Rheumatic Heart Disease: Global Failure in Tackling a Common Killer

Abstract

Rheumatic heart disease (RHD) remains a major cause of preventable morbidity and premature death, affecting over 40 million people worldwide and causing more than 300,000 deaths annually, predominantly in low- and middle-income countries. Children and adolescents bear a substantial burden, with 1-year mortality rates up to 17%, primarily from heart failure, especially among those with poor adherence to benzathine penicillin prophylaxis. RHD is entirely preventable through timely diagnosis and secondary prophylaxis, yet access to prevention, medical therapy, and surgical care remains inconsistent. Girls and women face delayed diagnosis, high maternal mortality, and inequitable access to gender-sensitive care. Fewer than 10 African countries have implemented national or pilot RHD programs, and despite the 2018 World Health Assembly Resolution 71.14, progress remains slow. Sustainable, African-led programs integrated into national healthcare systems are urgently needed to reduce RHD-related mortality and achieve its long-term elimination.

In the 21st century, rheumatic heart disease (RHD) remains a leading cause of morbidity and premature mortality among children and young adults in low- and middle-income countries, particularly Africa.1, 2, 3 Although RHD has been virtually eradicated in high-income nations through early antibiotic treatment of streptococcal pharyngitis and improved living conditions, it persists in regions where poverty, fragile healthcare systems, and structural inequities prevail.^1,2 The ongoing high burden of RHD is driven not by scientific uncertainty but by persistent failures in global health policy, equity, and solidarity.

Globally, over 40 million people live with RHD, resulting in more than 300,000 deaths annually, predominantly in low- and middle-income countries.¹ Africa alone accounts for approximately 80% of new diagnoses each year.⁴ Despite the availability of low-cost, effective preventive strategies, comprehensive RHD control programs remain absent in most African countries,2, 3, 4, 5, 6, 7, 8, 9 reflecting the persistent neglect of diseases that disproportionately affect the poor, the young, and women in marginalized settings.

In 2018, the World Health Assembly (WHA) adopted Resolution WHA 71.14,¹⁰ calling for global and national action on RHD prevention and control. Although this call marked a milestone in placing RHD on the international health agenda, implementation across African countries has been uneven and largely underreported, highlighting the gap between global commitments and tangible impact at the local level.

A Preventable Disease of Poverty

RHD is the long-term consequence of acute rheumatic fever, which follows untreated group A streptococcal pharyngitis. Repeated episodes of rheumatic fever cause progressive, permanent damage to the heart valves, ultimately leading to heart failure, arrhythmias, stroke, and early death.^1,2 In high-income countries, timely antibiotic therapy has rendered the disease rare; yet, children across Africa continue to develop and die from RHD due to limited access to primary care.^6,7

Recent data from Uganda highlight this pediatric burden and cardiac-related mortality: in a cohort of 449 participants aged 5-60 years, 1-year mortality was 17.8%, with most deaths occurring within the first 3 months, primarily due to heart failure. Poor adherence to benzathine penicillin was associated strongly with both incident heart failure and death, underscoring the importance of early detection and consistent prophylaxis.¹¹

Targeted interventions are urgently needed, including strengthening primary healthcare systems, not necessarily by expanding infrastructure, but by enhancing the capacity of existing facilities to deliver prevention and early diagnosis. This approach requires training primary care providers to recognize and manage acute rheumatic fever and RHD, ensuring consistent penicillin supply chains, integrating RHD care into routine primary healthcare services, and implementing community-based health education campaigns to raise awareness and improve health literacy. Such strategies can optimize the limited resources already available and support timely antibiotic treatment. Without these measures, many patients will continue to present with advanced disease requiring complex surgical interventions.⁵ Late presentation is driven by poor access to diagnostics, fragmented referral systems, and limited community awareness,¹² resulting in high burdens of heart failure, school dropout, lost productivity, and catastrophic healthcare expenses often borne by women as primary caregivers. Integrating RHD screening into school healthcare programs and community outreach activities can help identify cases earlier and reduce long-term burdens on families.

