Chapter 5: First-aid remedies

The probably most important task is to substituted chemical film processing with other technologies, and the key-word is nothing less than digital radiography. Today it is possible to install, or even upgrade much of the already available X-ray equipment from analogue film based systems to digital solutions relatively simple and to affordable costs. Although specific calculations are needed for each facility, the initial costs for purchasing and installing digital radiography solutions may be financed by savings in film and chemicals thereby giving a break-even after two or maximum three years. Electronic detectors (“electronic X-ray film”) that is placed into the machines in stead of cassettes loaded with conventional X-ray films, are available on the open market at prices ranging between 20,000 and 40,000 EURO, depending on type of computer and software wanted. In contrast, however, fully digitized, modern X-ray equipment as found in several hospitals in the rich part of the world may easily cost more than a million EURO. In addition to being too costly, such equipment is technically too complicated to be installed and run in areas with poor infrastructure. The diagnostic quality of images produced with simple digital radiography is overwhelmingly much better than most conventional images thereby improving the standard of imaging services to what is internationally accepted and medically needed.

The second obstacle to medically acceptable diagnostic imaging services in several poor countries, the lack of medical specialists, may be a permanent situation. After years of education and training, very few specialists seem to be ready to settle permanently and to work under conditions often found in small and mid-size hospitals in countries with few resources. They tend to move to the larger cities, and to get an employment in private institutions where conditions, including salaries are much more attractive. Furthermore, a serious “brain-drain” to other countries is unfortunately seen. Lack of specialists in rich countries make them look for well trained radiologists from elsewhere offering salaries and working conditions that could never be matched in poor countries.

Consequently, it seems necessary to find acceptable solutions. The key-word is what is generally called teleradiology, meaning that images are sent electronically from end-user sites to another institution where radiologists are available. Although analogue images theoretically can be digitized, this process requires high quality images normally not available. Sites using digital radiography systems, however, can easily send electronic images to other places. Although communication may be a problem still, an increasing number of medical facilities even in remote areas have access to conventional e-mail. Broad band is certainly desirable, but not absolutely required. X-ray images compressed and attached to normal e-mail messages as jpg-files are in most practical situations sufficient for urgent diagnostic evaluation, and the reader can transmit her or his opinions back to the remote site within a minimum of time. Such a system, however, requires a formally developed collaboration and certainly some sort of remuneration for the reading institution and doctor, but it is doable.

No health care system can function properly without the necessary “bits and pieces” in place. Adequate diagnostic imaging service is one of these “bits”, which has to be integrated and developed as a crucial part of any health system. In many countries with limited resources, however, priorities are often given to far more simple medical solutions such as developing the primary health care system. On the same time, however, also hospitals and more sophisticated medical institutions are built following similar considerations as for primary health care facilities. Often they are also functioning like primary health care facilities, however equipped with bed stations and possibilities for simple, although often life saving surgical procedures. Over time these institutions may develop more and more into what is generally accepted as hospitals, but necessary funding and possibilities for purchasing and running equipment and procedures urgently needed and expected at such facilities, are mostly not in place.

It seems that very few politicians responsible for health care within their country has the necessary knowledge about what is needed in a hospital. They may not even know how the situation may look like some miles outside the capital. No doubt that political consideration such as assuring re-election and increased popularity is of great importance. Few media headlines, however, are offered on somebody giving priorities to upgrading small and mid-size hospitals in remote locations. In this context a purchase of totally useless and immensely expensive equipment that in many cases will not and cannot be utilized properly (no proper infrastructure and no proper staffing), seems to be more important than a large number of adequate and urgently needed machines for the same amount of money to the benefit of patients living in remote areas.

In addition, international organizations and so-called experts may convincingly try to tell what is needed and how things should be, such as stating that “a district hospital should at least have one CT machine”. The only problem not realized by the external “experts” is the lack of necessary infrastructure and the lack of specialists to maintain and run such equipment. In too many hospitals in poor countries unused and sometimes also un-installed CT machines are “hidden away” whereas urgently needed equipment for diagnosing pulmonary disease, or skeletal problems and injuries may hardly be functioning and often suffering long-lasting break-downs due to lack of maintenance and spare parts.

- 4 b: Specific problems on site

Keywords are lack of technical and medical know-how mostly in combination with insufficient and malfunctioning equipment and lack of necessary infrastructure. Even well educated and properly trained technologists / radiographers cannot do very much to improve quality of examinations and images when proper film and chemicals for film development and adequate storage and film developing facilities, i.e. “dark-rooms” are not in place. A majority, probably more than 70% of poor quality images, are so because dark-room facilities are insufficient. Mostly they are not dark, i.e. not properly protected from intruding day light, or other light sources. In addition, water needed for film processing is not sufficiently clean, and temperature control of water and chemicals is mostly not available. Any chemical process, including development of X-ray films is highly influenced by temperature. For film processing working temperature should be in the lower twenties (Celsius), and should certainly be known. Several such facilities, however, do not have as much as a simple thermometer, and working temperatures of 40 degree Celsius or more, are not unusual under tropical conditions. Consequently, no proper film development is possible.

