WORLD HEART DAY: SA’s heart health crisis demands a public health response

Every day, about 225 South Africans die of heart disease or stroke, according to the Heart and Stroke Foundation South Africa. Together these conditions account for almost one in six deaths in the country, and more than half of cardiovascular deaths occur before the age of 65. Many of those who die are breadwinners, parents or caregivers in midlife.

This World Heart Day, on 29 September, the World Heart Federation asks that we “Don’t Miss a Beat”: recognise the hidden signs, protect our hearts and demand action. As public health researchers, we have a crucial role to play in producing the evidence needed to strengthen our country’s health policies, systems and reform.

Silent killer we must track and link early to care

High blood pressure drives much of this burden, contributing to one in two strokes and two in five heart attacks. It is invisible until it strikes. An analysis of blood pressure screening campaigns across South Africa between 2017 and 2021, covering more than 11,000 people, found that nearly 30% had hypertension. Only 54% of them knew it, 47% were on treatment, and about a quarter had their blood pressure under control. Awareness was just 24% among adults under 40. Given the strides South Africa has made in HIV screening and linkage to care, we should commit more budget and resources to driving down the prevalence of hypertension as a starting point.

Heart disease rarely travels alone

At PRICELESS SA, our projects show why fixing this means looking beyond the heart itself. Hypertension sits alongside diabetes, HIV, cancer and depression, yet our system was built around single diseases.

In our breast cancer study, which has yet to be published, hypertension was one of the most prevalent comorbid conditions among participants. That underscores the close link between breast cancer and cardiovascular health, and calls for routine blood pressure screening and integrated cardiovascular care throughout treatment.

The heart and the mind are entwined, too. Our systematic review of 11 studies of more than 730,000 adults aged 50 and under found that better cardiovascular health was linked to lower odds of depression and anxiety, and that depression and anxiety were linked to poorer cardiovascular health.

The people who hold the system together are at risk too. In our study of caregivers of adolescents living with HIV in KwaZulu-Natal, 52% had depressive symptoms and three in four were living with HIV themselves. With depression linked to poorer cardiovascular health and HIV adding its own risk, these caregivers face a heavy cardiovascular burden. Those we rely on to look after others need care themselves.

A system that cannot see the whole patient

Our health system is too fragmented to monitor and support efficiently patients living with heart-related and other conditions. We lack the digital tools for comprehensive multimorbidity management and surveillance. Our team is currently evaluating the cost and national scale-up of the Madiva dashboard, a digital platform that supports clinicians and nurses in managing patients who have several chronic conditions at once, such as HIV, hypertension and diabetes. Our health economics team is also evaluating the cost-effectiveness of the Enhance intervention, which combines a clinical decision support tool, health literacy materials and stronger referral pathways supported by community health workers, to help clinics detect, treat and control common combinations of chronic conditions, with hypertension a key condition.

Health is a right, not just a choice

We cannot place the responsibility for heart health solely on individuals when the environments in which people make health-related decisions are shaped by policies, markets and unequal access to resources. Preventing cardiovascular disease requires more than educating people to eat better, exercise and seek medical care. It requires policies and interventions that make healthier choices accessible and affordable, alongside health systems that provide timely screening, medicines and ongoing care. A commitment to the right to health means paying particular attention to those who face the greatest barriers to prevention and treatment.

What needs to happen

Find the people we are missing. Make blood pressure checks routine at clinics, workplaces and pharmacies, especially for men and young adults.

Close the treatment gap. Hypertension medicines are cheap. Reliable supply and follow-up matter more than any new technology.

Remove the hidden costs. As National Health Insurance takes shape, transport support and community-based chronic care should be treated as core financial protection, not extras.

Invest in data and people together. Fund the specialist workforce and shared patient-level data foundations together.

Raise and index the levy. Move the Health Promotion Levy toward the WHO-recommended 20%, which modelling suggests could avert 619,000 new cases of type 2 diabetes over 20 years, and allocate the funds to strengthening primary and community-based healthcare services.

Fund African evidence. Local research on how heart-related and other chronic conditions interact should guide our guidelines. DM

Dr Darshini Govindasamy is the director at PRICELESS SA (SAMRC / University of the Witwatersrand, School of Public Health).

Ruth Negepah is a PhD candidate leading research into breast cancer and hypertension comorbidity at PRICELESS SA (SAMRC / University of the Witwatersrand, School of Public Health).

Dr Akim Lukwa is a Senior Health Economist consultant with PRICELESS SA (SAMRC / University of the Witwatersrand, School of Public Health).

Dr Aisosa Omoruyi is a senior law researcher at PRICELESS SA (SAMRC / University of the Witwatersrand, School of Public Health).