Consultant - Heart & Lung Transplant and Vascular Surgery, Artemis Hospitals, Gurgaon
Series overview · 9 articles
Valvular Heart Disease in Emerging Countries
April 5, 2026
Valvular heart disease is often treated as a disease of ageing in wealthy countries and a genetic misfortune everywhere else. Neither is true. This guide draws on a Jivo Masterclass by Dr. Biswarup Purkayastha, Consultant in Heart and Lung Transplant and Vascular Surgery at Artemis Hospitals, Gurugram, on why the disease behaves so differently across Africa, the Asia Pacific and the developed world, and what can actually be done about it.
The proof that this isn't genetics
Rheumatic heart disease affects more than 1,000 people per million in Sub-Saharan Africa, against a global average of 55 per million, a twenty-fold gap. If that reflected some inherited vulnerability, calcific and degenerative valvular disease, which have nothing to do with untreated childhood infections, should show the same pattern. They don't. Africa has among the lowest rates of calcific valvular disease in the world, 0 to 10 per million against a global standard of 13.3, while the developed world runs past 200 per million. The disease that is entirely preventable with basic antibiotics is the one hitting Africa hardest; the diseases of ageing and diet are largely absent from the same population.
A diagnostic system that can't see the disease coming
A quality echocardiogram costs around 250 US dollars in Africa, against an average monthly income of roughly 150 dollars, nearly two months' wages for a single scan. Machines and trained technicians are scarce outside a handful of urban centres, and the reports that do arrive often skip the measurements that matter for a valvular disease diagnosis, in favour of vague descriptions such as "mild mitral regurgitation with hypertensive heart disease."
A younger, sicker patient by the time anyone sees them
Valvular disease progresses silently for years before symptoms appear, so patients in Africa and the Asia Pacific are typically diagnosed only once they've already reached decompensated heart failure, unable to walk or breathe without high doses of diuretics. Because rheumatic disease strikes children and young adults rather than the elderly, this isn't the ageing population Western cardiology textbooks describe. Dr. Purkayastha has treated patients who developed rheumatic heart disease as children and, a decade later, needed mechanical circulatory support or a heart transplant.
The Four T's
Dr. Purkayastha's framework for closing this gap is Train the local doctors, Time the referral, Treat with whatever tools are already available, and use Telemedicine when nothing else is possible. The rest of this series works through each of these in turn, along with the specific mechanics of how Jivo Connect Clinic turns a single masterclass into an ongoing referral relationship rather than a one-off lecture.
This guide is based on a live Jivo Masterclass — Dr. Biswarup Purkayastha taught doctors across Africa on April 5, 2026.
Watch the full recording, or read the guide above.
FROM THE LIVE Q&A
Jivo Doctor Partner (name unclear from transcript)
Is it true that Africans are genetically more prone to valvular heart disease?
Dr. Biswarup Purkayastha
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.
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Frequently Asked Questions
What does a good echocardiogram report for valvular heart disease actually need to say?▼
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.
Why does timing the referral matter so much, even in a case that seems complex?▼
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.
Why doesn't sending doctors on short surgical camps solve this problem?▼
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.
What would you actually be willing to do to help train local doctors?▼
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.
Is it true that Africans are genetically more prone to valvular heart disease?▼
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.
Is valvular heart disease in Africa caused by genetics?▼
No. Rheumatic heart disease affects more than 1,000 people per million in Sub-Saharan Africa against a global average of 55 per million, but calcific and degenerative valvular disease, which have nothing to do with childhood infection, are among the lowest in the world in the same population, ruling out an inherited explanation.
Why do patients in Africa and the Asia Pacific tend to be diagnosed so late?▼
Valvular disease progresses silently for years before symptoms appear, and with limited screening and diagnostic access, patients are typically identified only once they've reached decompensated heart failure, unable to walk or breathe without high doses of diuretics.
Who does valvular heart disease affect most in these regions, compared with wealthier countries?▼
Because rheumatic disease drives most of the burden, it strikes children and young adults rather than the elderly population typically associated with valvular disease in the West.
What is the Four T's framework for closing this gap?▼
Train local doctors, Time the referral so patients are seen before the disease becomes unmanageable, Treat with whatever tools are already available locally, and use Telemedicine when nothing else is possible.
In This Series: Challenges with Valvular Heart Disease in Emerging Countries
- 1.Valvular Heart Disease in Emerging Countries
- 2.Why Africans Are Not Genetically Predisposed to Valvular Heart Disease
- 3.The Real Cost of an Echocardiogram in Sub-Saharan Africa
- 4.What a Useful Echocardiogram Report for Valvular Heart Disease Needs to Say
- 5.Why Valvular Heart Disease Presents Late in Africa
- 6.The Four T's: A Framework for Valvular Heart Disease in Africa
- 7.How Jivo Connect Clinic Turns One Masterclass Into an Ongoing Referral Pathway
- 8.A Referral Delayed Five Years: Why Timing Changes Everything
- 9.Why Flying Doctors In for a Weekend Doesn't Fix Valvular Heart Disease in Africa