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By Philip Ward and Paula Gould, Ph.D.Although the World Health Organization's first meeting on training and education in diagnostic imaging did not attract massive media attention, it was hugely symbolic. Thirty-eight invited attendees, all deeply

By Philip Ward and Paula Gould, Ph.D.

Although the World Health Organization's first meeting on training and education in diagnostic imaging did not attract massive media attention, it was hugely symbolic. Thirty-eight invited attendees, all deeply involved in radiological education in developing nations, attended the four-day seminar in June 1999 at the Geneva headquarters of the WHO.

This influential group, representing all the main international health organizations, created a blueprint for change. One result was the creation of the Global Steering Group for Education and Training in Diagnostic Imaging, cochaired by Dr. Harald Østensen of the WHO and Prof. Holger Pettersson, chairman of the International Commission on Radiological Education.

Since Dr. Gro Harlem Brundtland became director-general in 1997, the WHO has attached greater importance to diagnostic imaging, a field in which it had not been particularly active. While it has done a great deal to raise awareness of AIDS, tuberculosis, tobacco control, and other major public health concerns, its imaging work was primarily confined to radiation protection, radiotherapy, and development of the Basic Radiological System in the 1980s.

Østensen's appointment as coordinator of the Diagnostic Imaging and Laboratory Technology section of the WHO's Health Technology and Pharmaceuticals cluster provided evidence of the organization's shift in priorities. Diagnostic Imaging met with Østensen in Geneva to discuss his plans and ideas for radiological education and training in developing nations.

DI: What do you regard as the main challenges facing radiology in the developing world?

Østensen: The lack of functioning equipment and the lack of educated or trained staff to operate it, maintain it, interpret images, and make diagnostic decisions after the exam. It is certainly possible to pour in a lot of money if you have it, but I don't think this helps. Put a machine in a hospital where there is no trained staff to operate it and it will work for two days.

DI: Less than half of the world's population has access to even basic x-ray equipment. Do you hope to widen access to basic systems or raise standards in those areas that do have access to equipment?

Østensen: Access is important, but access at any price is not good, so this should be a combined effort. We hear a lot of horror stories about donations of equipment by well-meaning organizations and individuals. This equipment is too often not used or not installed properly.

Anybody who would like to make contributions should contact us. There are guidelines: a checklist of what is necessary, from the papers for customs to the correct wall socket in the hospital or clinic where the equipment is being installed. These recommendations are updated all the time.

DI: There seem to be two main ways to approach education and training. Either you have someone go into the field and educate locally, or you bring local doctors to a regional or international center. Which do you support?

Østensen: I support the approach of Prof. Philip Palmer (professor emeritus at the University of California, Davis) and many others. They believe that you shouldn't take people from a remote area to, for example, London's Hammersmith Hospital and have them trained there. When?and if?they return home, they will be completely frustrated.

The central issue is to train the trainers. We must accept that we cannot train everyone; that would be an impossible task.

We are trying to set up regional centers of excellence where we can take people in, rather than send them to institutions in the developed world. We need some focal centers in the main areas. There are a lot of very good textbooks written by people in the industrialized world, but most are completely inadequate for basic needs in many developing countries.

We have started a process of building up generic training material that can be adapted into Swahili or whatever language is needed. We are developing practical manuals that fit inside doctors' coat pockets. We try to avoid large glossy publications and to use resources in a proper way. Where images are used, they need to be good quality and the paper must be adequate for tropical conditions. Manuals consist of illustrations and checklists and should not resemble a textbook. The material is being developed so that it can be used all over the world.

To begin with, we are focusing on printed material, but these manuals should eventually be available on CD-ROM and on the Internet. That's what we are aiming at. There are a lot of computer users, even in remote areas of Africa, but technology remains very expensive for those in developing countries.

DI: How many centers of excellence will be established in the next few years?

Østensen: This depends on funding. We will need at least three in Southern Africa, two in the rest of Africa, and two in Southeast Asia and India/Pakistan/Bangladesh. We will need one or two in the Western Pacific area and at least two in South America and then in Central America. In some areas, we may have to use less experienced centers and support them even more.

The main way to help is by providing appropriate education and training. Trying to spread good practice from developed to developing countries is a fine idea, but people in the U.S. and Europe will never be able to prepare a product that can be properly used in an African district hospital. For that, the heavy involvement of local experts is needed.

This model would also work well in other medical disciplines. There are a lot of educational programs going on around the world, and our small global steering group may be extended by linking up with others.

DI: What funding you would need?

Østensen: We need about $1 million per year over the next five years. If we can raise $10 million, we can go into other areas as well as Africa.

DI: You have developed a good support network, but don't you feel constrained by the fact that you are still the sole representative for imaging within the WHO?

Østensen: This is not a one-man show. I am part of the radiological scientific world. My first aim was to reestablish connections with international organizations and the scientific world. I can help to coordinate work being done by various groups.

It is a new idea for the WHO that diagnostic imaging should take such priority. Budgets have increased substantially since we started this project, which I think is recognition that the work is important. In the past, there weren't enough resources to cover everything, and diagnostic imaging had slightly lower priority.

It is important to note, however, that my predecessors did some excellent work for diagnostic imaging, especially in the 1970s and 1980s, by developing the Basic Radiological System. This is a robust machine designed mainly for developing countries, where there is no power supply or there is high humidity and dust. If I were based in a medium-sized hospital and I had to buy new equipment for general radiology, I would definitely choose that system, even if I were in a highly developed industrialized country.

Editor's note: The goals of the diagnostic imaging and technology laboratory (DIL) unit of the WHO are to improve the quality of healthcare worldwide by promoting cost-effective, safe, and standardized procedures, equipment, and materials. Support is also provided for practical training under local conditions and the transfer or adaptation of essential technology to meet the needs of local communities. A detailed statement of the unit's objectives can be found on the WHO website. ( http://www.who.int/ ).

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