Blood pressures are rising in the Middle East and North Africa (MENA) and they show little sign of cooling down. They began simmering over shishas in el kahawi (coffeehouses) in Tahrir Square, Eqypt; steaming over fried malsouka snacks in Habib Bourguiba Street, Tunisia; and bubbling over smoke filled debates at Pearl Roundabout, Bahrain. People from all classes and walks of life are equally affected. And without revolutionary change, it will exact a high human and economic toll.
The reference to rising tensions in MENA is not only meant as an analogy for the political changes in the region. It is also meant as a literal reference to what is happening to people’s health. High blood pressure caused by high fat and sodium diets (local deserts like kunafah and pickles like torshi), high rates of tobacco use (shisha and cigarettes), and a sedentary lifestyle contribute to almost half a million deaths in MENA annually. The theme of this year’s World Health Day on April 7th is hypertension or high blood pressure, an especially timely issue for MENA.
Globally, hypertension affects four out of every ten adults, and MENA is no exception. In 2010 high blood pressure affected up to one in two people in certain MENA countries like Libya. Hypertension rates are equally high in men and women, and it is the leading risk factor for death in women and second leading risk factor in men. More worryingly, its dominance as the leading cause of death has not waned with time. In the last twenty years, high blood pressure has stubbornly clung to its position as the second leading cause of death and disability in the region (pole position is “dietary risks”). Unless something is done urgently, it is unlikely that this alarming trend will change.
The consequences of hypertension for MENA are sobering. If untreated, hypertension leads to ischemic heart disease and stroke, the leading causes of death and disability in MENA. The economic costs of hypertension are also sizable. A 2007 study estimated that the total annual cost of treatment for cardiovascular disease and diabetes in Egypt was $100 million. This could rise by 125 percent by 2015. Given the shrinking fiscal space in Egypt this is, quite simply put, unaffordable.
However, there are steps to minimize the impact. Not only is high blood pressure both preventable and treatable, but prioritizing interventions is also cost effective. Hypertension can be prevented by reducing salt intake (laying off on the torshi); eating a balanced diet (skipping that extra piece of baklawa); avoiding tobacco use (staying away from cigarettes and shisha); and engaging in regular physical activity (replacing driving with walking). Early detection and regular screening, while scarce in most MENA countries can effectively manage symptoms and reduce complications. Treatment options abound and include a pharmacopeia of drugs at affordable prices. Research has shown that for MENA it is cheaper for governments to provide these medicines upfront, even for medium and high risk groups, than to bear the cost of intensive care later in the stage of illness.
So why do blood pressures continue to rise in MENA? The reasons may be systemic.In comparison to countries of similar economies, MENA governments spend less on health, resulting in patients bearing the brunt of the cost. On average, households in the Maghreb and Mashriq pay almost forty per cent of all health care costs, forcing people to forego care or face impoverishment due to medical expenses. This is compounded by health systems that are unresponsive to patients’ needs with high levels of corruption and low levels of trust.
Specific to hypertension, MENA has not invested in limiting drivers of the epidemic. Despite being signatories to the Framework Convention on Tobacco Control, proven and effective tobacco control measures are not in place. Tobacco taxes are low, few countries have smoke-free legislations, and only two countries have large graphic warnings on cigarette packaging (found to be very effective in getting smokers to cut back). Socio-cultural norms and lack of public spaces restrict regular exercise, manifested in women in MENA having some of the highest rates of obesity globally. In addition, weak surveillance and lack of reliable data make it hard for public health agencies to track prevalence rates and respond appropriately.
The poor prevention, detection, and management of hypertension are indicative of the many gaps in MENA health systems. As a way to bring attention to this issue, the World Bank is redoubling efforts in MENA and launching a new Health Nutrition and Population Sector Strategy for the next five years. Drawing from the discourse of the Arab Spring, this strategy is premised on the principles of “Fairness” and “Accountability”. It is committed to translating them in a sustainable way into health systems in the region. Creating fair and accountable systems should hopefully help lower rising blood pressures -- not just figuratively but also quite literally.
 WHO (2008), Global atlas on cardiovascular disease prevention and control, WHO: Geneva. Available at http://www.who.int/cardiovascular_diseases/publications/atlas_cvd/en/index.htm
 Murray et al (2013). TheGlobal Burden of Disease Study 2010 (special issue),Lancet 380 (9859): 2053-2260. http://www.healthmetricsandevaluation.org/gbd/visualizations/gbd-arrow-diagram
 Abegunde et al (2007). “The burden and costs of chronic diseases in low-income and middle income countries”, Lancet, 370 (9603): 1929-1938.
 GrazianoTA, Opie LH, Weinstein MC (2006), “Cardiovascular disease prevention with a multidrug regimen in the developing world: A cost effective analysis. Lancet, 368: 679-686.