There is a rapid development of the ‘second wave epidemic’ of cardiovascular disease that is now flowing through developing countries and the former socialist republics. It is now evident from WHO data that coronary heart disease and cerebrovascular disease are increasing so rapidly that they will rank No. 1 and No. 5 respectively as causes of global burden by the year 2020. In spite of the current low prevalence of hypertensive subjects in some countries, the total number of hypertensive subjects in the developing world is high, and a cost-analysis of possible antihypertensive drug treatment indicates that developing countries cannot afford the same treatment as developed countries. Control of hypertension in the USA is only 20% (blood pressure <140/90 mm hg). in africa only 5–10% have a blood pressure control of hypertension of <140/90 mm hg. there are varying responses to antihypertensive therapy in black hypertensive patients. black patients respond well to thiazide diuretics, calcium channel blockers vasodilators like α-blockers, hydralazine, reserpine and poorly to β-blockers, angiotensin-converting enzyme inhibitors and aii receptor antagonists unless they are combined with a diuretic. a comprehensive cardiovascular disease (cvd) programme in africa is necessary. there are social, economic, cultural factors which impair control of hypertension in developing countries. hypertension control is ideally suited to the initial component on an integrated cvd control programme which has to be implemented. primary prevention, through a population-based lifestyle linked programme, as well as cost-effective methods of detection and management are synergistically linked. the existing health care infrastructure needs to be orientated to meet the emerging challenge of cvd, while empowering the community through health education.