African radiology competes for scarce health money

While radiologists in heavily industrialized parts of the world contend with rising volumes of increasingly complex imaging procedures, the situation in sub-Saharan Africa is vastly different. Dr. Peter Corr, a professor of radiology at the University of Natal in South Africa, and Dr. Genny Scarisbrick, who taught radiology in Ghana, share their views on the practice of radiology in Africa.

How serious is the shortage of radiologists in Africa?

Corr: We probably have fewer than 400 radiologists working in South Africa for a population of 42 million, and the majority of them actually work in private practice. There are probably fewer than 50 radiologists working in the public health system, which caters to the needs of almost 65% of the population. Most hospitals in the public sector have never seen a radiologist.

There has also been a severe shortage of radiographers in the last five years. A lot of health professionals are working overseas for better salaries.

In the rest of sub-Saharan Africa, there are very few radiologists. I know Zimbabwe is trying to train radiologists.

Scarisbrick: The shortage of radiologists is critical in Ghana. When I went there in January

2000 there were no radiologists in Kumasi, the second largest teaching hospital in the country, with 800 beds. In all, there were four radiologists in the capital and none elsewhere (apart from myself, and I was on a year's contract). There is now one-full time radiologist in the main teaching hospital in Accra and, since I left in March 2002, no radiologist in Kumasi.

How much of a priority is radiology in Africa?

Corr: Until recently, a priority hadn't been placed on radiology. In South Africa, HIV/AIDS is a huge problem, so there's a need for public health specialists and infectious disease specialists rather than radiologists.

Scarisbrick: It's hard to know just where radiology fits into the priorities of healthcare at local and national levels. The government of Ghana does not appear to have a budget for buying its own x-ray equipment. Equipment is usually bought when a government sends a "package." Holland has given money to equip the x-ray departments in the polyclinics with Philips products, and these are all quite well equipped. Germany is giving money to equip the teaching hospital in Kumasi with Siemens equipment.

This means that they are very dependent on what Siemens or Philips decides to provide, and the x-ray staff are never consulted about equipment. In the teaching hospitals, for instance, both of which have a large trauma workload, there are no rooms with ceiling-suspended tubes.

How does radiology fit into the way healthcare is provided?

Corr: Radiology is important even at a primary care level. Certainly in South Africa, which is reasonably technologically advanced, there is an appreciation that to practice medicine efficiently, especially at the secondary and tertiary levels, you need good imaging services.

The chest x-ray for TB and infectious diseases is the most common imaging examination used in South Africa. Extremity x-rays are next, and that's due to trauma. Those are the big two throughout the continent.

Scarisbrick: The most common x-ray examinations performed in our department were first, chest x-rays, and second, hysterosalpingograms. Pulmonary tuberculosis and simple pneumonias were common. Infertility was a common problem, and we performed around 60 hysterosalpingograms each week. Many of the pathologies seen were not tropical. Sickle cell disease, with its complications, was common.

What imaging modalities are available? How is radiology practiced?

Corr: It depends where you go. In the last two or three years, there has been a rapid increase in the number of CT and MR scanners available in public hospitals in South Africa, but smaller hospitals rely on plain film and ultrasound. Ultrasound has become a very important imaging modality - it's cost-effective and mobile.

Scarisbrick: Outside of the main centers, radiology consists of simple x-rays taken by x-ray technicians and interpreted by doctors with no training in radiology. However, barium meals, enemas, IVPs, and hysterosalpingograms are also performed.

The actual x-rays in Ghana are taken by x-ray technicians. Very few are taken by nurses or pathology lab technicians. Most of the ultrasound is performed by doctors from all specialties. In the teaching hospital in Kumasi, we had no ultrasound machine in the x-ray department. Each department - pediatrics, surgery, and obstetrics - had its own machine. Poorly trained doctors performed the scans, and many mistakes were made.

What are the main problems facing radiology in Africa?