Inadequate Healthcare System Response

Despite the magnitude of the problem, national RHD prevention and control programs are rare across Africa.^7,9 A survey by the Cardiac Society of Eastern, Central, and Southern Africa (2024) found that fewer than 10 countries have implemented school-based screening or penicillin prophylaxis programs.⁸ Evidence from pilot initiatives in Uganda,¹³ South Africa,¹⁴ and Mozambique¹⁵ has demonstrated that echocardiographic screening in schools is both feasible and effective for detecting latent RHD, enabling timely prophylaxis and follow-up. In Mozambique, a campaign coordinated by the Instituto Nacional de Saúde in Maputo showed that multidisciplinary, school-based approaches, including cardiologists, cardiac surgeons, noncardiologists, nurses, and technicians, can be successfully implemented, even in resource-limited settings (Fig. 1, A and B). Countries should prioritize the development and funding of national RHD programs, integrating prevention into existing childhood immunization platforms to leverage established infrastructure for penicillin delivery and screening.

Figure 1.

School-based echocardiographic screening for rheumatic heart disease in rural Nhamatanda, Mozambique, November 2024. (A) Echocardiogram performed during a school campaign. (B) Multidisciplinary team from Mozambique and Angola, including cardiologists, physicians, nurses, cardiopneumologists, and technicians, working together to deliver early detection and strengthen community-based prevention efforts.

Long-acting benzathine penicillin G, the cornerstone of secondary prevention, remains inconsistently available, with frequent stockouts and low provider confidence in its administration.^4,8,16 Strengthening supply chains, providing healthcare worker training, and establishing clear national guidelines could improve both access and provider confidence in RHD prophylaxis.

Diagnostic capacity remains similarly constrained. Although echocardiographic screening is validated for early RHD detection, it is not widely deployed, owing to equipment costs, workforce shortages, and limited policy support.^8,9,17 Where available, cardiac surgery is often restricted to urban tertiary centres with limited outreach.⁵ Investment in diagnostic infrastructure, training of specialized personnel, and expansion of surgical and outreach services are essential to improve timely care and reduce regional inequities.

Global Health Neglect and Missed Opportunities

RHD historically has been absent from global healthcare funding priorities. In 2023, donor investment in human immunodeficiency virus / acquired immune deficiency syndrome (HIV/AIDS) exceeded $20 billion,¹⁸ supporting robust systems for diagnostics, supply chains, surveillance, and workforce development. By contrast, RHD receives less than USD$2 per patient per year, highlighting a stark inequity, compared with the amount for HIV/AIDS and tuberculosis (hundreds of dollars per patient annually). This gap is illustrated in Table 1 with approximate funding data across major diseases.^1,10,19,20

Table 1.

Comparison of annual global health funding per patient: rheumatic heart disease vs human immunodeficiency virus / acquired immune deficiency syndrome (HIV/AIDS) and tuberculosis

Disease	Patients affected globally (millions)	Global funding (USD$ billions/y)	Funding per patient (USD$/y)
Rheumatic heart disease1,10	∼40	∼0.05	∼1.25
HIV/AIDS19	∼39	∼20	∼512
Tuberculosis20	∼10.6 (new cases/y)	∼6	∼566

The 2018 WHA Resolution 71.14 emphasizes the need to strengthen RHD prevention, improve access to penicillin prophylaxis, and integrate RHD prevention and treatment into national strategies.¹⁰ However, implementation in Africa remains limited, with few countries translating these recommendations into actionable programs.⁸

Affordable tools exist—penicillin prophylaxis costs less than $0.10 per dose, portable and handheld echocardiography enables diagnosis and follow-up, even in rural areas (Fig. 1A), and task-shifting to nurses, tecnicians, and community healthcare workers has proven effective in school- and community-based screening programs in countries such as Mozambique, Uganda, and South Africa.^8,9,13, 14, 15^,17 Without coordinated prioritization, however, implementation remains fragmented and insufficient. To achieve population-level impact, global and national policies should scale up these interventions through coordinated strategies, leveraging existing healthcare platforms and primary healthcare systems.

Gender Inequity and Cultural Barriers

RHD disproportionately affects girls and women in Africa.^5,7,12 Young girls often experience delayed diagnosis, due to limited access to care, cultural stigma, and gender-based neglect.²¹ As they grow older, women with RHD face high-risk pregnancies, increased maternal mortality, and social exclusion.^22,23 To mitigate these risks, reproductive and maternal healthcare programs should integrate routine cardiac screening, particularly for RHD, and community education campaigns should address cultural stigma and encourage early care-seeking for girls.

