Hypertension in the political arena.

The science of hypertension has been one of the success stories of modern medicine. The risks of high blood pressure have been defined, and through rigorous trials, effective treatments have been developed and shown to work. Pathophysiological mechanisms have been identified at least in part, and the future seems brighter as the full potential of molecular genetics is realized. A glance through previous issues of Hypertension testifies to all this: the increasing pressure on the pages of this and other prestigious journals indicates the growth both in volume and quality of relevant science. Yet, there is a paradox that is apparent to those of us who treat individuals or advise on population health. Progress in the real world has been much less impressive; indeed, it has faltered at times.1 The problems of applying knowledge to the prevention and management of hypertension seem orders of magnitude more complex than the scientific work that provided us with the understanding in the first place. We are forced to practice and advise in a social environment that seems far from perfect and that presents us each day with formidable obstacles that seem to defy rational analysis. Basic science seems somehow easier and less messy. This would not be obvious from cursory reading of specialist journals. Only occasionally do published papers demonstrate how far from the ideal, for instance, the management of hypertension is, even in a society that spends more per capita on health than any other society.2 There is a clear-cut need to improve the delivery of care whether this is part of a state-funded or insurance-based system. At the same time, I believe that clinicians and scientists who are concerned with the avoidable morbidity and mortality from hypertension should recognize that the issues extend far beyond the implementation of expert guidelines. This was brought home to me when for 3 years I was seconded from my university to become Director of Research and Development for the National Health Service (NHS), a post that involved membership to the NHS Executive Board, which manages the NHS. Although my experience was confined to the United Kingdom healthcare system, it has a much wider application both to developed and developing countries. I would like to illustrate this with 2 examples: social inequalities in health and the role of economics. These issues are of particular relevance to hypertension, because of its major importance as a treatable health hazard.