Global health is an area of medicine that many medical schools and academic departments are introducing into their curriculum as they recognize the interdependency of health status around the world. In this commentary, I will describe some of the challenges and opportunities that advanced technology holds for the global health movement.

My introduction to global health came from my orthopedic surgeon, who was treating me after a bad skiing accident. He shared with me a photograph he had recently taken on a volunteer trip to Haiti. It showed x-ray films, clipped to an iron gate, drying in the sun because the x-ray processor did not have a functioning film dryer.

He encouraged me to get involved and described the need for radiology experience and leadership in his global health setting. Four years later, the organization for which I volunteer, Partners In Health, has made major strides in radiology but tremendous challenges remain.

To understand the scope of the challenges in global radiology, you need to look no further than a report from the World Health Organization that found that one-half to two-thirds of the worlds population lack access to basic radiology services. Furthermore, the report found that up to 70% of imaging equipment was nonfunctional because of limitations in acquisition, user training and technical support. Technological advances in medical equipment have led to significant improvements in diagnosis and treatment, but to succeed, any advanced technology requires an equally advanced support structure which, in the case of digital image acquisition, typically requires radiology and hospital informatics.

Advanced Imaging Technologies Require Support

We have all seen photos of those beautiful American cars from the 1950s still being driven through the streets of Havana. Imagine for a minute that instead of cars from a simpler age, the cars in Cuba are current models and the country had been cut off from access to U.S. automobile parts this year.

How long would those 2014 model cars function when an electronic ignition or engine control computer needed replacement? This advanced technology is well beyond the scope of the homemade repairs that can keep a 1957 Chevy on the road and illustrate the issues that permeate the decision to use advanced imaging technology in developing countries.

What type of equipment qualifies as “advanced imaging equipment”? If the imaging equipment is electromechanical, the skill set to maintain and repair such equipment has been unchanged for decades. Once you introduce computerization and software, you have crossed the Rubicon into the land of advanced imaging technology.

Advancing Global Health MendelThe challenges created by crossing this “digital divide” raise the question of why many of us are pushing to introduce this technology into the developing world. Surprisingly, the argument for and the benefits of advanced technology in the developing world are similar to that in the developed world: Better images, improved local access and ease of remote collaboration. These benefits apply whether you replace manually developing in open tanks of potentially toxic chemicals with digital radiography or add new technology, such as CT scanning.

Before considering advanced imaging technology in the developing world, one critical question is whether the local environment is ready for these radiology advances.

Take, for example, a locale in which tuberculosis is prevalent. Clearly, a digital chest radiography unit would seem to be a great tool. Beyond the foreseen issues involving roads, reliable electricity, access to the Internet and possibly air conditioning, a critical issue is whether the local medical environment is ready to use this technology.

Diagnosing tuberculosis is of little use without a mechanism for distributing anti-tubercular medications and medical personnel to monitor response to drug therapy. Similarly, adding CT scanning is of little use without a mechanism for interpretation of these complex imaging studies.

The ultimate goal of any global health project is self-sufficiency. Detailed knowledge of the local medical, political and geographic factors is the first step. Ultimately, knowledge transfer creates the most self-sustaining environment.

Education is a critical component, as many countries simply do not have a sufficient pool of technologists, technicians and radiologists to independently manage advanced technology. As technology is added in the developing world, operational costs may increase. These can be mitigated by the training of and the technology transfer to local biomedical service personnel. For many organizations, these educational functions provide the true capital for technological advancements. Partnership with the local government and/or medical structure serves to blunt the natural tendency of donors and volunteers for whom a single intervention, be it capital purchase or a one-week volunteer visit, is much more manageable than longer term giving for operational costs or the dealing with the ongoing issues that arise in these projects.

Deploying CT Capabilities in Haiti

As an example, let me describe the process of deploying the first CT scanner in the public sector in Haiti. After the 2010 earthquake, the government of Haiti approached Partners In Health with the request to expand what had been a project to build a 100-bed local hospital to a 330-bed regional teaching medical center. As planning progressed, the decision was made to create a digital radiology department. This was a first for Partners In Health, but the decision made sense given the teaching function of the hospital and the planned deployment of an EMR along with a strong intranet backbone.

