Because I am a cardiologist, people often ask me how they should live to help their hearts. The truth is, it matters more where you live than how you live.
Traditionally, heart disease was considered a disease of affluence; today, it is more an economic ailment than a medical disorder, correlated far more closely with one’s ZIP Code and bank balance than with one’s gene pool. As medical treatments have rapidly advanced, the chasm in heart disease risk between haves and have-nots has stretched further.
Closing this gap will require more from public officials and politicians than from doctors and nurses.
Heart disease remains the most common cause of death in the United States and around the world, killing an ever increasing number of Americans. Yet, while diseases such as Alzheimer’s or many types of cancer still await effective treatments, these already exist for heart disease. Since World War II, the risk of Americans dying from heart disease has dropped by about 70%, compared to only 20% for cancer. The change is attributable to a variety of factors: the identification of risk factors for heart disease such as smoking and diabetes, the discovery of groundbreaking medications to lower cholesterol and blood pressure and the development of procedures for patients having heart attacks.
But some of the recently developed life-saving medications for heart failure, high cholesterol and diabetes aren’t reaching the people who most need them. Affluent people have far better access to quality healthcare than those living in poverty, and they are better able to afford medication. They also are more likely to live in healthier neighborhoods, eat healthier foods, outsource stressful activities such as caregiving for old parents, and partake in aerobic exercise. Deepening income inequality will exacerbate the situation.
Heart disease is also political, and who wins the 2020 U.S. presidential election matters to those with heart issues. Gaining insurance has been found to lead to a reduction in deaths among people with heart disease and its risk factors, such as high blood pressure and diabetes.
Political polarization, though, can drive people to vote against their own health interests. Many more rural Americans die of heart disease, for example, than those living in large metropolitan areas, and that gap, instead of getting smaller as it has for cancer, has actually widened over time. But rural Americans are more likely than those in cities to vote for politicians who oppose Medicaid expansion, a policy associated with a drop in deaths from heart disease and fewer rural hospital closures.
When I was growing up in Pakistan, I was told that heart disease was a side effect of high-income countries’ relentless pursuit of material progress. The tables have turned though and heart disease is sky-rocketing in low- and middle-income countries in part because of the globalization of the Western lifestyle.
If we are to continue making headway against heart disease in the next century, we will have to ensure that innovations are accessible to all. Drug pricing reform has bipartisan support, and progress on that issue would be a win for lawmakers on both sides of the aisle as well as their constituents.
But access to heart treatments is not just about cost. With my colleagues, I have shown that almost half of patients with heart disease aren’t even prescribed statins, life-saving cholesterol-lowering medications for those with heart disease. Women, racial and ethnic minorities, and the uninsured are the least likely to get these dirt-cheap drugs. Of those prescribed statins, few are given the right dose. We need to develop systems that can help deliver the right therapies to all who would benefit from them.
One way to do that is to change the incentives in medicine: Health systems get paid for treating heart attacks but not for those they prevent. Another is through better public policy. Not only must clinicians advocate for patients at their bedsides; they need to put pressure on elected officials to expand access to healthcare. A healthy heart should be a right, not a privilege.
Haider Warraich is a cardiologist at the VA Boston Healthcare System, Brigham and Women’s Hospital and Harvard Medical School, and author of “State of the Heart — Exploring the History, Science and Future of Cardiac Disease.”