Why more residents, especially drivers, are developing hypertension —Adeoye

Professor Abiodun Moshood Adeoye is a consultant cardiologist with University College Hospital. In this interview with SADE OGUNTOLA, he spoke about the impact of air pollution on the heart and what individuals need to do for healthy hearts.

Increasingly, experts are linking air pollution to ill health. Is there any link between air pollution and heart disease?

Air pollution is a silent public health emergency. The poor, the rich, the old, and the young breathe polluted air daily, leading to an increase in cardiovascular diseases, especially heart disease and stroke. Our team, the Air Pollution Climate Change Expert Committee (APCCEG) for the World Heart Federation, reports that the number of cardiovascular diseases linked to air pollution is rising. Air pollution is responsible for more than 20% of cardiovascular deaths. Additionally, roughly seven to eight million deaths occur each year due to air pollution.

The air we breathe might not be visible, but it is filled with chemicals and particles. When you see smoke, it is air with a high concentration of floating particles. These particles are harmful to the body. Air pollution can come from particulate matter, but it can also originate from gases such as nitrogen dioxide and ozone. Particulate matter in the air varies in size, with some particles being up to 10 micrometers. These fine particles, when inhaled, can penetrate deep into the lungs. From there, they can enter the bloodstream and reach other parts of the body, including the heart.

In the heart, what do they do?

These tiny particles are foreign to the body, so they trigger inflammatory responses in the organs. As a result, the body’s defense cells come to attack them. While attacking, they can cause damage to more cells. The heart vessels have an inner lining called the endothelium. Damage to the inner lining of the heart’s blood vessels can occur, making the vessels that should remain flexible stiff. Mixing with other toxic components in the blood, such as fats, this can lead to atherosclerosis (a buildup of fatty deposits in blood vessels). Additionally, blood clots may form more easily. Such a condition can lead to hypertension, heart failure, a heart attack or even a stroke.

Is the risk for cardiovascular diseases as a result of exposure to air pollution higher in men or women?

The policy report from the World Heart Federation, based on the level of exposure, categorised people into susceptible, vulnerable and both.  The vulnerable ones include women who cook with unclean energy like biomass, wood and charcoal. So they are more exposed. Similarly, women who roast maize and plantain, as well as men who make suya, are more exposed to smoke from charcoal cooking.

Commercial drivers, who are mostly men, are also exposed to air pollution. That’s why statistically in our community it may be difficult to say women are more at risk from air pollution than men. It all depends on the rate of exposure. Studies in Nigeria showed that those exposed to high concentrations of this particulate matter also have higher blood pressure than those with lower exposure. People with high concentrations of particulate matter have difficulty with their blood pressure dropping at night. So we call them non-dippers.

With funds from WHF, we also sought to assess the knowledge, attitudes, and behaviours of vulnerable groups, including healthcare providers, regarding air pollution and cardiovascular disease. Even people who you expect to know don’t know the relationship between air pollution and cardiovascular disease. Those who know, their attitude and behaviour do not show that they are informed. You expect them to stay away from the sources of air pollution, but they still get exposed to it as if nothing will happen.

What can individuals do to protect their health against the negative effects of air pollution?

The first thing we need to do is to understand the link between air pollution and cardiovascular health. What are those things that we need to do? We have to cook with clean energy sources; we should discourage incessant bush burning. And if we have people who are doing it, we educate them. Also, as individuals with vehicles, they should service the engine on time to reduce air pollution emissions from their exhaust. This will reduce the level of air pollutants individuals on the street are exposed as to. Generally, there can be indoor and outdoor air pollutants. Indoor pollutants might be easy for individuals to control, but the outdoor pollutants are a bit difficult to control. There are policies on clean air; the relevant government agencies should enforce them. We need to monitor and ensure good air quality for everybody. If we can do that, then it will help everyone.

What are those practices at home and at the workplace that leave people’s hearts at risk of air pollution in Nigeria?

Well, apart from the industrial pollution, our housing arrangements in many settlements expose many people to high levels of air pollutants. You find a residential six-room apartment without a detached kitchen building, and everybody has their cooking stove in front of their rooms. Also, people roasting maize, yams, plantain or even suya should look for another way around it. And we should desist from using unclean energy like wood and dung for our cooking. High levels of air pollutants also exist in the workplace. I was surprised one day when, in the corridor, one of my colleagues tested for the pollutants and discovered that even in that corridor, the level of particulate matter was far above what is recommended by the World Health Organisation (WHO). It buttresses the fact that we have to desist from practices that pollute the air. Certainly, along that corridor, there is likely to be more particulate matter than any combustible or oxidative gas. We have a lot of those in our corridors, offices and workplaces. But regularly cleaning our homes and offices will undoubtedly reduce the dust level and make the air cleaner. But when you stack things up for a while before cleaning up, you might run into issues later. When there is raised dust, we might need to wear nose masks to protect ourselves.

