Building on this great momentum, RAD-AID is already working hard in the first few weeks of January with exciting plans ahead. RAD-AID’s Haiti Team arrived in Milot, Haiti on January 4th to work in post-earthquake devastated Haiti. The team is working to build medical and nursing education programs in Haiti as a means of restoring Haiti’s health care capacity.  RAD-AID’s India team returns to Northern India in January to begin launching the Women’s Healthcare Mobile Outreach Program, which follows more than 18 months of collaborative planning with hospital and public health partners in India.  RAD-AID’s China delegation returned from Beijing in December in ongoing work to advance Chinese educational radiology, offering new opportunities for radiologists in the U.S. and China to work together in research, training, and patient-care.  In the first quarter of 2012, a RAD-AID team heads to Ghana for a Radiology- Readiness Assessment, after meeting with Ghana’s Ambassador in 2011.  Plans are underway with WHO/PAHO to deploy Radiology-Readiness in multiple Latin American countries such as Nicaragua in 2012.  RAD-AID is now piloting a Chapters Program, enabling ACGME-accredited institutions in the U.S. to establish RAD-AID Chapters for residents, faculty, technologists, nurses, and other staff for their own grass-roots global health projects.

All this effort is aimed at addressing critical health care disparities around the world.  Medical imaging is a vital part of health care, particularly for diagnosing disease, screening populations for early detection, and monitoring treatment, such as chest x-ray radiography for lung infections, ultrasound for maternal-fetal health, and mammography for breast cancer.  RAD-AID enthusiastically pursues a strategy of having projects in multiple regions, involving multiple imaging technologies, and diverse multi-skilled teams to develop and test new solutions.  We hope you will continue to support RAD-AID. Please join our online forum at Facebook, form a chapter at your academic medical center, and attend the 2012 RAD-AID Conference at Johns Hopkins.  By working together, our creativity, drive and vision of a better future can be achieved.

Happy New Year from the RAD-AID Team!

GNI per capita-Atlas is reported in current US Dollars. The statistics are recalculated every year as are the criteria for the 4 groups. For 2009, the 4 income groups are depicted on the world map to the right. A quick survey of the map demonstrates the following:

1. Most low income nations are on the continent of Africa. The remaining low income nations are in Central and Southeast Asia.
2. Most South and Central American nations are in the upper middle income category.
3. China and India, the two most populous nations, are both in the lower middle income category.
4. If low and middle income nations are considered “developing”, then most of the world’s nations are developing countries.

NEXT TIME: Relationship between the economic development of nations and their public health.

Filed under: Journal Club Tagged: Developing country, Economic, Economic development, GNI per capita, Gross National Income, World Bank ]]> http://radaid.wordpress.com/2011/06/02/economic-classification-of-developing-nations/feed/ 0 eazene GNI per capita map 2009 http://radaid.wordpress.com/2011/05/27/whitia-brings-whis-rad-digital-radiography-unit-to-guatemalan-clinic/ http://radaid.wordpress.com/2011/05/27/whitia-brings-whis-rad-digital-radiography-unit-to-guatemalan-clinic/#comments Fri, 27 May 2011 12:22:46 +0000 RAD-AID http://radaid.wordpress.com/2011/05/27/whitia-brings-whis-rad-digital-radiography-unit-to-guatemalan-clinic/ ]]> http://www.auntminnie.com/index.aspx?sec=sup⊂=xra&pag=dis&ItemID=95001&wf=1236

Interesting article worth reading.

Some consider “developing” a pejorative and derogatory term.  They have proposed other terms, including “lesser developed”, “under developed” and “least developed”. In the end, the terminology is less important than the criteria used to define it.  At RAD-AID, we prefer the term “developing world” because of its widespread use and understanding in the lay public. RAD-AID has adopted the per capita income based World Bank criteria for developing nations, which I will describe in the next blog post. On occasion, RAD-AID will also refer to he United Nations Human Development Index (HDI). The HDI is a single statistic (from 0 to 1) that reflects both economic and social development.

NOTE: “Third World” is an outmoded term and no longer used in the field of international development; not because of a pejorative connotation, but because of its origin as a geopolitical divider and lack of specific criteria measuring economic, infrastructure, or social development. During the Cold War, the Liberal West and NATO comprised the ”First World”, the Soviet Bloc comprised the ”Second World”, and the majority of other nations were grouped as “Third World.”

NEXT TIME: Stratification of nations based on Gross National Income (GNI)

I will be presenting RAD-AID’s answers to these questions in upcoming Journal Club blog posts.  The next few postings will lay the groundwork for how we will approach identifying, selecting, reviewing, and discussing the body of literature in the field of international radiology development.  But before we discuss our first Journal Club paper, we need to answer the above rhetorical questions– beginning with defining “developing nation“.

