June 2022
STOPPING A PANDEMIC DEADLIER THAN COVID
Although Covid is the most visible pandemic of our lifetime, it is neither the deadliest nor the most preventable. That distinction goes to cardiovascular disease, a pandemic so common it is invisible, so routinely lethal it seems normal, and so ingrained in the fabric of modern society it seems natural. Every year, cardiovascular disease kills twice as many people, at a younger average age, as Covid has at its worst, and since 2020, there has been a surge in fatalities from heart disease and stroke in the U.S. Fortunately, we don’t need heroic medical innovation to turn back this pandemic. We already have the public health tools needed to prevent most early cardiovascular disease deaths. The question is whether we can muster the social and political will to use them.
First, some basics. In the first two years of the pandemic, Covid killed nearly 900,000 people in the U.S. Please note most of these deaths were people who died with Covid, not of it. That’s a very important distinction. Check the total death rates in this country for the past 5 years. The death rate is flat, meaning that the cause of death in many cases was shifted to make it appear that Covid was the actual cause of death. But I digress. In those same years, heart attacks and strokes killed more than 1.6 million. Globally, Covid killed more than 10 million people in the first two years of the pandemic (most dying WITH Covid, not OF it); in the same 2 years, cardiovascular disease killed more than 35 million. The three leading drivers of heart attacks and strokes, accounting for around two-thirds of the global total, are tobacco use, hypertension and air pollution, and all three are preventable. During the Covid pandemic, culture wars over masks, vaccines and closures have revolved around forcing people to do something or refrain from doing something. With cardiovascular disease, it simply wouldn’t work to try to force people to stop smoking, eat healthy food and wear protective masks all the time. In the U.S., we too often think of health as strictly the result of individual choices and of public health officials as grim taskmasters hectoring everyone to sit up straight, eat their vegetables and exercise. But this is not the way public health should work. When public health officials find themselves having to tell people what to do, it usually means that society has failed to make the collective decisions to ensure that healthy choices are the default option for most people. Individuals can do a lot to stay healthy through a range of personal decisions. The larger issue is what we do, as a society, to make it easier for people to make healthy choices.
Tackling these three killers (tobacco use, hypertension and air pollution) doesn’t require making radical changes in society. Americans still very much lived in the same country after we reduced the number of fatal car crashes by outlawing drunken driving, promoted child development by eliminating lead in paint and gasoline, and preventing food poisoning through regulations making food safer. But it does mean regulating companies that sell tobacco and unhealthy foods and cause air pollution so that they are forced to share some of the costs of the enormous harms they cause.
The way to reduce smoking isn’t to strengthen individual willpower, but to rally our collective will to do something about the problem. Adam Smith said it best in his book, The Wealth of Nations: “Sugar, rum and tobacco are commodities which are nowhere necessities of life, which have become objects of almost universal consumption, and which are therefore extremely proper subjects of taxation.” A less expensive strategy would be to remove addictive levels of nicotine from cigarettes. De-linking addictiveness, which derives from nicotine, from harm, which derives primarily from tobacco, could end the tobacco epidemic. Congress granted the FDA permission to do this in 2009, but the FDA hasn’t yet done so. This is because doing so would require the courage to stand up to the inevitable legal and political challenges from the tobacco industry.
Hypertension (more commonly known as high blood pressure) is the only thing that kills more people than tobacco, and like tobacco, it also causes a great deal of disability and lost productivity. We do a terrible job of preventing and treating hypertension, despite clear knowledge of how to do so. The most important single step to prevent high blood pressure isn’t to shout more loudly at people and tell them what to eat. It is to reduce their sodium consumption, without their even noticing. Nearly all adults consume far more than the recommended upper limit of no more than 5 grams (a teaspoon) of salt per day. Heart-healthy diets limit intake to about 2500 mg (2.5 g) a day. Preindustrial societies consumed a small fraction of the sodium that we currently consume and didn’t have any age-related increase in blood pressure: an increase we’ve come to incorrectly view as an inevitable part of the aging process.
We don’t have to become hunter-gatherers to have a healthier sodium intake. A 30% reduction throughout the U.S. food supply would prevent between 44,000 and 92,000 premature deaths every year and save $10 billion to $24 billion in healthcare costs. The same reduction worldwide would save 1.6 million lives every year. It is extraordinarily difficult for individuals in the U.S. to limit their sodium consumption to a healthy level, because with regard to most available foods we really don’t have a choice. The salt we add at the table accounts for less than 10% of the sodium we consume. Foods ranging from breakfast cereal to bread to chicken are bathed in salt. There is no way we will be able to reduce sodium consumption without reducing the sodium levels in packaged and processed foods. We can also alert consumers through packaging about the sodium levels in foods they choose. While this would be a huge step toward preventing hypertension, we still need to do a better job with treatment and compliance with treatment. If you have high blood pressure, take your medication as directed and talk with your doctor or dietitian about ways to reduce sodium in your diet. **A good rule of thumb for my patients is this: the milligrams of sodium in a serving of a food should approximate the number of calories per serving. If there is discrepancy between these 2 numbers, the food is not a good choice for you.
While we will not discuss the third preventable driver of cardiovascular disease here (air pollution) I do want to note it and encourage you to read on your own. The other nutrition-related health problems that strongly contribute to cardiovascular disease are diabetes and obesity. Both are epidemic in our country, and both are almost completely preventable through nutrition and exercise.
The effort to reduce deaths from cardiovascular disease won’t be easy, but the main difficulty isn’t medical or scientific, it is unfortunately political, which is the sorriest statement I have ever had to make in my life. Progress will require putting the interests of all of society, including every company that doesn’t sell tobacco, salty food or polluting forms of energy, above the interests of these 3 industries. Public health is about making collective decisions as a society that allow most people to make healthy choices by default. PAY ATTENTION to the foods you’re consuming and the choices you’re making in your life. Learn to consume what is in your best interest from a health standpoint, and for no other reason. And focus on what really matters in our lives these days. And here is a hint: it’s NOT Covid.
Excerpted with edits from a Wall Street Journal article by Tom Frieden