Are there programmes in Nigeria to prevent problems that could arise in the heart due to air pollution?

We have a lot of policies on air quality control, environmental safety, climate change and all that. What we need to do now is enforce and implement those policies. There’s a regulation on the permissible level of sulphur in petrol sold in Nigeria. I was reading about a group that recently imported adulterated petrol with high sulphur content. That shouldn’t be the case if the regulatory policies on the quality of petrol imported into Nigeria are strictly enforced. Of course, all WHO guidelines on air quality should be implemented. We have to support research work to show more evidences that there is a link between air pollution and cardiovascular diseases in our community. A systematic review by a group of colleagues found that across Africa, only six studies clearly linked air pollution to cardiovascular health. Those six studies were conducted in South Africa and involved Caucasians. We need funding to support additional studies on air pollution and cardiovascular health.

I am aware of studies in Nigeria that linked air pollution with specific chemical changes at the placenta that affect the perinatal health of the fetus. A study in Nigeria has shown the benefits of clean stove and clean air on hypertension in pregnant women and the results of the ongoing clustered randomised trial in Lagos on the effect of the intervention on blood pressure are awaited.   The challenge is the sustainability of the clean cooking stove intervention. If you prove it works, will the masses continue to use it after the study’s funding expires? So, we need the goodwill of the government or philanthropists to make sure that good ideas like that are sustained. I hope the 80 million clean cooking stoves project in Nigeria will be implemented soon.

Are there other things aside from air pollution that are contributing factors to heart diseases and heart problems generally?

Talking about air pollution and the heart, you cannot exclude tobacco smoke. Aside from tobacco use being generally injurious to the body, smoking will increase the risk of atherosclerosis. Other contributory factors to cardiovascular diseases include a sedentary lifestyle, poor diet and stress, as well as conditions like uncontrolled hypertension and diabetes. We cannot overemphasise the sedentary lifestyle. If you are sedentary, you are going to be obese. If you overeat, you are going to be obese. Then if you eat junk, your lipids will go up. So we have to eat a heart-healthy diet. Green, leafy vegetables and fruits will be helpful. Regular exercise and a low-salt diet is helpful.  Uncontrolled hypertension and diabetes can lead to stroke and heart attack. Some things predispose us to cardiovascular diseases that are beyond us, like age, being a man and family history. If there’s a family history of hypertension, there’s a higher risk of the offspring of hypertensive parents developing hypertension. If both parents have hypertension, that carries a higher risk compared with those who have a single parent with hypertension.

Moving forward, what are the things that Nigeria needs to add to its health reform for the overall goal of health for all?

I must commend the government, under its current ministers and all the agencies working with them. They are making a frantic effort. But to me, if you want to sort out the issues of universal health coverage, we have to start from the basis, which is primary healthcare. If you can take care of the community and services at the primary healthcare level, we’ll be able to increase health coverage rather than focusing only on secondary and tertiary healthcare institutions. They all have to be empowered. No doubt, there have been improvements in the PHCs; renovations and new structures are coming up. Take, for instance, the Health Insurance Agency in Oyo State: they are recruiting people at the community level, and they can access their health care at the primary care centres. So, whatever is happening to someone, if they have a health facility to get care, they can be stabilised and, if need be, referred promptly to the next level of care, as the case may demand.

Of course, the recent appointment of one National Health Fellow per local government to go into the community to advocate for good universal care and to educate people about matters, including why they should patronise PHCs, is a step in the right direction. So, education is important for increasing people’s health consciousness and encouraging them to visit government health facilities for healthcare services. Of course, health insurance will increase access to healthcare services. Already, the federal government is working to create an enabling environment for pharmaceutical production in the country. Many pharmaceutical companies are doing a great job, but we need more locally produced drugs.

Emigration of the health workforce persists as a big challenge in Nigeria. What’s the way forward?

The emigration of health workers, ‘Japa’, as it is commonly called, is due to both the pull and push factors. Pull factors are things outside where they are going, like a better work environment. The push ones in our environment are incentives, wages paid to health workers, insecurity and so on. So, Nigeria needs to improve its work environment and give adequate wages to encourage people to stay. Some people want to stay back but become frustrated when things do not work out.

No doubt, every sector is affected by emigration, but the health sector is worst hit. But now, most schools have been encouraged to produce more. They are given more quotas, so there should be more facilities for training. Even university lecturers who are supposed to train students are leaving. Then, the regulatory bodies have been encouraged to be a bit more lenient, without compromising standards. There are many tasks, shifting and sharing programmes; therefore, with training, community health workers, for instance, can take on more roles in the health sector. With time, we’ll have more hands. If there’s a portion that will still want to go out, they will go out. It may not affect the human resources. With time, I think we’ll stabilise. Nigeria will continue to produce good hands for the world. The qualities of students who come to read medicine are good; they are toppers. They will hardly fail in medical school. We need to keep them; we need to create an environment that encourages them to stay.

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