11 May 2021
As the COVID-19 pandemic spread, we quickly observed that although a disease can affect people across the globe, the experience of individuals will differ drastically. Far from being equalisers, health crises often expose pre-existing inequalities. A person’s health is determined not just by biological factors and medical advances, but also by socioeconomic circumstances.
As the leading cause of death worldwide, cardiovascular diseases play a significant part in health inequality. Most countries are unprepared to face the growing burden of cardiovascular diseases, and those with higher levels of poverty could struggle to keep their health systems afloat.
An example of this can be seen in heart failure, a major driver of mortality and hospitalisations. The global prevalence of heart failure has doubled in the past 30 years, and low- and middle-income countries have seen the biggest impact. Even within Europe, we can see disparities in the prevalence and patient outcomes for heart failure.
Hungary has over 1,000 cases of heart failure per 100,000 people, whereas Portugal has about half that number.
Along with the Middle East and North Africa, Central Europe is among the regions most affected by heart failure worldwide – a striking fact when compared with other European countries. Hungary, for example, has over 1,000 cases of heart failure per 100,000 people, whereas Portugal has about half that number. Poland has almost five times the number of heart failure hospitalisations as Ireland. Though remarkable, these differences are not surprising; higher rates of cardiovascular disease prevalence and mortality in Central and Eastern European countries, compared to Western Europe, have been well-documented.
Best-practice care for heart failure is often limited to a few centres of excellence, as innovative models are more difficult to implement in settings with lower resources. Problems that hinder improvements in healthcare delivery for heart failure are magnified in certain countries. For example, the natriuretic peptide test used for the diagnosis of heart failure is less widely available in Eastern European and Mediterranean countries, possibly due to a lack of reimbursement.
Interestingly, there can also be significant health inequalities within the same country. For instance, higher mortality of cardiovascular disease in Spain has been observed in people with lower educational attainment. There is also a big contrast in mortality and rehospitalisation rates between the autonomous communities of Spain, with some experiencing twice as great an impact as others.
Although the underlying reasons for within-country health inequalities remain unclear, there is evidence that increased economic inequality is associated with worse outcomes for heart failure. Even after controlling for biological factors known to predict outcomes, such as the levels of natriuretic peptide, people living with heart failure in countries with high levels of income inequality have significant higher mortality.
Addressing issues in cardiovascular disease is an important opportunity to tackle health inequality as part of countries’ COVID-19 recovery plans.
The causes of health inequalities are complex, so to find solutions we must increase our understanding of them and how they have developed. Relatively little information is available on inequalities among people with heart failure; there are not many studies, and data are lacking across Europe. But there have been some efforts to change this in recent years.
One ambitious initiative is the Heart Failure Association Atlas by the European Society of Cardiology, which has taken action to find hidden inequalities. The first report was published in April 2021, even though national data were scarce; only three out of 42 countries were able to provide complete epidemiological data. Despite the difficulties with data collection, this project is an important investment in improving the available data across Europe and will hopefully spur governments to address gaps.
It can also be helpful to think about how we can mitigate the detrimental effect of economic factors. For instance, there is evidence that strengthening primary care systems could counteract economic inequality and improve health outcomes in Europe.
Addressing issues in cardiovascular disease is an important opportunity to tackle health inequality as part of countries’ COVID-19 recovery plans. As our understanding of health inequalities improves, we become better equipped to develop strategic measures that ensure everyone’s health is protected, irrespective of their income or where they live.
