In a recent blog, I noted that the infant mortality rate in the US is higher than the other ten richest nations in the world, and that our life expectancy was three years less.  Our health care system is partly responsible for these disturbing statistics, but many extra-medical factors play an important role, including obesity, poverty, racial discrimination, etc.  

Nevertheless, there are gaps in our health care system that contribute to our poor showing on the international scene.  They are all the more reprehensible because some of them are easy to fix, at least theoretically.  Hypertension, high blood pressure, is front and center.

With revised definitions of hypertension in 2017 (blood pressures of greater than 130 systolic, the higher number, or greater than 80 diastolic, the lower number), 47% of Americans have high blood pressure, of whom about 20% are unaware of it.  In 2019, over one half million deaths in the US had hypertension as the primary or contributing cause.  One estimate of the average yearly cost to our society from 2008 to 2014 was $131 billion.

What’s exasperating is that none of this is necessary.  There are simple interventions for the prevention, diagnosis and treatment of hypertension.  Conservative measures such as  improved diet, weight control, exercise, limiting alcohol ingestion, and not smoking are all effective, and when it comes to medications, the cupboard is full.  We have an array of pharmaceutical treatments for hypertension that are safe and effective, most of them with few side effects.  And most can be taken once a day.   

So what’s the problem?  In my judgment, it is a simple lack of prioritization.  We are in the thrall of high tech interventions that grab the headlines, but they do not have nearly the impact on our nation’s health that control of hypertension would have.

It starts with detection.  Blood pressure machines that are now common in drugstores may not be dependable–repeated measurements in a medical setting are necessary.  And what about medical settings?  I am sure your primary care doctor checks your blood pressure, but I bet this does not happen reliably in visits to your dermatologist, ophthalmologist, orthopedist, etc. Or the dentist’s office.  Had we the will, we could make this happen: insurers (Medicare and Medicaid included) could simply withhold reimbursement for services unless a blood pressure is recorded in the medical record.  If the BP is high, there should also be documentation that the patient was advised to see his/her own primary care doctor.

Another hurdle is compliance once the diagnosis is made.  I am reminded of “directly observed therapy” (DOT) used in the treatment of tuberculosis.  To enhance effectiveness and minimize resistance to drugs for TB, some clinics have devised means to observe notably unreliable patients actually ingesting the medicines.  This intervention would not translate to the hypertension problem, but I cite it as an example of a policy that reflects a will to get a job done.

Some years ago, I visited some medical clinics in Tanzania.  They were primitive by our standards, but highly effective for the needs of the population.  In the rare instance that you needed an intervention for cardiac disease, you had to go to the neighboring country’s capitol, Nairobi.  But if you had malaria, tuberculosis, or HIV-Aids, these clinics were well equipped to handle these problems that were common in Tanzanians.

Our medical technology is the envy of the world.  We have easy access to scans that give us staggerly detailed information, cancer treatments that actually cure previously fatal disease, transplants, robotic surgical interventions that were previously impossible, etc.  It goes on and on.  These are the touchdown passes of our system,  but somehow we don’t provide the basic blocking and tackling needed for the routine and important problems that afflict most Americans.

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