BullPan Am Health Organ 13(3), 1979.

“DOWN WlTH HIGH PRESSURE,” A THEME WITH A WARNING FOR PHYSICIANE+ *

Emma C. Balossi’ and Julia H. Hauger-Klevene4

Hypertension, the subject of World Health Day 1978, is a serious health problem that, once detected, can be effectively controlled. This article reviews detection and treatment pattel-ns in Argentina, the United Kingdom, and the United States and suggests ways these patterns might be im- proved

Hypertension and Health tion are to be reduced. It is also clear that hypertension control activities (mainly per- The World Health Organization selected formed during medical visits) do reduce the arterial hypertension as the topic for World demands on inpatient facilities Health Day, 7 April 1978, and publicized and so indirectly improve both the quanti- the slogan “Down with high blood pres- ty and quality of work that can be accom- sure] ” The choice of this theme was not plished by those facilities. Seen either from casual, but was based on the fact that mor- the viewpoint of reduced medical costs (4) tality figures in the developed countries (1, or in terms of patient workdays gained as Z), and in most developing countries as well as the impact that hospitalization has well, (3) show to be on the family and community, this is an im- the leading cause of death. Arterial hyper- portant consideration. tension -together with various complica- tions including cerebrovascular accidents, Detection and Treatment of cardiac insufficiency, and renal insuffi- Hypertension ciency -contribute to maintain these high rates of cardiovascular mortality. It has been argued-and with good Thus, it is clear that pro- reason -that the greatest problem of hyper - grams must make control of arterial hyper- tensive disease is the absence of symptoms tension a priority goal if the risks of sick- prompting medical consultation. For this ness, disability, and death from this condi- reason, part of a hypertension control pro- gram’s strategy is based on making the population realize the importance of get- ‘Also appearing in Spanish in the Boletin de la Oficina Sanitaria Panamericana, 1979. ting periodic medical checkups (4). 2Work carried out with the support of Argentina Within this context, it is also useful to Program 1700 sponsored by the Pan American Health take a look at what happens to patients who Organization and the Secretaria de Estado de Salud Ptiblica, Argentina. enter a country’s for reasons SChief, Noncommunicable Diseases Division, Secre- unrelated to hypertension, vis-g-vis exami- taria de Estado de Salud Pablica, Defensa 120, Bue- nation for this problem, in order to see nos Aires, Argentina. aChief, Arterial Hypertension Research Center, whether appropriate medical services are Hospital de Clinicas JosC de San Martin, Centro de being supplied. Some examples of investiga- Medicina Nuclear, Buenos Aires Medical University: tions that have provided useful data on this and Investigator, National Council of Scientific and Technical Research (CONICET) and CNEA. Ar- subject in the United Kingdom, the United gentina. States, and Argentina are as follows:

249 250 PAHO BULLETIN l vol. 13, no. 3, 1979

The United Kingdom The United States

In 1977 Heller and Rose reported the In a similar manner, a review of clinical results of studies made in England to eval- histories in the United States (9) has shown uate the frequency with which physicians that arterial blood pressure levels are not in private practice (6) and those in general determined in a routine, systematic man- (5) determined their patients’ ner. In this study, it was found that arte- levels of arterial pressure. This research rial blood pressure readings appeared in 74 showed that neither private physicians’ per cent of inpatient clinical histories, 43 offices nor general hospitals were function- per cent of outpatient clinical histories, ing as effective centers for detection of and 14 per cent of emergency room patient arterial hypertension. At the London hos- histories. pitals studied, only 1,027 of 1,784 inpatients The frequency with which U.S. physi- (58 per cent) had their arterial blood pres- cians recommend anti-hypertensive treat- sure taken. And although arterial hyper- ment has also been found to vary, even in tension had been detected in 167 (16 per cases where high levels of arterial pressure cent) of those tested, only 18 of these patients are detected. Thus, Frohlich et al. (9) (12 per cent of those found with the prob- found that anti-hypertensive treatment was lem) were actually treated for hypertension prescribed for fewer than 5 per cent of 108 (8. patients whose clinical histories showed The findings based on private practice arterial pressures higher than 160/100 mm clinical histories were similar. In a random Hg, while Wilber and Gordon-Barrow (1) sample of 669 patients visiting 15 private found that anti-hypertensive treatment was practitioners (for whatever reason) in the recommended to 70 per cent of a group of London area over a period of five years, patients found to have high arterial pres- only 24 per cent had their arterial pressure sures. taken; of the 74 patients found to be hyper- tensive, only 28 (38 per cent) were treated Argentina for hypertension. Also, a study of emergency room clinical In Argentina, an evaluation was made of records in Great Britain found that 73 per 4,405 outpatient histories at a Buenos Aires cent of the inpatients admitted through the hospital. The patients in question had been emergency room had their arterial pressure examined at hospital outpatient clinics taken, but that this was done for only 45 per devoted to various medical specialties. In cent of the patients who visited the emergen- all, the study covered a total of 18,632 con- cy room but were not hospitalized (5). sultations conducted from August 1976 to In addition, a 1973 report evaluating the December 1977; 14,160 of these (76 per quality of medical care in Scotland (7) cent) were repeat consultations. found that only 9 to 15 per cent of one The study found that the patient’s arte- group of physicians were using the sphyg- rial pressure had been measured in 30 per momanometer in their practices. Further cent (1,341) of the first-time consultations research in Scotland, published in 1976 (S), and 20 per cent (2,832) of the subsequent indicated that arterial pressure was being consultations. Arterial hypertension was measured in about 40 per cent of the pa- detected in 12 per cent (500) of the total tients 45 to 64 years of age who consulted number of consultations, and some type of private physicians. medical action relating to hypertension Balossi and Hauger-Klevene l DOWN WITH HIGH BLOOD PRESSURE 251

