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.