Corr: One of the main problems is that many public hospitals in Africa are dependent on aid grants. They get an MR scanner, but the trouble is they can't afford to maintain it. So when it breaks down, it breaks down permanently. We've seen examples of that in central Africa and East Africa. That's probably the biggest problem. I know the World Health Organization is trying to get a training program to train engineers to fix the equipment.

The WHO developed the Basic Radiological System a few years back, and that seems to be a very durable and good system. Apart from plain films, ultrasound is really booming. There's huge demand for training of health professionals in ultrasound - not necessarily radiographers or radiologists; it could be nurses. One can buy a machine for maybe $10,000, so the technology is affordable even for poor countries.

Scarisbrick: The largest problem is the expense of equipment and its maintenance. When I went to Kumasi, a fluoroscopy unit had recently been installed, but when I left over two years later it was still nonfunctional. Similar problems also occurred in Tanzania.

What sort of training programs are in place?

Corr: The WHO has a fellowship program in which they send doctors from certain African countries to South Africa and Europe to train as radiologists. It's had mixed results. Some of these doctors don't return to their countries of origin but go on to developed countries. We know of one doctor from Sierra Leone, for example, trained here in Cape Town by the WHO for five years, who ended up in New Zealand. Because it's a global market, people do move around.

There's a huge demand in Africa for people to train in radiology. It's one of the areas that doctors and governments see a need for. The demand is certainly there, it's just that the training facilities are limited.

Scarisbrick: A training program was set up for radiologists in Accra beginning in October 1999. This is linked to the West African training program based in Nigeria. Unfortunately, there is only one full-time radiologist employed in the teaching hospital, who has to cope with all the work of a large department. It's just impossible for one person to offer a comprehensive training program. None of the trainees has completed the four-year course yet. The course has yet to prove itself.

How does training take place? Are there training routes outside of official channels?

Corr: It's expensive to train radiologists. There aren't enough trainers. We're dependent on people to stay in the academic system and train rather than go into private practice. There are fewer then 20 trainers in our country.

There are quite a few training centers around, but the number of people who are trained from each center is not very big. Cumulatively, there are probably fewer than 25 radiologists trained each year in South Africa. That's being addressed now by the government; they're increasing the number of training positions by about 20% to 25%. It'll be a few years before we see any difference in terms of impact on services. Our biggest problem is that doctors will train as radiologists and then they immigrate immediately afterward, so you won't actually see any benefit. I don't think that trend can be reversed in the short term.

Scarisbrick: There is no national training program for ultrasound in Ghana, and many people do it because they think it's easy to learn and it's a money spinner. The setting up of a good national training program is a matter of priority. At one time an ultrasonographer came from the U.S. for a year and was attached to a private clinic. She advertised a training course for anyone interested in ultrasound. People attended this course for three months or so, many with no previous medical training, and at the end of it they went to work in private clinics. They were all dangerous.

There are private clinics all over the towns advertising scans. Philips Medical Systems in the past has installed basic ultrasound machines in all the polyclinics and offered a week's training. I have no words to express my contempt for this marketing strategy.

What do you see happening in the near future?

Corr: We try to keep radiologists on for a few years after they complete their training to gain experience and confidence in subspecialty training. That has mixed results.

The government is going to increase salaries for specialists in areas where there is an acute shortage.

Scarisbrick: I left Ghana because I saw little future for radiology in the short term. I waited over two years for an ultrasound machine and never got one. Similarly, I waited impatiently for the fluoroscopy unit to be fixed, and again this didn't happen. I hear that new equipment has recently arrived for the radiology department in Kumasi, but there is now no radiologist.

Recruitment from other countries will be very difficult unless more money is on offer for willing radiologists. I found it difficult to live on the salary, and I had no family over there. There doesn't seem to be any sense of urgency or importance to recruiting radiologists, and they seem to be a fairly low priority at the moment. X-rays get done without them, and clinicians cope somehow on their own.