Global radiology expands, one scanner at a time

Earlier this year, the Mater Dei Hospital in Bulawayo, Zimbabwe, was in desperate need of up-to-date x-ray equipment. The 180-bed private hospital was equipped with outdated x-ray machines, including an 18-year-old portable x-ray unit and two 27-year-old film processors. Several part-time radiographers and no staff radiologist completed the dismal picture. On March 21, the hospital received a $40,000 no-frills x-ray unit courtesy of the Park Ridge, IL, Rotary Club.

Other regions around the world are not as lucky as Bulawayo and have no access to diagnostic imaging of any kind. The severe shortage of radiology services in underserved nations is a complex problem. Those struggling to provide solutions run the gamut from individual radiologists to international charitable organizations.

The World Health Organization has reported that safe, reliable diagnostic radiology is unavailable to two thirds of the world's population. Many of these regions have their hands full simply trying to provide elementary healthcare. Basic radiology services could help buttress efforts not only to diagnose trauma and infections, but also to address international epidemics such as AIDS and tuberculosis.

Many manufacturers are involved in equipment donations. Siemens Medical Solutions donated an echocardiography system to the Larry King Cardiac Foundation for Caribbean Citizens in February, and GE Medical Systems bestowed 200 ultrasound systems, probes, and accessories to Assist International, a nonprofit humanitarian organization.

Assuring sustainable radiology services, however, requires more than just free equipment. Maintenance and radiological training for medical professionals are mandatory components of a successful charity mission (see accompanying article).

MAKING THE CASE FOR CHARITY

Charitable organizations exist to meet almost every need imaginable. Whether you're concerned about bringing basic medical services to East Timor or providing sustainable healthcare to the citizens of Papua, New Guinea, you can find an appropriate association that is probably desperate for money, volunteers, and supplies.

There are, however, few radiology-specific charitable organizations. When the focus is on the essentials for survival such as clean water, reliable electricity, and basic healthcare, radiology may not be a top priority. But as advances in medical imaging technology widen the gap between the radiology haves and have-nots, several organizations and individuals have taken responsibility for delivering medical imaging where it is needed most.

"Radiologists should look at the results of a particular organization. They should research to see what's been accomplished, and whether they know any of the members of the advisory board so they can get an inside understanding of the organization," said Dr. Barry B. Goldberg, director of the Jefferson Ultrasound Research and Education Institute (JUREI).

Because of their low cost and usability, ultrasound and x-ray are the two imaging modalities that many organizations seek to bring to emerging nations in need of radiological services. The JUREI, which is part of the radiology department at Thomas Jefferson University, has developed a program called Teaching the Teachers Initiative for Ultrasound Training in Africa. Supported by an RSNA research and education grant, the initiative supports use of ultrasound in Africa by providing local physicians with 12 weeks of ultrasound training in the U.S. The program also instructs the physicians in training others to use ultrasound.

Once trained, the doctors take their education back to ultrasound educational centers established by the JUREI in their home countries. Complementing the training, the organization strives to provide ultrasound equipment to the centers as well. In collaboration with other nonprofit groups, the JUREI formed the Global Ultrasound Equipment Donation Consortium, which has procured 800 ultrasound machines from Siemens Medical Solutions. The systems will be distributed in developing countries over the next four years.

The organization currently sponsors 55 affiliated ultrasound education programs in countries around the world, including Uganda, South Africa, Nigeria, and Ghana. Each program receives equipment and training in the use of ultrasound.

MAMMOGRAPHY FOR MASSES

In 1989, Dr. Richard Hirsh, a staff radiologist at Summa Health System in Ohio, began his odyssey into international radiology by volunteering in India. His mission was to help establish a mammography screening program by bringing training and equipment to cities throughout India. The volunteers were successful in sharing their knowledge but were unable to sell all their mammography machines and had to ship most of them back to the U.S.

"I learned some strong lessons there, such as the importance of sustainability," Hirsh said.

The experience did not extinguish his zeal for volunteering, and in 1996 Hirsh founded Radiology Mammography International to bring mammography to developing nations. The group scouts out prospective sites before organizing teams that comprise eight to 12 technologists, engineers, and radiologists. The volunteers bring mammography equipment with them and train medical professionals in reading mammograms during two- and three-week sessions.

Hirsh relies on grants from foundations and individuals and donated mammography systems and film from companies such as Lorad, Cook, and All Pro Imaging.

Prospective sites must meet all the requirements on an extensive checklist. Because these locations are in developing nations, there are no givens when it comes to infrastructure. Each site must have a satisfactory building with electricity and clean water. In addition, Hirsh looks for sites that have a functioning radiology department with x-ray technologists and at least one radiologist.

"The success of any project depends on the ability to sustain what was accomplished during the mission. If this cannot be done, the project is a failure," he said.

The work is hard, and the conditions are tough, but the ultimate goal can be tremendously rewarding.

"On the flight home from one trip, we were exhausted and dirty. It had been a long final day and a half. One technologist was going on about what a long mission it had been. And then she smiled and said, 'When's your next mission? I would like to join,'" Hirsh said.

