Helping means more than a handout –
Radiology in developing countries
ravel broadens the mind. Your horizon widens and when you return, certain aspects of your daily life that were more or less taken for granted suddenly seem provincial and just a small facet of the big picture.
Many of us have experienced an illness during a holiday abroad. Going to a doctor in a foreign country makes you realize that medical treatment varies tremendously, which alone shows that medicine is not an exact science. For example, your cold may be treated with pills in Germany, with inhalations in the U.S.A., or with suppositories in France.
Similar discrepancies exist in diagnostics. Radiological examinations elsewhere are different from how they are performed at home. Even if you only move from France to Germany, you will see variations. In many respects, radiology in Europe is completely different from radiology in the U.S.A.
It is never possible to comprehend the entire picture or to generalize, because unique circumstances exist in different countries, provinces, or even districts. Still, there are certain themes that turn up and keep repeating. These differences originate form the culture, the level of industrial development, and the financial potential of the region.
Trauma amounts to 9% to 15% of all situations where medical treatment becomes necessary, irrespective of where you are in the world. However, in the tropics and the subtropics, infectious diseases constitute the major part of diseases encountered, whereas noncommunicable diseases are less common. This is the opposite of what is found in industrialized countries.
Primary healthcare is not possible without diagnostic imaging. In many cases it can contribute to a quick and accurate diagnosis, leading to fast and adequate treatment. To fulfil these basic needs, medical imaging relies on plain x-rays, and to a limited extent on ultrasound. More sophisticated radiological equipment, such as computed tomography scanners, angiography units or magnetic resonance imaging machines, is of no use for most primary diagnostic imaging questions..
X-ray examinations, at their most simple level, are the most important application of diagnostic imaging worldwide. Cardiac angiography and magnetic resonance imaging, for instance, must seem like games played by pampered radiologists when your are in rural Pakistan or in the Gambia and you only need are chest or skeletal x-rays. Thus, the possession of a simple x-ray apparatus makes all the difference.
It is one thing to have an x-ray machine, however, and quite another to obtain electricity to make it run and to have x-ray films and get them developed.
In daily routine practice in Europe, hardly any radiologist thinks about developing x-rays any more. All developing is performed automatically. An x-ray technician takes care of it, the supply of developer and fixer is assured. When you want to take x-rays in developing countries, you often have quite different concerns. How can you get new processing chemicals where there is no the money to pay for them, and you are in a small tropical village during the rainy season? How do you dry x-rays during the monsoon – or during the hot season without destroying them with dusts and insects that get caught by the sticky surface of the pictures?
These problems are not new, they are is well-known. While to us they may sound simple, unimportant, and even easy to solve, the World Health Organization (WHO) estimates that between half and two-thirds of the world’s population have no access to medical imaging. The WHO has tried to address these issues.
Its Radiology Quality Project and the Basic Radiological System (BRS) developed in the 1980s proved that simple imaging can be inexpensive and give excellent results.
The design requirements for a BRS comprise five main points. The equipment must produce:
(1) high quality images
(2) in the standard projections, while
(3) being safe for both patients and staff;
(4) installation, maintenance and operation must be easy, and
(5) the equipment must be able to operate with poor electrical supply.
The system includes rechargeable batteries, making it independent. It should be cheap and very easy to handle, allowing the production of excellent x-rays with minimum training and little margin for error.
This kind of equipment which is offered by a number of small and large x-ray equipment manufacturers. Sometimes one wonders why is only used in developing countries, by the military, and by civilian protection organizations – but not by regular European hospitals. The answer is simple: There is not too much profit to be made by selling basic systems.
Approximately 90% of all x-ray procedures in the developing countries are essentially simple procedures. Health centers and rural hospitals should be able perform out basic examinations like chest, skeletal, skull, spinal, abdominal, and obstetric x-rays and simple oral contrast examinations. Neither a trained x-ray technician nor a radiologist are necessary for such examinations.
Radiologists and trained technicians are essential to carry out work done at the general hospital level and upward which, as minimum equipment requirement, should possess a fluoroscopy unit. Still, many general hospitals in Africa and Asia even lack this, combined with the absence of a reliable supply of electricity as well as films and chemicals.
According to a World Development Report by the World Bank, developing countries could reduce the burden of disease by up to one-third if they spent less on high-technology medicine and more on basic public health and clinical services for the rural poor. The World Health Organization agrees, and the Basic Radiological System constitutes an answer to this problem.
Recently an ultrasound unit has been added and the system has been renamed WHO Imaging System - WHIS. Ultrasound is considered the best possible supplement to plain x-rays in primary care for abdominal and obstetric examination, but as with the BRS, guidelines aimed at the end-user must be followed for ultrasound. Thus, the design requirements are similarly elementary to those for the x-ray machines.
The desire to help the people and physicians in developing nations is widespread. Giving them some of the bread crumbs falling off our richly laid tables is not only desirable but morally compulsory. In our consumer-driven radiological environment, equipment is out of date after an average of seven to eight years. Why not send it to Africa or elsewhere?
This practice of sending used medical equipment to developing countries as a gift has become a nightmare in many cases. When the big wooden boxes arrive at their destination – if they arrive at all – often it is found out that there is no electricity. When the equipment is sent without accompanying technicians or physicians it can neither be installed nor operated because nobody understands the instructions – or the need for such a machine.
Similar considerations hold for new equipment. There is one well-known example of a country where a brand-new MR machine was bought for the small village where the president was born. It still is stored in the original wooden crates because there is no access to electricity nor to specialists who can install and operate it.
On the other hand, donations to hospitals in the capitals or other big cities are often unnecessary because they have the best equipment money can buy – usually in government, military, or private hospital. WHO officials have attacked the sales of such equipment to developing countries for several reasons: waste of limited resources and dishonest transactions are among them.
Wherever I travel, I hear about questionable practices by the representatives of some companies in developing countries, where lies and bribes seem to be part of the tradition. However, most of the developing countries have an influential and well-educated elite which insist on the best possible healthcare. They used to fly to Europe or the U.S.A., but with the proper equipment and well-trained physicians, they can get the same quality diagnostics and therapy at home.
They can also afford to pay examination fees which seem low to us but are high for them. In India, there are approximately 60 magnetic resonance imaging systems. Patients are charged 5,000 rupees (DM 250) per scan, if contrast enhancement is needed, they pay another 3,000 rupees (DM 150). This equals one month's salary of a well-paid professional, and generally, there is no reimbursement by insurance companies.
Throughout Asia, there are excellent radiologists in teaching hospitals, but they all work in big cities to survive. In rural areas, a typical problem is that there are very few specialist physicians, because hardly anybody wants and can afford to live and work there. There is a lack not only of radiologists but also of technicians and trained physicians in general. To solve this problem will be another, probably more complicated task for WHO.
As European radiologists, we may be considered by radiologists in developing countries as “expert first users”, and many of them seek our advice. In such situations, it could be wise to remember that our needs are not necessarily the same as theirs. The best advice is for them to consider precisely their own needs, i.e., first determining what is needed, who will need and use it, where it will be used, and what resources are available. Information about the most appropriate type of equipment and procedures can then be sought.