In some African settings, maternal mortality among women with RHD can reach 30%, making it a leading indirect cause of maternal death.²³ Despite this alarming statistic, reproductive and maternal healthcare programs rarely include cardiac screening. Integrating cardiovascular healthcare into gender-responsive healthcare strategies is therefore critical to reduce maternal mortality and improve outcomes for women with RHD.⁷ Furthermore, the underrepresentation of women in healthcare leadership across Africa may contribute to the marginalization of conditions that affect primarily women and children.²⁴ Promoting female representation in healthcare policymaking, incorporating women’s perspectives into program design, and dismantling institutional norms that deprioritize women’s healthcare needs are essential steps to ensure equitable attention and resource allocation for RHD.

Rethinking Global Missions: From Pediatric Congenital to African-Led Rheumatic Initiatives

Over the past 2 decades, international surgical missions have focused primarily on managing congenital heart disease (CHD) in hundreds of African children.²⁵ Although these efforts—mostly led by Western nongovernmental organizations—have saved lives and fostered partnerships, they reveal a deeper imbalance in global health priorities. Although CHD remains important, RHD is the leading cause of heart failure among children and adolescents in underserved African communities.^2,7,12 Yet RHD receives far less international attention, funding, and programmatic investment than does CHD (Fig. 2). WHA Resolution 71.14 emphasizes the importance of strengthening RHD prevention and control, integrating it into national healthcare strategies, and ensuring sustainable access to prophylaxis. Aligning surgical missions with these recommendations can help bridge the gap between episodic interventions and long-term system strengthening.

Figure 2.

Estimated annual global funding by disease (USD$ billions). Although human immunodeficiency virus / acquired immune deficiency syndrome (HIV/AIDS), tuberculosis, and malaria receive billions (B) in global funding each year, rheumatic heart disease remains severely underfunded, estimated at USD$0.05 billion annually. This stark disparity illustrates the historical neglect of RHD in global health agendas, despite its high burden among vulnerable populations. Data compiled from the World Health Organization, Global Fund, and the Institute for Health Metrics and Evaluation (IHME, Washington, 2023).

This discrepancy partly reflects the familiarity of high-income-country teams with CHD,²⁶ as most have limited experience with advanced RHD, which is now rare in their populations. Consequently, missions often focus on less common but familiar diseases while overlooking the most prevalent surgical needs among African youth.

Private funders and nongovernmental organizations have played a key role in bridging gaps by sponsoring surgical missions, supporting training programs, and enabling regional initiatives. Successful experiences in Uganda, Mozambique, and Sudan demonstrate how such collaborations can expand access and build capacity.²⁷ However, their long-term impact depends on transitioning from episodic, externally driven missions to sustainable, African-led models that integrate prevention, early diagnosis, and follow-up care.

Africa requires not only a shift toward RHD missions but also African-led, collaborative models emphasizing sustainability, capacity-building, and regional ownership.²⁸ Currently, only 18 of 45 African countries (40%) provide full pediatric and congenital cardiac services, and 10 countries (22%) have no services at all.²⁹ The density of pediatric cardiothoracic surgeons is only 0.04 per million population, far below the recommended 1.25 per million, and no African country meets this standard.²⁹ To address these gaps, we propose doing the following: (i) establishing regional training hubs for congenital cardiac surgery; (ii) instituting structured fellowship exchanges between high-volume and emerging centres; (iii) incorporating cardiac surgery into national postgraduate curricula; and (iv) limiting international support to the arenas of logistics and funding, while ensuring African surgical and clinical leadership. This approach includes south-south partnerships between high-volume centres and emerging programs across the continent. In parallel, integrating RHD screening, prophylaxis, and follow-up into these programs ensures that surgical interventions are complemented by comprehensive prevention and care strategies.

Despite years of international missions, progress toward local surgical autonomy remains limited, as some centres still depend entirely on visiting teams, raising questions about their long-term effectiveness.^26,30 Scaling up intra-African missions led by African teams, with international partners providing logistical and financial support, should explicitly focus on training, mentorship, outcome tracking, and integration with primary and preventive care. Such alignment ensures that every intervention contributes to sustainable healthcare system strengthening and aligns with WHA priorities.

If global resources can be mobilized for rare CHD, the same must be done for common, deadly, and preventable RHD.

Conclusion

RHD remains a symbol of global health inequity, persisting due not to technical complexity but to collective neglect. In Africa, RHD is a disease of poverty, gender inequity, and systemic failure. Elimination is feasible, cost-effective, and morally imperative. Urgent, African-led, sustainable, and gender-sensitive programs integrated into national healthcare systems are needed to reduce morbidity and mortality associated with RHD and achieve its long-term elimination.