**2. Poverty in sub-Saharan Africa**

SSA is home to 14% of the 7.8 billion world's inhabitants but contributes to more than half of the global poor [8, 9]. Using the 1-dimensional measurement of poverty that focuses on income or wealth, over 40% of SSA residents live below the poverty line of \$1.90 per person per day [9]. This poverty level is far above the average poverty rate of 13% in other regions of the world [10]. While the rest of the world has observed a significant decline in extreme poverty, SSA observed a rise in the number of people living in extreme poverty from 278 million in 1990 to 413 million in 2015 [9, 11]. Even those who live above the \$1.90 poverty, a significant proportion of them are still very poor due to deprivations in various aspects of well-being [9, 11]. Using deprivation from education, health, and assets as multidimensional measures of poverty, about half (51%) of the poor population in the world lives in SSA [12]. Therefore, most sub-Saharan inhabitants lack sufficient income and basic needs, including quality health and education [12]. Most of the causes of poverty in SSA are not different from the rest of the world. They include colonialism, war and political instability, national debts, discrimination and social inequality, and vulnerability to natural disasters [13]. The impact of colonialism, the slave trade and resource extraction from SSA likely contributed in some ways to the persistent poverty in the region [14]. The existence of a significant inequality in income distribution and access to productive resources, essential social services, opportunities, markets exacerbate the already existing poverty despite the autonomy of African countries following their independence [15]. Women and children are the most affected groups with inequalities and natural catastrophic events such as drought, flooding, and frequent disease epidemics in the region [14, 15]. In these events, the already impoverished people are often displaced, lose their belongings, and remain in the vicious cycle of poverty [15].

Similarly, violent regional conflicts, forced displacement and political instability in a significant number of SSA countries interfere with safety, stability and security needed for investment and economic growth [13]. The situation is made worse by weak national institutions permissive to corruption and resource misallocation in many SSA countries [9]. As a result, these countries carry significant debts that have high-interest rates and are linked to conditions that may be unfavourable to the development of local economies [13]. The impact of HIV and AIDS is also significant as the disease affected the working-age population leading to a reduction in economic productivity [16]. In the context of all these factors, it remains unclear if the region will end poverty in all its forms by 2030 as per the Sustainable Development Goal 1 (SDG 1) [17].

## **3. The effect of poverty of CVD in Africa**

With poverty, SSA has the lowest healthcare expenditure, the lowest life expectancy, and inadequate access to health care services, safe water, education, and sanitation facilities [18, 19]. Although poverty is among the reasons behind the region's high burden of infectious diseases such as malaria, tuberculosis and human immunodeficiency virus (HIV), it is also a reason behind the rising burden of CVDs [4]. Economic development in SSA leads to urbanisation and increased tobacco consumption, harmful alcohol use, unhealthy diets, and physical inactivity [2]. While

**19**

levels [20, 21].

by 25 goal) in SSA [36].

*Poverty and Cardiovascular Diseases in Sub-Saharan Africa*

educational programmes on modifiable CVD risk factors.

the wealthy population can revise their lifestyle, lack of access to both preventative and remedial health care among the poor partly explains the high burden of CVD risk factors [20, 21]. Besides poor access to healthcare services for CVD prevention and control, low education significantly affects a good understanding of the disease process and promoting a healthy lifestyle among the poor [22]. With poverty encompassing low income and consumption, poor education, health, nutrition, and other human development parameters, its effect on CVD is complex [23]. It affects different stages, ranging from primordial prevention that targets the emergence of CVD risk factors, primary prevention in the presence of CVD risk factors, and

Unfortunately, data on the overall burden of CVD and its association with poverty are scarce in SSA [24]. With the weak state of the health systems in many SSA countries, typical patient record systems are not sufficiently functional to support accurate morbidity and mortality data documentation [25]. Given the high burden of environmentally induced risk behaviours and limited access to good-quality and affordable health care, the CVD burden, morbidity, and mortality are disproportionately higher among the poor than the affluent population in the region [20–22, 26–28]. Only a few countries (e.g., Botswana) have a universal healthcare system that extends coverage to poor communities [28]. Besides, CVD modifiable risk factors such as hypertension, diabetes, and cholesterol disorders remain undiagnosed or untreated in a significant proportion of the poor communities in SSA [28–33]. The situation is concerning because early detection and effective management of risk factors can substantially reduce most CVD [34]. Over and above the behavioural and physiological risk factors, anger, anxiety and depression are important risk factors for CVD [35]. Poor housing, sanitation and limited access to healthcare are psychosocial stressors that may lead to anger, anxiety and depression in the poor urban sub-Saharan populations [35]. Psychosocial stressors lead to an increased behavioural risk factors for CVD such as tobacco consumption, harmful alcohol use, unhealthy diets, and physical inactivity [2]. Also, most of these populations live in overpopulated unplanned urban settlements, which are often not conducive for establishing healthy behaviours [2, 18, 19]. These communities can hardly afford healthy food and have high illiteracy

