Radiologists work together to help developing countries from afar, but could short-term solutions undermine long-term progress?
It's a common refrain to those in the international development field: how do we do the most good in the short term while also giving developing countries the tools they need to improve conditions in the long term?
The imaging situation in much of the developing world is cause for concern. While the WHO estimates that 20 to 30 percent of cases cannot be diagnosed with clinical exam and patient history alone, two-thirds of the earth's population has no access to one of the key diagnostic tools at a physician's disposal: medical imaging.
Imaging equipment, the building blocks of a modern radiology infrastructure, often finds its way to countries in need through nonprofits and private donations. But once the images have been obtained, the challenge becomes finding a qualified radiologist to read them. That's where teleradiology outreach comes in.
In countries that lack personnel with the necessary experience to read the images, volunteer radiologists and radiology residents around the world lend their expertise. The images are beamed from country to country, physician to physician, resulting in improved health for patients in some of the world's most underserved nations. While the short-term benefit to developing countries is huge, organizations are also structuring their programs with an eye to the future.
A Short-Term Solution to a Complex Problem
Through teleradiology outreach, patients in developing countries are able to benefit from specialized medical expertise beyond what is available in their own country. In-country hospitals and clinics are able to better optimize their imaging equipment, physicians can expand their ability to treat patients more effectively, and the population gains access to valuable tools for diagnosis and treatment.
A white paper report of the 2012 RAD-AID Conference on International Radiology for Developing Countries, published in JACR®, defined sustainability in radiology as "the ability to develop and maintain knowledge, equipment, skills, and other resources as part of an enduring radiology infrastructure that addresses the health-care needs of a community by integrating with existing health-care infrastructure."1 While teleradiology brings many benefits to countries in need, most do not see the practice as a long-term part of a standalone radiology infrastructure. By outsourcing the reading of the images, an important link in the care supply chain is missing, limiting the country's ability to sustain health-care gains without outside help and removing a potential revenue system from within the country.
"We aim to get radiology programs up and on their feet and ultimately move to a more supportive role." — Garry Choy, MD
For this reason, most organizations see humanitarian teleradiology as a short-term solution to the widespread lack of radiologists in developing countries. In Haiti, for example, there are 19 known radiologists for a population of nearly 10 million. No radiology residency programs exist, and basic radiology education is also lacking. Although humanitarian efforts have helped increase patient access to imaging studies, the country lacks trained radiologists to read the resulting images. In many cases, long-term goals include training radiologists within a country to serve the growing needs of the population.
In the meantime, teleradiology also has potential for education. The chance to share knowledge in real-life cases is an important opportunity to further the knowledge of health-care professionals who are doing their best with the resources they have. In this way, teleradiology can serve as a bridge along the path to sustainability.
Putting Ideas into Practice
In 2008, Garry Choy, MD, along with colleague Sung Han Kim, MD, recognized a need to support developing countries that were gaining access to imaging equipment but lacked radiologists to read the resulting studies. They founded the nonprofit iRadX to respond to the immediate challenges but also built in sustainability mechanisms to help countries move to a more independent model. "We aim to get radiology programs up and on their feet and ultimately move to a more supportive role," says Choy.
When iRadX volunteer radiologists interpret imaging studies from referring physicians in developing countries, both parties see the consultation as a two-way conversation. "Sometimes, the relationship between referring physicians and radiologists goes one way," says Choy. "A lot of times in outreach teleradiology, the report becomes a discussion. And in that way, the report becomes richer than just an interpretation. It is also a teachable moment and serves as an educational platform, key to long-term development of radiology capabilities and local expertise."
In addition to the report, iRadX radiologists often get to know their foreign colleagues. In-country physicians can receive responses to questions and garner advice, further enhancing their ability to serve their patients. In western Uganda, iRadX has established a relationship with Mbarara Hospital. The hospital employs one part-time radiologist and one radiology resident and recently installed a CT scanner, one of the few in the country. While there are also several non-radiology physicians who are skilled in reading studies, more radiologists with dedicated imaging interpretation skills are needed. So iRadX has been working with the hospital to provide mentorship and consultation to the current radiology resident and future trainees. "Hopefully in a couple of years one of their residents will become the expert and the go-to person for local reads," says Choy. "In the meantime, we're helping."
Choy is headed to Uganda in the near future to meet the resident in person, set up a more efficient teleradiology link, and find out how best to help Mbarara Hospital move towards a stand-alone radiology department. Choy sees this kind of sustainability as the long-term goal for developing nations and an important area for outreach organizations to focus. "But the world is a pretty big place," he says, "so I think we'll be busy for a while."
By Lyndsee Cordes
1. Welling RD, et al. “White Paper Report of the 2010 RAD-AID Conference on International Radiology for Developing Countries: Identifying Sustainable Strategies for Imaging Services in the Developing World.” JACR 2011;8(8):556–62.