NO FREE LUNCH

International radiology donation is not without its critics. Failure to assure maintainability and sustainability of donated equipment is one of the biggest criticisms. Older, used equipment will break down or require extensive maintenance, and recipient hospitals that couldn't afford to buy the equipment in the first place won't have the money to fix it (see accompanying article).

Low-cost, easy-to-use new x-ray equipment could provide an alternative to donated used equipment.

In 1975, the Pan American Health Organization, the WHO's regional office for the Americas, met to discuss efforts to disseminate diagnostic radiology services. The meeting resulted in a set of specifications for an ultrasimple x-ray machine, initially called the WHO basic radiology system (BRS). It included a detailed, color-coded manual that would walk intended users through the process step by step.

"The original idea was to design a general-purpose x-ray machine, which should be inexpensive and easy to operate and maintain, should produce high-quality radiographs, have all possible radiation protection measures built in, and be able to function in areas where general infrastructure, such as electricity, water, and building facilities, is not in existence," said Dr. Harald Ostensen, coordinator of diagnostic imaging and laboratory technology at the WHO.

Designed to perform more than 80% of all general radiographic procedures, the unit could be powered by a battery system to account for the often variable electricity streams in many hospitals in rural and developing areas.

Ironically, the system's usability was one of its first hurdles. Radiographers were initially concerned that the units might undermine their jobs by allowing nonradiologic personnel to perform x-ray exams.

"The mentality was, we are the professionals and the only people who can perform x-rays. Radiographer and technologist societies have realized that they can't x-ray every single person who needs it," said Dr. Philip Palmer, emeritus professor of radiology at the University of California, Davis.

Palmer, a WHO consultant, developed the extensive manuals for the system, later renamed the World Health Imaging System for Radiology (WHIS-RAD).

The WHIS-RAD equipment is manufactured by only two companies. Philips Medical Systems in Hamburg, Germany, produces the Philips Multi-Radiography System, and Internazionale Medico Scientifica in Bologna, Italy, produces the IMS Wizard.

"The companies themselves are responsible for promoting and selling the systems, and the WHO has no part in this," Ostensen said.

Nor does the WHO inform or advise its member states about where and when a WHIS-RAD system should be considered and how it can be purchased. Although it might seem that the availability of an inexpensive, easy-to-use system would encourage all those in need of vital x-ray services to take advantage of the opportunity, leading the horse to water turned out to be more difficult. When the system was first developed, the WHO estimated that 70% of the world population did not have access to basic radiology services; their estimate improved to only 66% this year.

To deliver basic x-ray services to all who need it would require installation of 80,000 machines, said John Vanden Brink, project leader for the Park Ridge Rotary Club WHIS-RAD project.

"Fewer than 1500 have been installed since the early 1980s, when the first commercial units became available. The location of half of those is not known," he said.

In a 1993 meeting at which the WHO changed the name of the system to WHIS-RAD, a consultation committee examined issues that might be affecting the dissemination of the technology.

"Cost: that's the number one, two, three, and four reasons why so few units are deployed. Units are selling for about $40,000, and you can buy less satisfactory but much cheaper units for $20,000," Palmer said.

The costs for digital units can be even higher.

"The going price for digital equipment is $100,000, which just doesn't make sense if your total budget for healthcare is $1 to $2 per person for a year," Palmer said.

DONATION COLLABORATION

Physicians at Mater Dei Hospital are already taking x-rays with their new WHIS-RAD unit. After assessing the hospital's need for a basic radiography unit, the Park Ridge Rotary Club had to designate a recipient Rotary Club in Bulawayo that would contribute to its purchase and manage the installation.

The Park Ridge club eventually committed $29,000 to the project and received a $21,000 grant from Rotary International as well as a $2500 grant from its own Rotary district. But the path to international radiology donation can be fraught with more than just financial hurdles. Many emerging nations are not politically stable, and governmental obstacles can interfere with importing expensive equipment into the country.

"The concern was that the unit needed to be turned over to the hospital, and that in the process it might be confiscated. We were also concerned that once the government learned the unit was coming into the country, the government would impose a duty on it for which neither we nor the hospital had planned," Vanden Brink said.

With careful coordination with the Rotary Club in Zimbabwe, the Park Ridge group applied for and received a duty-free certificate from the Zimbabwe Association of Christian Hospitals, which allowed the unit to enter the country.

"The key to getting it into the country without duty was the Bulawayo South Rotary Club and the support of that Rotary district. They had the contacts and relationships that made it happen, which is why it is essential to have an on-the-ground contact at the recipient site," Vanden Brink said.

According to the Park Ridge Rotary WHIS-RAD Web site (www.rotarywhis-rad.org), two other clubs are now requesting x-ray units: Tbilisi in the Republic of Georgia and St. Lucia in the West Indies.

While the debate continues over the best way to bring radiology to areas in need, the Park Ridge Rotary Club model could potentially lower the price of WHIS-RAD units.

"I think that as soon as some large organization like the Rotary Club gives a big enough order, the major manufacturers will realize the price has got to go down," Palmer said. "If the price comes down to around $20,000, it would do an enormous amount of good."