Hence, poverty leads to CVD through multiple ways that lie within and outside

Although not related to the epidemiological transition, rheumatic heart disease (RHD) is another poverty-related CVD that has remained unconquered in SSA [30, 37]. The disease is responsible for over 95% of the 492 042 global deaths per year among the young population in SSA and other impoverished communities in Oceania, South Asia, Central Asia, and the Middle East [38]. SSA (5·7 cases per 1000), the Pacific and indigenous Australia and New Zealand (3·5 cases per 1000), and south-central Asia (2·2 cases per 1000) are the regions with the highest prevalence of RHD [38]. The disease results from acute rheumatic fever (ARF) - an abnormal immunological response to Group A Streptococcal (GAS) infection of the throat [39]. Risk factors of ARF include poverty, overcrowding and reduced access to medical care, all prevalent in SSA [38, 40]. Primary prevention of ARF involves early detection and antibiotic treatment of streptococcal pharyngitis [38, 41]. Early detection and treatment of streptococcal pharyngitis require functional health care services and a community with enough health literacy and appropriate healthseeking behaviour. With rampant poverty and the absence of universal healthcare, the treatment of streptococcus pharyngitis is poorly practised in many SSA countries [42]. Consequently, RHD remains prevalent in SSA versus other countries

the health sector. Consequently, broad partnerships across various sectors are needed to achieve the 25% reduction in premature NCD mortality by 2025 (the 25

*DOI: http://dx.doi.org/10.5772/intechopen.98575*

#### *Poverty and Cardiovascular Diseases in Sub-Saharan Africa DOI: http://dx.doi.org/10.5772/intechopen.98575*

*Lifestyle and Epidemiology - The Double Burden of Poverty and Cardiovascular Diseases...*

**2. Poverty in sub-Saharan Africa**

and remain in the vicious cycle of poverty [15].

**3. The effect of poverty of CVD in Africa**

Development Goal 1 (SDG 1) [17].

responsible for the increasing burden of CVD [7]. Consequently, this report looked at CVD and poverty interconnection in SSA and the implications for the future.

SSA is home to 14% of the 7.8 billion world's inhabitants but contributes to more than half of the global poor [8, 9]. Using the 1-dimensional measurement of poverty that focuses on income or wealth, over 40% of SSA residents live below the poverty line of \$1.90 per person per day [9]. This poverty level is far above the average poverty rate of 13% in other regions of the world [10]. While the rest of the world has observed a significant decline in extreme poverty, SSA observed a rise in the number of people living in extreme poverty from 278 million in 1990 to 413 million in 2015 [9, 11]. Even those who live above the \$1.90 poverty, a significant proportion of them are still very poor due to deprivations in various aspects of well-being [9, 11]. Using deprivation from education, health, and assets as multidimensional measures of poverty, about half (51%) of the poor population in the world lives in SSA [12]. Therefore, most sub-Saharan inhabitants lack sufficient income and basic needs, including quality health and education [12]. Most of the causes of poverty in SSA are not different from the rest of the world. They include colonialism, war and political instability, national debts, discrimination and social inequality, and vulnerability to natural disasters [13]. The impact of colonialism, the slave trade and resource extraction from SSA likely contributed in some ways to the persistent poverty in the region [14]. The existence of a significant inequality in income distribution and access to productive resources, essential social services, opportunities, markets exacerbate the already existing poverty despite the autonomy of African countries following their independence [15]. Women and children are the most affected groups with inequalities and natural catastrophic events such as drought, flooding, and frequent disease epidemics in the region [14, 15]. In these events, the already impoverished people are often displaced, lose their belongings,

Similarly, violent regional conflicts, forced displacement and political instability in a significant number of SSA countries interfere with safety, stability and security needed for investment and economic growth [13]. The situation is made worse by weak national institutions permissive to corruption and resource misallocation in many SSA countries [9]. As a result, these countries carry significant debts that have high-interest rates and are linked to conditions that may be unfavourable to the development of local economies [13]. The impact of HIV and AIDS is also significant as the disease affected the working-age population leading to a reduction in economic productivity [16]. In the context of all these factors, it remains unclear if the region will end poverty in all its forms by 2030 as per the Sustainable

