Retiring imaging chief reflects on time with WHO

November 1, 2007

When they approach their mid-50s, many people start taking life a little easier, reducing their workload and turning their attention to more leisurely pursuits. Dr. Harald Ostensen adopted the opposite strategy. At the age of 54, the single-minded Norwegian took on the immense task of organizing a training and education program for radiologists and radiographers in the developing world.

When they approach their mid-50s, many people start taking life a little easier, reducing their workload and turning their attention to more leisurely pursuits. Dr. Harald Ostensen adopted the opposite strategy. At the age of 54, the single-minded Norwegian took on the immense task of organizing a training and education program for radiologists and radiographers in the developing world.

Nearly a decade later, he can feel satisfied that he contributed to improvements in the quality and safety of diagnostic imaging, particularly basic x-ray and ultrasound examinations in small and midsized hospitals. Under his personal supervision, the World Health Organization has run about 80 training courses in Africa and the Asia Pacific region since the late 1990s. Thousands of training manuals have been distributed. He has also helped foster closer cooperation between radiologists and radiographers.

Sadly, though, Ostensen did not go happily into retirement at the end of July because his legacy was not secure. A successor as coordinator of WHO's Diagnostic Imaging and Laboratory Technology Branch is not in place. By September, no listing for the job had appeared, which means there will be a gap of at least a year before a new person could start work. The International Society of Radiology (ISR) is leading a campaign to ensure that a new person is appointed, but senior managers have indicated to Ostensen that the imaging budget will be allocated to other areas of medical devices and regulations.

"This is of great personal concern to me. I have nourished this baby, and I would like to see it grow up," he said. "The issue of practical training for radiologists and radiographers may come up again in another five or 10 years, but by then our efforts will be dead, and the new people would have to make a totally fresh start."

Ten local expert groups have been established in Africa, Southeast Asia, India, and the South Pacific, and their activities are continuing, but Ostensen fears that some of them may soon fall apart without contact with or support from WHO. On the plus side, though, these people have seen what can be done when they take action themselves, and hundreds of medical staff have received high-quality training during the past decade.

Ostensen has a long track record in this field. In 1991, he cofounded the Nycomed Amersham Intercontinental Continuing Education in Radiology (NICER) Institute with Prof. Holger Pettersson, former chair of radiology and deputy medical director at Lund University in Sweden. At the time, Ostensen was responsible for internal education at Nycomed. NICER organized 50 courses in 22 nations and published a range of multilingual educational materials prior to its closure in the late 1990s.

In June 1999, Ostensen and Pettersson organized a four-day summit in Geneva to discuss how to promote training and education. Each major organization and society sent at least one person, and industry was also represented. A global steering group was formed at the meeting, and thanks largely to the enthusiasm and efforts of Dr. Milcah N. Wambugu from Nairobi University, Kenya became a focus of attention. Centers of excellence were established to "teach the teachers" (see "WHO builds support for bold five-year project," April 2000, page 34).

The steering group that still meets once or twice a year consists of up to 30 representatives. They help to identify training needs, set up and organize courses, decide on topics to cover, and distribute literature, including WHO manuals. From a political perspective, it is vital to have such a group assisting WHO's activities, Ostensen said.

TRAINING MODEL

Before each course begins, an initial meeting of the local expert group (radiologists, physicists, radiographers, and administrators) is held over two or three days. WHO then asks the government to select around 50 relevant people, most of whom are radiographers, for each training course. Involving governments from the outset is essential, and Ostensen requests that delegates be released from work for a week on full pay and have their travel costs covered.

"We have to limit the number of attendees so that there is some hands-on training, and not only theory," he said. "Basic quality assurance and radiation protection must be included in any course, and they need to be repeated and repeated. We then look at various organ topics but only on a pattern-recognition basis. Radiographers don't read x-rays without the government's permission, but they can help clinicians by giving a radiographer's opinion. This can create problems in poorer countries, where turf battles may be great, but normally an agreement can be reached."

The WHO has also organized around 10 high-tech courses, mostly for radiologists from both public and private hospitals. This serves to increase their knowledge of state-of-the-art imaging, because that is the future, and helps ensure that patients do not go abroad in search of better treatment, according to Ostensen. Diplomacy is used to guard against brain drain. He communicated regularly with representatives from government and radiological associations and societies in an attempt to make sure that the best talent did not leave the country after the course. Speakers generally come from the U.S. and Europe.

