Identifying the 'Imaging Gap' in Global Health
How can radiologists provide access to care for all patients?
Radiology has the potential to contribute an important component to evidence-based medicine in United States (US). It is intriguing to know the way medicine is practiced in other parts of the world, especially in resource-restrained countries. Do they rely more on radiographs and ultrasound, or do they depend mostly on the disease endemicity, medical history and physical examination? Empirical literature is available on health care gap across the world, but the literature is severely limited when it comes to imaging resources, their availability and utilization. This raises the need to identify this gap in radiology healthcare and literature to help us build a strong foundation on which we can judiciously and effectively allocate resources for global health.
In most areas of the US, the ability of a primary care physician to utilize any imaging modality instantaneously to diagnose disease or to generate a differential diagnosis is taken for granted. In resource-restrained countries, the problem is multifaceted. The disease burden is heavy and diverse. Additionally, populations in these countries typically have little income and no health insurance. Due to the absence of medical screening, patients usually present late in the disease cycle.
The absence of resources only contributes to the challenges a physician may face. Emergency physicians themselves usually lack proper facilities, supplies and equipment to effectively manage trauma and treat disease. This is compounded with the shortage of imaging equipment, trained staff, equipment maintenance, and quality and safety standards. Radiological imaging is an essential component in the management of trauma, obstetrical and gynecological issues, HIV/AIDS, tuberculosis and cancer, just to name a few.
In resource-restrained settings, patients presenting with right lower quadrant pain maybe denied a basic computed tomography (CT) scan or even an ultrasound due to absence of imaging resources. This may be further accentuated by the absence of trained radiologists in settings where the resources maybe available. Moreover, even if there is a radiologist available, he or she may not be equipped with sub-specialty knowledge. It becomes an essential first step in outreach efforts to understand the current health care system including the distribution of imaging resources, presence of radiologists per population segment and the availability of sub-specialty radiology services.
While we are struggling with the question of imaging utilization in developed countries, the gap is enormous compared to other countries where the imaging resources are not even listed.
Another problem resource restrained countries are currently facing is inequitable resource distribution within the health care system. This difference is not just in equipment but is also seen in terms of training. Not only must the radiological equipment be accessible and maintained, but also trained staff and skilled physicians must operate and utilize the equipment. There are usually central or capital cities that are diversified with multiple resources including sub-specialty radiology services. Conversely, more remote locations have a significantly different set of resources and quality of care.
With this overwhelmingly obvious ‘Imaging Gap’ across the globe, what can be done? Utilization of ultrasound is promising, as this equipment has no ionizing radiation, is portable, and provides real-time images that can instantly aid in diagnosis. Who will interpret the studies generated? Should the primary care physician be required to gain knowledge in image interpretation during their training? This model is plausible as emergency medicine residents learn how to perform the focused assessment sonogram for trauma. However, what about the complicated study? Is teleradiology a possibility? Would US radiologists volunteer services to assist colleagues in diagnosing disease overseas?
These learning opportunities would be extremely valuable for radiology residents to gain exposure to pathology abroad and generate a sense of global community that may foster increasing support for global imaging initiatives. Significantly, there is also the critical question of sustaining the equipment, training and payment of radiology services over time.
Gauging the wide gap in availability of imaging services on one end and dealing with appropriate imaging utilization on the other end helps us realize the efforts which need to be undertaken. Several efforts have been made by American College of Radiology and other organizations in radiology as first steps. However, such efforts need to be supported on a larger scale to mitigate the current existing gap.
By Supriya Gupta, MD, and LaDawn Hackett, MD