With poverty, SSA has the lowest healthcare expenditure, the lowest life expectancy, and inadequate access to health care services, safe water, education, and sanitation facilities [18, 19]. Although poverty is among the reasons behind the region's high burden of infectious diseases such as malaria, tuberculosis and human immunodeficiency virus (HIV), it is also a reason behind the rising burden of CVDs [4]. Economic development in SSA leads to urbanisation and increased tobacco consumption, harmful alcohol use, unhealthy diets, and physical inactivity [2]. While

**18**

the wealthy population can revise their lifestyle, lack of access to both preventative and remedial health care among the poor partly explains the high burden of CVD risk factors [20, 21]. Besides poor access to healthcare services for CVD prevention and control, low education significantly affects a good understanding of the disease process and promoting a healthy lifestyle among the poor [22]. With poverty encompassing low income and consumption, poor education, health, nutrition, and other human development parameters, its effect on CVD is complex [23]. It affects different stages, ranging from primordial prevention that targets the emergence of CVD risk factors, primary prevention in the presence of CVD risk factors, and educational programmes on modifiable CVD risk factors.

Unfortunately, data on the overall burden of CVD and its association with poverty are scarce in SSA [24]. With the weak state of the health systems in many SSA countries, typical patient record systems are not sufficiently functional to support accurate morbidity and mortality data documentation [25]. Given the high burden of environmentally induced risk behaviours and limited access to good-quality and affordable health care, the CVD burden, morbidity, and mortality are disproportionately higher among the poor than the affluent population in the region [20–22, 26–28]. Only a few countries (e.g., Botswana) have a universal healthcare system that extends coverage to poor communities [28]. Besides, CVD modifiable risk factors such as hypertension, diabetes, and cholesterol disorders remain undiagnosed or untreated in a significant proportion of the poor communities in SSA [28–33]. The situation is concerning because early detection and effective management of risk factors can substantially reduce most CVD [34]. Over and above the behavioural and physiological risk factors, anger, anxiety and depression are important risk factors for CVD [35]. Poor housing, sanitation and limited access to healthcare are psychosocial stressors that may lead to anger, anxiety and depression in the poor urban sub-Saharan populations [35]. Psychosocial stressors lead to an increased behavioural risk factors for CVD such as tobacco consumption, harmful alcohol use, unhealthy diets, and physical inactivity [2]. Also, most of these populations live in overpopulated unplanned urban settlements, which are often not conducive for establishing healthy behaviours [2, 18, 19]. These communities can hardly afford healthy food and have high illiteracy levels [20, 21].

Hence, poverty leads to CVD through multiple ways that lie within and outside the health sector. Consequently, broad partnerships across various sectors are needed to achieve the 25% reduction in premature NCD mortality by 2025 (the 25 by 25 goal) in SSA [36].

Although not related to the epidemiological transition, rheumatic heart disease (RHD) is another poverty-related CVD that has remained unconquered in SSA [30, 37]. The disease is responsible for over 95% of the 492 042 global deaths per year among the young population in SSA and other impoverished communities in Oceania, South Asia, Central Asia, and the Middle East [38]. SSA (5·7 cases per 1000), the Pacific and indigenous Australia and New Zealand (3·5 cases per 1000), and south-central Asia (2·2 cases per 1000) are the regions with the highest prevalence of RHD [38]. The disease results from acute rheumatic fever (ARF) - an abnormal immunological response to Group A Streptococcal (GAS) infection of the throat [39]. Risk factors of ARF include poverty, overcrowding and reduced access to medical care, all prevalent in SSA [38, 40]. Primary prevention of ARF involves early detection and antibiotic treatment of streptococcal pharyngitis [38, 41]. Early detection and treatment of streptococcal pharyngitis require functional health care services and a community with enough health literacy and appropriate healthseeking behaviour. With rampant poverty and the absence of universal healthcare, the treatment of streptococcus pharyngitis is poorly practised in many SSA countries [42]. Consequently, RHD remains prevalent in SSA versus other countries

and an appreciable cause of premature mortality with a mean age of death as low as 25 years [43]. While medical and surgical management can reduce morbidity and mortality, poverty reduction and improvement of overall living standards are crucial in reducing the overall burden and complications of RHD [44].