The courses are free of charge and fully funded by WHO, but Ostensen has always managed on a fairly lean budget. During his first two years, in 1998 and 1999, he had only US$22,000 to spend, which was partly because his position had been unoccupied for more than three years. His total budget rose steadily to US$150,000 for the two years prior to his retirement. He asks associations and societies to provide only human power, not cash.

Course attendees often travel huge distances to attend the courses. One radiographer, who is running a hospital single-handed on the border between Ethiopia and Kenya, had to travel three days each way to attend a meeting in Nairobi. On the first day and night, he traveled with animals and goods in a truck that used dirt tracks. It was too dangerous to use the proper roads.

"He was absolutely fantastic and was very active on the course. You know a person like that is genuine when they are getting nothing else but knowledge," Ostensen said. "I've sent him a lot of books over the years."

Training in Latin America is taken care of by WHO's Regional Office for the Americas (AMRO), located in Washington, DC. Some of its activities are carried out jointly with WHO's head office team.

PROFESSIONAL COLLABORATION

A positive change during the past decade is that radiologists and radiographers have become closer and are working together more often, Ostensen said. Many now go to the same congresses and are speaking the same language.

He has been one of the drivers behind this process by getting the societies and associations to talk to each other and persuading both groups that their mutual survival depends on cooperation. Due to cultural and demographic factors, the developing world is lagging slightly behind Europe and North America in this area.

Some smaller hospitals and clinics in remote areas have no radiologists, and the only option is to extend the knowledge and role of radiographers. WHO's strategy is to offer practical support to anybody involved in medical imaging and enable them to do a better job, even if they do not have the necessary qualifications.

Some radiologists in developing nations have resisted WHO because they fear that deskilling will occur and its activities will produce second-class radiologists out of radiographers.

They also worry that it will become feasible for more radiographers to set up in private practice. Ostensen has always done his utmost to reassure radiologists that their patients would ultimately benefit from training programs, but sometimes he has had to get tough with them.

He despairs at the efforts of some large international bodies that spend hundreds of thousands of dollars organizing training programs about radiation protection that are geared toward physicists, not end users and medical staff. These programs often provide lots of formulae and technical information but no practical details on topics such as how to use an apron properly.

"They really have no idea what they are doing," he said. "They think their courses for physicists are also needed in Africa, but they are not. They may have good intentions, but people end up learning absolutely nothing. We could do much more for a fraction of the cost."

Mobile phones and e-mail have made communication much quicker, and they have made Ostensen's job easier. Getting reception for a mobile phone is now feasible in most remote areas. Obtaining useful feedback after the training courses, however, has remained a major challenge. Ostensen does not attach much importance to questionnaires but prefers to visit attendees at their hospitals about a year after the courses. He has visited more than 100 radiologists and radiographers who have attended WHO courses, and he thinks this is the best way to find out if they have implemented what they have learned.

Another difficulty is keeping delegates focused on their everyday working tool: basic x-ray. Many of them are desperate to learn about MRI and CT, but if their hospitals do not have the resources and essential backup services for these modalities, there is no point in them becoming diverted, according to Ostensen. In some nations in sub-Sahara Africa, there are only one or two CT and MR systems in the whole country, and they are located in private hospitals.

Training courses and manuals have their limitations, however, and Ostensen admits that they are really only drops in the ocean. Therefore, for the past few years he has tried to promote the use of low-cost digital equipment that is easy to use and maintain. Efficient analog systems exist, but they rely on the availability of clean water, suitable chemicals, and well-constructed and controlled darkrooms. In comparison, digital units offer greater versatility in the developing world and facilitate teleradiology and remote consultations.

WHO has worked with CR Tech, a small Israeli producer of computed radiography plates that can be used with any analog machine. One of the company's CR systems has been installed in Dar es Salaam, Tanzania, and reportedly is producing impressive results. Each system costs between US$25,000 and US$35,000.

Ostensen's efforts were recognized in 2004, when the ISR bestowed on him its highest honor, the Beclere Medal. The society paid tribute to his efforts to build up a network of worldwide experts, which strengthened WHO's efforts to provide high-quality, relevant, and accessible education to local medical staff in developing nations. It also praised him for boosting collaboration and teamwork among those involved in diagnostic imaging, including doctors, nurses, technicians, and industry.

He will also carry on as the joint editor, along with Pettersson, of the WHO manuals of diagnostic imaging. The most recent volume about radiographic anatomy and interpretation of the chest was published last year, and the 152-page volume costs 28 Swiss francs. Previous manuals have focused on the musculoskeletal system and radiographic technique and projections, the latter also available in Russian. Most of the manuals are selectively distributed free of charge to developing countries upon request.

