonary artery, branching left and right into the interior of the lungs. Tiny blood vessels in contact with the air sacs of the lungs then ensure that the tired blood receives a fresh supply of oxygen. The newly oxygenated blood returns along the pulmonary veins and enters the left auricle of the heart. The first phase of the next heartbeat is starting again. (All the diagrams on these pages are taken from "Le Livre de la Sante", volume 4, published by Andre Sauret, Monte Carlo 1967. They are reproduced by kind permission of the author, Joseph Handler). SWALLOW 600 FROG 30 MOUSE 500 RABBIT 200 MAN 70 BULL 25 ELEPHANT 20 Electrical stimulation reaches the two ventricles which contract violently; the reading marks a massive but short- lived peak. This is the systolic phase, as we have seen in the diagram on the opposite page. Blood is pumped abruptly into the pulmonary artery and the aorta. No electrical stimulus. The ventricles have stopped contracting. This is the start of the rest period, or diastole, during which the ventricles again start to fill with blood in a passive way. The slight bump on the reading marks a discharge of electricity from the relaxing heart muscles. The heart starts preparing for the next pulse. ORDER FORM Please enter my subscription to "World Heal:h" as follows: US$" Sw.fr.' One year 10.— Tv,:o years 18.— TI- ree years 24.— One year: Two years: Three years: I enclose cheque/postal order in the amount of ....- Name: Street: City: Country: or equivalent in local currency. World Health, WHO, Avenue Appia, 1211 Geneva 27, Switzerland 25 — 45 — 60 — [7] Li "READING" THE PULSE An instrument called an electrocardio- graph is used to measure the electric currents generated by the heart muscles. The diagram shows as a b ack line, amplified and traced by a "pen" on a strip of paper, an electrocarciograph reading of the different phases in the course of a single heartbeat. The upper row of hearts shows the electrical events H EARTB EATS PER MINUTE NUMBER OF that are taking place, and the lower row shows the physical events. The heart is in a state of electrical rest. There is no contraction but blood is trickling passively from the auricles into the ventricles. The electrocardio- graph reading is flat. Electrical stimulation (shown in pink) starts in the auricles, which contract and force blood into the ventricles. This triggers a slight bump on the reading. The auricles have stopped contract- ing, and the electrical stimulus starts to move towards the ventricles. The line on the electrocardiograph again goes flat. Authors of the month Dr H. MAHLER is Director-General of the World Health Organization. Dr J. I. S. ROBERTSON, of the Medical Research Council Blood Pressure Unit, Western Infirmary, Glasgow, is President of the Inter- national Society of Hypertension. Mr T. SELLERS is science editor at Emory University, Atlanta, Georgia, USA. Dr S. HATANO is at the Tokyo Metropolitan Institute of Geron- tology, Japan. Mr N. WILLARD and Mr J. BLAND are members of WHO'S Division of Public Information in Geneva. Dr O.O. AKINKUGBE IS Principal of University College, Ilorin, Nigeria. Professor A. FROMENT is Professor at the Cardiovascular Clinic, Lyon Cardiovascular Hospital, France. Dr Z. PISA is Chief of the Cardio- vascular Diseases unit at wit) headquarters, and Dr. T. STRASSER is a Medical Officer in the same unit. WORLD HEALTH Regular checking helps tc prevent high blood pressure. (Photo WHO/P. Almasy)