CT was not considered initially because its electrical usage, cost and complexity appeared to be beyond the capacity of this project. However, as building progressed, it became clear that the absence of a CT scanner in a modern teaching hospital with ICUs and six U.S.-grade operating rooms would significantly limit our ability to provide care in the complex cases that this facility would inevitably attract. 

The first issue was the electrical requirement. A modern CT scanner has the same peak electrical needs as 10 typical U.S. homes. In a facility that uses solar panels for a significant portion of its power, this was untenable. Fortunately, we found a CT scanner designed for mobile operation that used 110/220v wall receptacle to trickle-charge a bank of batteries that provide for the peak power needs of the scanner. Limited electrical power was also a concern when it came to cooling our CT suite, located in a tropical country, down to the typical 70 degrees common in hospitals in developed countries. However, we had already realized that this degree of cooling was not mandated in the specifications for most digital equipment, so we were able to size the AC unit to maintain a temperature of 80 degrees.

Advancing Global Health CT ScannerCost is a major factor in the decision to deploy any CT scanner. While cost remained an important factor for us, the programmatic needs made the acquisition of a CT scanner vital to our long-term mission. After a strong fundraising effort and with the collaboration of the manufacturer, we were able to fund the scanner.

For this project, the staffing needs were one of the principal sources of complexity. We had no access to technologists with CT training and, in Haiti, there were no radiologists working in the public sector. To develop local skills in technologists, we created a mini-school, using the applications personnel from the CT vendor and volunteer U.S. CT technologists who visited Haiti and intensively trained our local staff. For radiology support, the solution involved our digital backbone. We reconfigured our PACS system so that the archive in Boston could also serve as the portal for a web-based PACS system. Again, volunteer support was critical. This time it was our PACS vendors employees who gave tirelessly of their time to help us create this novel PACS infrastructure.

This allowed us to recruit radiologists from the U.S. and Canada to volunteer a few hours a month to remotely interpret the CT scans from Haiti. Organizing a group of volunteers sufficiently large to provide coverage for a daily volume of 15-20 CT scans is an ongoing project in which we have had our share of Internet outages and organizational stumbles. However, we do have a growing group of highly dedicated radiologists that daily assist our clinicians in their patient care by providing high-quality CT interpretations. Long-term, we are partnering with several nongovernmental organizations in Haiti and the American College of Radiology and plan to start a radiology residency within the next five years. Again, the goal is the transfer of knowledge to the Haiti medical community.

Advancing Global Health X-raysThe above example highlights several key elements in the implementation of advanced technology in global radiology. First, decisions to deploy advanced technology must flow from a clear-cut medical need. Second, the assumptions surrounding deployment of advanced technology in the developed world are only that, a set of assumptions. Each of these needs to be re-evaluated on a case-by-case basis and adapted or even abandoned based on the local environment.

We totally redesigned the conventional PACS architecture, creating an Internet-connected archive that also functions as a web-server for our interpreting radiologists. We repurposed digital equipment, using a mobile CT scanner in a fixed CT suite. These are both typical examples of the innovation required in the developing world. And third, volunteer support will wax and wane over the course of a long-term project but the transfer of knowledge to local medical providers creates a truly self-sustaining project.

Multiple Avenues to Getting Involved in Global Health

All of us in the developed world have skills that are needed in developing world. There is as great a need for volunteerism from those with skills in medical equipment, software, hardware and administration, as from those with direct patient care skills. My experience has shown me that every facet of the U.S. healthcare sector has its equivalent in the developing world.

There is simply no substitute for the extensive local knowledge that comes from an organization that has made a long-term commitment to a specific region of the developing world. Becoming involved with an experienced organization is the safest way to know that your efforts will be put to the maximum use. My volunteer team at Partners In Health consists of administrators, physicists, specialists in informatics, technologists and radiologists. This group has accomplished so much, but yet has so much more to do. If you are interested in our organization, contact me at jmendel@pih.org or, if you know any interested radiologists, they can sign up at pih.org/radiologists.

We, in the developed world, often forget how fortunate we are and take for granted the medical care and diagnostic capabilities that are nonexistent in many parts of the world. Involvement in global health brings me to the front lines of the delivery of care and constantly reminds me of the phrase “he who saves one life, saves the world entire.”

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