Ostensen relishes in his retirement the prospect of looking after the garden at his home in Cluny, in Southern Burgundy, France. He is looking forward to spending more time at home with his wife, Monika, who is a professor of rheumatology at the University of Bern, Switzerland, specializing in research into pregnancy in patients with rheumatic disease. He will continue to be involved in radiological training, particularly in Africa and India, but only in a personal capacity.

"It has been very interesting work-depressing at times, but also encouraging at times," he said.

INTERNATIONAL EXPERTS PRAISE NORWEGIAN'S CONTRIBUTION TO TRAINING AND PATIENT CARE

Ostensen's colleagues give their verdict

To mark Prof. Harald Ostensen's retirement, we asked some of the people who have worked with him over the years to comment on his main achievements. This is what they told us.

"Harald has a unique gift in that he is able, in a very quiet, unassuming way, to get colleagues from different regions of the world to work together in an effective manner for the betterment of international radiology education. He has been very successful in promoting the role of imaging education, both in the corridors of WHO and at regional radiology societies. His promotion of ultrasound education, basic radiological systems, quality assurance, and education for radiographers through the many textbooks and manuals published by WHO and "hands-on teaching" in various regional centers has made a positive contribution to improving patient care."

-Prof. Peter Corr, chair, department of radiology

United Arab Emirates University, Al Ain, United Arab Emirates

"I got to know Harald as an exquisite administrator of international radiological education when he was in charge of the practical aspects of the NICER Institute. When the former Norwegian prime minister (and physician) Dr. Gro Harlem Brundtland took over as director general of WHO, she put radiology into the program of WHO by selecting Harald as the director of the diagnostic imaging and laboratory branch in Geneva. Radiology had never been strongly represented within WHO before, and he did a great job with very limited resources. His most important contribution was the concentration on radiological equipment, education, and radiation protection in the least developed parts of the world."

-Prof. Hans Ringertz, chair, Center for Medical Image Science and Visualization, Linkoping University Hospital, Sweden

"Harald's overriding concerns were always those of the patient and how the resources available could be best be utilized to improve the health of the population. In addition, he was always realistic and was quick to pass this realism to those who worked with him. His greatest attribute was in getting health professionals to work as a team and to respect the value of each other's contribution to the care of the patient. He was instrumental in breaking down professional barriers. Harald's enthusiasm and commitment will be greatly missed."

-Dr. Alexander Yule, chief executive officer, International Society of Radiographers and Radiological Technologists

"Before Harald started work with the WHO, there had been a hiatus between the resignation of his predecessor, a physicist, and his arrival. The WHO program was dormant. All they had was the teaching center in Nairobi and a few pamphlets left over from Prof. Philip Palmer's work. He proposed a conference in 1999 at which we mutually organized the Global Steering Committee for Radiologic Education. WHO and ISR were co-sponsors, and Harald ran it out of his office. He then set about getting three other teaching centers going in Cameroon, Tanzania, and Fiji. We have found him a pleasure to work with: genial, practical, and always willing to help.

WHO has taken no action to find a replacement, and the rumor is that the radiology section will be abandoned in favor of a broad medical equipment program. ISR wrote a letter to Margaret Chan, the new WHO director general, objecting to this. The letter was co-signed by ESR, ACR, RSNA, IACR, AOSR, and a dozen other international groups."

-Mr. Otha W. Linton, executive director, International Society of Radiology

"Harald has focused his efforts exactly where efforts in medicine should be focused: trying to help people in practical ways and with simple means. He knows the best way to help is to teach and educate. He has also tried to instil in the minds of people that appropriate use of existing or add-on techniques or technologies is far more valuable than buying or donating high-tech equipment. His mission has taken him tirelessly out into the field to many places of the world of which he has got a deep knowledge and understanding of the countries and of their citizens. Whenever I meet him, I think to myself: I have met a humanist."

-Prof. Robert Muller,
Department of general, organic and biomedical chemistry
University of Mons-Hainaut, Mons, Belgium

"He helped organize what is widely regarded as the most successful (and much-imitated) medical imaging outreach symposia ever done: the NICER series. He drew together (and herded--some would say!) the most outstanding and best-known teachers from the U.S., Europe, and Asia to lecture to literally thousands of radiologists all over the world. Symposia were held in India, South America, Scandinavia, China, and Africa. Those who attended the lectures also received educational materials and in turn helped teach their colleagues the most up-to-date concepts in medical imaging."

-Dr. Anne Osborn, professor of radiology, University of Utah School of Medicine, U.S.