(referral or treatment) was noted in the diagnostic examinations while omitting records of 12 per cent (60) of the patients. this highly sensitive and specific instru- No significant differences were observed mental test. between the proportion of hypertensives Because of the “silent” nature of hyper- referred or treated on initial consultation tensive disease, the battle against it is being and the proportion referred or treated on waged through efforts (such as those cited subsequent consultations. The overall pro- in references l-4 and 10) to screen the sup- I portion of hypertensives referred or treated posedly healthy population, together with (12 per cent) was consistent with the values measures designed to provide continuing (lo-15 per cent) reported by a number of medical education and medical audit. In studies carried out among the general addition, advantage should be taken of the population (10). opportunity to screen people admitted to If the arterial pressure of every patient hospitals-where the patient, physician, had been taken during the patient’s first and sphygmomanometer come together visit, assuming the prevalence of hyperten- within the framework of the doctor-patient sion remained constant, then 536 cases of relationship. hypertension would have been detected; Within this context it is worth noting this is 70 per cent more than the number of that a person entering a hospital is a person cases actually found. Just as serious as this worried about his health. This fact creates failure to detect hypertension was the fail- special conditions encouraging changes in ure to offer effective treatment. As far as is behavior, attitudes, and beliefs that are re- known, only 35 of the 500 diagnosed hyper- quired for the health education process to tensives were given treatment or referred to succeed. The patient’s presence in the hos- special services, which means that 465 pital also makes it possible to apply treat- hypertensive patients (93 per cent) were lost ments currently available for the effective to effective medical control. control of arterial hypertension. In addition, the hospital is a medical Conclusions training center. Accelerated changes in medical knowledge make it necessary to These investigations demonstrate that apply methods of continuing medical even when appropriate resources (a physi- education and review in the hospital that cian and a sphygmomanometer) are avail- will enable the physician to acquire new able, and even when the patients involved knowledge and, more important, to use have consulted the health system, arterial such knowledge effectively in patient care. hypertension (a biologically important This specific medical education and review diagnostic variable) is not being measured process should direct special attention to systematically, nor are the findings of ar- the hypertension problem, since countering terial hypertension being controlled effi- this “silent” enemy requires that the physi- ciently or confirmed by subsequent exami- cian first unmask it and then remain suffi- nation. Furthermore, the physician often ciently aware of it to procure proper applies a number of more sophisticated control.

SUMMARY

Hypertension and its complications-the alike. Nevertheless, physicians often fail to con- theme of World Health Day 1978-cause heavy duct the routine blood pressure tests and follow- mortality in developed and developing countries up measures needed to detect this “silent” 252 PAHO BULLETIN l vol. 13, no. 3, 1979

enemy and bring it under control. The fore- United States) and describes some of the preven- going article reviews hypertension detection and tive measures needed to further reduce the im- control patterns observed in three countries pact of the disease. (Argentina, the United Kingdom, and the

REFERENCES

(I) Wilber, J. A., and J. Gordon-Barrow. 1:1441-1442, 1977. Hypertension, a community problem. Am J (6) Heller, R. F., and G. Rose. Current man- Med 52:653-663, 1972. agement of hypertension in general practice. Er (2) Christmas, B. W., and A. S. Turner. Pre- Med J 1:1442-1444, 1977. valence of high blood pressure treated and un- (7) Buchaw, I. C., and I. M. Richardson. treated in an urban adult New Zealand popula- Time Study of Consultations in General Prac- tion: Napier, 1973. New Zealand Med J 86:419- tice. Scottish Health Service Studies, No. 27. 423, 1977. Scottish Home and Health Dept., Edinburg, (3) Akinkugbe, 0. O., and E. Bertrand. Hy- 1973. pertension in Africa. Literamed Publications (8) Heller, R. F. Doctoral dissertation. Uni- Nigeria Ltd.; Lagos, Nigeria, 1975. versity of London, England, 1976. (4) Stamler, J., R. Stamler, W. F. Riedlinger, (9) Frohlich, E. D., C. Emmott, J. E. Ham- G. Algera, and R. H. Roberts. Hypertension marsten, W. M. Linehan, D. Pollack, and A. W. screening of 1 million Americans: Community Horsley. Evaluation of the initial care of hyper- hypertension evaluation clinic program, 1973 tensive patients. JAMA 218:1036-1038, 1971. through 1975. JAMA 235:2299-2306, 1975. (10) World Health Organization. Hy$erten- (5) Heller, R. F., and G. Rose. Current man- sion and Control in the Community. Non- agement of hypertension in hospitals. Br Med J serial publication. Geneva, 1976.

THE WORLD NEEDS MANY MORE NURSFS*

The world needs many more nurses than the estimated 4 million now in action throughout the world, writes Dr. Halfdan Mahler, Director- General of the World Health Organization, in the December issue of the magazine World Health. auxiliaries, who are estimated now at about twice the number of qualified nurses, are also in demand. Pointing out that nursing, like medicine, has for far too many years been predominantly oriented to meeting the needs of the privileged few, Dr. Mahler said that only 15 per cent of all qualified nurses work in developing countries where 66 per cent of the world’s population live. The urgent health problems of the majority of the people relate to poverty, , malnutrition and undernutrition, the lack of potable water, and multiple environmental hazards. He emphasized that “if the needs of communities are to be met, the ranks of the health workers, including nursing and medical personnel, will need to consist predomi- nantly of people who genuinely care about the health and welfare of impoverished communities, who want to help such communities, who are willing to learn what has to be done, and who can not only do it, but do it without dependence on sophisticated and costly technology.”

*WHO press release. 3 January 1979.