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
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.
The 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
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
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.
Cost 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.
The 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
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 firstname.lastname@example.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