The production of conventional X-rays is a relatively simple procedure and can basically be done by anybody after some experience of type “try-and-fail. However, the production of images with sufficient diagnostic quality while reducing radiation hazard to patients and staff, requires extensive basic and continuing education and training. Ideally, nobody else than properly educated and licensed radiographers / radiological technologists should be allowed to be in charge of and to operate potentially dangerous equipment such as X-ray machines. Fortunately, a majority of the radiographers / technologists have enjoyed a relatively good basic education although often several years back with few if any possibilities for updating their knowledge.

In the ideal world only fully trained and certified medical specialists, mostly radiologists, is allowed to interpret X-ray examinations. In the real world, however, several countries have a severe lack of such specialists, leaving the interpretation of X-ray examinations to insufficiently trained medical staff. In general, it takes a minimum of four years of intensive radiological work in addition to being a medical doctor to become a radiologist qualified to conduct and interpret radiological examinations. Such specialists are rarely found in small and mid size hospitals in countries with limited resources.

Chapter 4: Conditions contributing to poor imaging services

- 4 a: General, overall problems

An overall reason for poor quality or sometimes total absence of diagnostic imaging services in is ignorance at political and economical level of the country. Such ignorance is especially seen with regard to importance and necessity of diagnostic imaging services as integrated part of any hospital care. Plans and priorities for how to develop national health plans and services are often adapted from recommendations and guidelines produced by international organizations, such as United Nations agencies. Unfortunately, however, such recommendations sometimes seem to lack certain understandings for real problems, and they are mostly being developed by experts living and working under totally different condition where “everything” is available and possible. Any attempt to transfer such conditions to countries with very limited resources and infrastructure in stead of suggesting steps and development adapted to what is absolute needed “here and now”, may prove unrealistic and sometimes counter-productive. Recommendations aiming at changing a practically non-existent health system “over night” into a system as found in some rich countries, have failed so far, and it is not reasonable to assume that this may change in the near future. For diagnostic imaging in particular, this is often the case in the sense that technically and medically sophisticated and complicated equipment and procedures may be “installed” - purchased or donated - for locations without necessary infrastructure and staffing for in place. The result is a large amount of expensive, useless and often unused, or not properly installed equipment lying around in various hospital facilities.

Chapter 3: How does it look like in many poor countries?

Ideal conditions as outlined in Chapters 1-2, are often taken for granted as being in place world wide, and it may be difficult to realize and accept that this is not always so. The situation for diagnostic imaging in a typical country with limited resources is often as follows:

i) Well-equipped, well-functioning, properly staffed and expensive private institutions – for the few.

ii) Poorly equipped, hardly functioning, and insufficiently staffed governmental institutions for the majority of the population.

iii) Close to nothing in place outside the capital and major cities.

In spite of a few high-standard hospitals and institutions the absolute majority of the population in most poor countries has no financial possibilities for being examined and treated in private, commercial institutions, and for all practical purposes they have nothing else than public, governmental hospitals often of questionable standard. Specifically for diagnostic imaging equipment and services, they are often sparse, malfunctioning, and incorrectly operated. Where available, long lasting breakdowns due to lack of proper maintenance and spare parts are common. In best case one single and rather basic X-ray machine may be available and functioning. Other imaging possibilities such as CT and ultrasound otherwise taken for granted are rarely found, and if so, very few may be able to operate and maintain them properly.

Chapter 2: Why is diagnostic imaging necessary?

Correct decisions on whether, when and how to give medical treatment should be based on a best possible diagnosis established by using generally accepted means such as doctors’ clinical judgment, clinical examinations, and some times additional tools such as laboratory examinations and diagnostic imaging.

In general, a majority of diagnostic decisions are based on simple clinical examinations without any need for more sophisticated tools such as laboratory examinations or imaging. Medical doctors as well as other health professionals are at least to some extent trained for such work and all diagnostic work should commence with a clinical evaluation of the patient. Any other tool shall be used only when clinical judgment and examination is not clarifying the situation sufficiently well. When needed, it is also important to use such additional tools after considering their diagnostic potential and possible risks for the specific patient and situation.

Chapter 1: What is Diagnostic Imaging?

The term diagnostic imaging within the medical field covers all modalities and procedures aiming at visualization of structures in the human body not seen directly. Until the 1980s diagnostic imaging, including computed tomography (CT) was based on X-ray principles as firstly described by the German professor Konrad Wilhelm Roentgen in December 1896 and consequently called “roentgen”, or “radiology”. The last 20-30 years, however, have seen the development of several imaging techniques based on other principles than X-rays. The most important of these modalities are probably ultrasonography (US), magnetic resonance imaging (MRI), and procedures based on nuclear medicine principles – various types of “scintigraphy” - including the so-called positron emission tomography (PET).

Ideally various imaging modalities should supplement each other, although this is not always the case. It is also the wish that new methods might substitute older and maybe more dangerous procedures. This situation is clearly seen with US versus X-ray examinations where US may offer more exact diagnostic information without exposing the patients to potentially dangerous ionizing radiation.