The Four T's: A Framework for Valvular Heart Disease in Africa

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.

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.

Train, Time, Treat, and Telemedicine, a framework covering how local doctors are trained, how referrals are timed, what can be treated locally, and what telemedicine can add when in-person specialist care isn't available.

Real, sustained exposure through observerships in India and camps where local doctors operate alongside visiting specialists rather than watching from the side, with enough repetition that they can manage these patients independently afterward.

Penicillin prophylaxis every three to four weeks to prevent further rheumatic damage, heart failure medications, a diuretic for symptomatic relief, and, where anatomy allows, basic interventions such as closed or balloon mitral valvotomy that can buy years before more definitive treatment is needed.

Specialists review DICOM imaging shared through a Google Drive link and give referring doctors specific, actionable guidance, such as adjusting a diuretic dose or requesting a repeat scan, rather than a generic instruction to refer the patient elsewhere.