The Real Cost of an Echocardiogram in Sub-Saharan Africa

Going to Africa to do camps is not the answer. That has been tried over the last 30 years by half a dozen people I know. It does not work. It is a financially profitable proposition to go and operate 30 to 40 cases and come back with a reasonable amount of money. But 30 or 40 lives saved is not an answer where 30 to 40 million lives are at stake. The answer is training, treating, and timing.

I would be happy to dedicate a little of my time for weekly or fortnightly consultations. I am happy to travel economy, live a very normal life for 10 to 15 days, and train a bunch of doctors in one specialty clinic on the ABCDs of seeing a valvular heart disease patient, the ABCDs of reporting it, how to follow them up in the community, and what the relevant paperwork looks like.

Africans are not genetically or racially predisposed to have valvular heart disease. It is primarily the socioeconomic factor which makes rheumatic heart disease such a huge problem, almost 20 times the global burden. The lowest rates of calcific and degenerative valvular disease are also found in Africa, which confirms this is not a biological phenomenon.

For stenotic lesions, whether mitral or aortic stenosis, we ought to be talking about orifice area, orifice area indexed to body surface area, pressure half time, and pressure gradients. For regurgitant lesions, it has to talk about jet surface area, vena contracta, pressure half times, and flow dynamics. You ought to be talking about valvular heart disease in terms of the AHA classification of A, B, C: at risk, progressive, and progressed.

What today would be a 10,000-dollar problem, tomorrow might become a requirement for an LVAD or RVAD and turn into a quarter-million-dollar problem. It is only this afternoon that I wrote such an email for a 14-year-old girl from North Africa, asking for a quarter of a million dollars even to begin treating her. She is in complete heart-lung failure. She is the fourth sibling to have hereditary congenital pulmonary hypertension. Three of them have died.

A quality scan costs around 250 US dollars, against an average monthly income of roughly 150 dollars in Sub-Saharan Africa, meaning a single scan can cost close to two months' wages for most families.

Machines and trained technicians are concentrated in a handful of urban centres. Point-of-care ultrasound systems capable of reaching high-risk or socioeconomically challenged communities exist but are not widely deployed, leaving large rural populations without realistic access.

Many omit the measurements a valvular disease diagnosis depends on, such as AHA A, B, C staging, orifice area, pressure half-time and pressure gradients for stenotic lesions, or jet surface area and vena contracta for regurgitant ones. Vague descriptions such as mild mitral regurgitation with hypertensive heart disease leave a remote specialist with little to act on.

No. Cost combines with a shortage of machines and technicians and, even when a scan is obtained, a report that frequently lacks the clinical detail needed for an accurate diagnosis.