Spotlight on

Cuba's national program for hypertension

Cuba's first National Program for Prevention, Diagnosis, Evaluation and Control of Hypertension (HTA Program) was developed in 1974, when the Public Health Ministry was one of 13 worldwide invited by the WHO to join the "Community-based Program for Control of Hypertension". During the next few years, 15% of the urban population over 15 was diagnosed with hypertension, and 7-8% of rural inhabitants. However, at that time high blood pressure was defined as 160/95. Thus, when the National Program was revised using 140/90 as the new definition, the prevalence nearly doubled.

In 1995, a National Survey of Risk Factors was conducted, corroborating a prevalence of 30.6% in urban areas of the country (three fourths of Cuba's population lives in urban zones).

By 1997, over 98% of Cuba's population was receiving regular primary care from family doctor and nurse teams living in the neighborhoods they serve. While community polyclinics had been a feature of Cuban public health practices since the 1970s, new possibilities opened up when each family doctor-and-nurse duo was assigned the job of promoting good health among a specific set of families (approximately 150). Prevention could be more tailored to generally known risk factors, relying on stronger community participation and consciousness-building; and individual diagnosis could be followed more closely with regular exams and counseling intended to achieve lifestyle changes.

Thus the HTA Program was reviewed once more, and an updated version published in 1998. It is noteworthy that the new edition relied not only on extensive bibliographic review and opinions from experts in the field, but also on those of primary care physicians, nurses, psychologists and other specialists. Internationally, the new Program also drew from the NIH's Sixth Report from the National Joint Comittee for Prevention, Detection, Evaluation and Treatment of Arterial Hypertension (JNC-VI), published in 1997.

Several aspects of the current 50-page program merit particular reflection:

Defining the Problem

Given the relationship of hypertension to heart and cerebrovascular disease in general—and particularly to mortality from these causes—the main problem identified by the program's designers was the underdiagnosis of the condition in the population, and consequently, its lack of adequate treatment and control. For example, in the 1995 National Survey, only 60.8% of the persons detected with hypertension had been previously diagnosed, and of these, only 75% were being actively treated. More worrisome still was the fact that of those known cases of hypertension, only 45.2% were under effective control.

Hypertension, in turn, is directly related to morbidity and mortality from cerebrovascular accidents (CVA) and cardiovascular disease, both of which are among the primary causes of death and potentially lost years of life in Cuba. Last year, these accounted for 29,920 deaths in the country, or 37.6% of the total of 79,486 (27% of total deaths were from heart deasese and 10.6% from CVA). In particular, hypertension has been associated with premature deaths from these causes.

On the positive end, the Global Cienfuegos Project (see Epidemiology of Hypertension in Cuba in this issue of MR) in central Cuba managed to reduce arterial hypertension in the population under study from 43.9% to 38.5% over four years. The WHO estimates that each 2mm Hg. reduction in average population blood pressure reduces annual morality by 6% for CVA, 4% for cardiovascular disease and 3% from associated illnesses. In the case of Cienfuegos, where the average reduction was 3.5 mm Hg, one could then predict that CVA deaths might decrease by as much as 9%, cardiavascular mortality by 6.0% and deaths associated with hypertension by 4.5%.

One key objective of the current Program was to significantly increase detection of hypertensives. And meaningful progress was reported by last year, when the number diagnosed rose to 1,428,247 (or twice those detected in 1996, when only 755,382 hypertensives had been detected).

Pointing Toward the Solution

Cuba's National Hypertension Program attempts to harness the epidemiological and clinical potential of virtually universal primary care, placing this considerable resource at the service of prevention, a strategy the Program defines as the "most important, comprehensive and economical" way to tackle hypertension and its collateral damage.

The program mandates family
doctors and nurses to pay particular attention to reducing obesity, stress, smoking,
and alcohol and salt consumption
in the patients and communities they serve, as well as to play a pro-active
role in nutritional education and physical exercise.

One risk factor of growing importance in Cuba is the aging of the population (see MR, Vol. II, Number 1, Aging in Cuba ), since the frequency of high blood pressure increases with age, and that almost half of the >50 population suffers from hypertension.

Public Health Meets Clinical Practice

Cuba's model of primary care takes on a consciously two-pronged approach when confronting hypertension, bringing into play the tools of good public health practice, as well as the clinical and psycho-social evaluation skills utilized for individual patients. Thus, the Program and its implementers are at ease moving from the community to the individual patient and back again—whether identifying and controlling risk factors, promoting lifestyle changes or defining treatment options. The program itself is designed for health professonals to address the community as a whole, and at the same time to tailor treatment to patients' individual needs.

In addition, the structural relationship between primary care and secondary level institutions allows particularly complex cases to be followed at both levels, bringing in local hospitals, or the national and provincial reference centers for hypertension (the latter being the national Institute of Nephrology and the Ameijeiras Brothers Hospital, both in Havana).

The Program's Objectives

As outlined in the text, the Program has one over-riding and six specific objectives, each of these broken down into measurable goals for periodic evaluation.

In general, the program proposes to "prevent and control arterial hypertension in order to reduce morbidity and mortality from high blood pressure and from other diseases associated with it."

In particular, to:

Increase preventive actions at the primary care level related to arterial hypertension (with specific attention given to minimizing a series of risk factors outlined under this point).

Increase detection of cases of arterial hypertension.

Diagnose the cases of secondary arterial hypertension.

Bring high blood pressure under control in hypertensive patients (including both lifestyle changes and recommended approaches to drug therapies; definition of a patient under control; and hypertension in children, the elderly, the black population, diabetics, pregnant women, and patients suffering from renal insuffiency and a list of other conditions of special concern).

Implement the National Program at all levels of the health system.

Increase public education on the importance of prevention and control of high blood pressure.