Now that three weeks have gone by in Rwanda, I cannot believe that I am headed back to the States. It seems that I did so much in that time, it warrants some recap.

I boldly proposed to travel to Rwanda for my dedicated research month during my residency program. I am delighted, as compared to prior classes, that my month was allocated in my 2^nd year and not my 4^th. Last June, I met with a mentor of mine Dr. Rheuban who mentioned that there was a team of surgeons doing work in Rwanda. From that, I contacted my colleague, and now friend, Robin Petroze to learn about what her plans were. Fast forward, many discussions and emails with her, paperwork to get permission, ACR travel grant, contact with RAD-AID, and Rwandan Hospital Ethics committee approval, I came to Rwanda to carry out my ambitious research project.

I say ambitious because, as I learned quickly, time in Africa is different than time in the States. I planned to go to 8 hospitals in less than 15 work days, not knowing anyone except for Robin initially and a few important email contacts of Rwandese physicians and medical professionals, not having a car and reliant upon drivers, and not speaking the prior formal language (French) or local language (Kinyarwandan). However, it all came together, and in fact I had completed my radiology needs assessment with not just 8 sites, but 9!

My goal was to complete said needs assessment of select hospitals prior to helping initiate a collaborative between CHUK (the main teaching hospital in Kigali) and UVA Hospital. Once done, I expected to have better idea of what resources are available and able to cater our support appropriately, specifically with respect to the adjunct of radiology education during surgical teleconferences.

CHUK Morning Report

Little did I know that my questionnaire may be very straight forward if I spoke to the right person, but often this person was gone, or did not speak English. Often I felt like it was a struggle to get every response. I completed as much of it as possible, with a focus on less financial-based questions and more radiology-oriented questions.

Oh but wait – let me explain how I chose my hospitals. I selected the main teaching/referral hospital in Kigali, the main teaching/referral hospital in Butare (where the medical school is), King Faisal Hospital (private hospital), and 6 district hospitals (referrals from health centers) – 2 in the greater Kigali area, and 4 in each geographic quadrant of the country. Themes that emerged included some of the following:

• Radiologists: There are 8 radiologists for the country of 10 million. All of which are working in Kigali, none of which are in smaller cities/towns. Training was from nearby African countries as currently there is no radiology residency program and no mention, at this time, of creating one as needs are more on a non-specialist, primary care level.  The private hospital has 4 radiologists, district hospitals have none – reliant on radiographers and general practioners to make their own “impression”.  They, collectively and individually, could not have been more welcoming with respect to their reception of me. I felt like one of the group right away, enjoying reading by the light box/work station side-by-side, with diagnoses not commonly seen in the States: sequelae of chronic developmental hip dysplasia, seizures secondary to Neurocystercosis, advanced (gross morphology included) hydrocephalus as sequelae of meningitis, and innumerous fractures due to “road traffic accidents”. Trauma/emergency radiology is certainly not lacking.

• Radiographers: There are about 100 radiographers now that have been trained in a 3 year program at the Kigali Health Institute. After graduation, technologists are placed in a district hospital without additional support. By this I mean, little if at all technical support, no quality assurance program, and variable degrees of radiation protection. There is a push for radiographers to have the opportunity to learn more about sonography, at the current time done by either radiologists, general practitioners, or OB/GYNs. I cannot begin to express my degree of respect and admiration for the lone radiographer, working often entirely by themselves, hand developing their own films, and relying on old equipment full of “personality”.

• Equipment: A spectrum of functionality, not entirely to my surprise. As one Hospital Administrator said, “the only difference between us and a health center is technology [radiology]”. Most all equipment is donated. Unless there is a warranty associated with the equipment (such as at King Faisal Hospital), broken equipment may go months without being repaired, if at all. A few district hospitals had a machine I had never heard of: Shiumadzu, manufactured in the 1950s, now many of which broken as there are no longer spare parts made and no one knowledgeable about how to fix them. Conversely, CHUK had 10 impressively working ultrasound machines scattered around the hospital campus. Regarding cross-sectional imaging, for example at King Faisal, the MR machine has its own warranty/technicians that would help with repair (from Kenya). With projected/planned acquisition of more cross-sectional imaging equipment, I wonder just how feasible it will be to maintain these machines. I mean, it is challenging enough at home! For a juxtaposition, see my pictures!

• Insurance: What’s American’s excuse? All Rwandese, to include anyone who wants to buy in (foreigners alike that is), can get basic medical insurance for the equivalent of 2 dollars. Immunizations, basic medications, basic health care, radiology examinations… are provided for. Also to include preventative/screening care, if that is a priority of the individual patient. With the current system in place, there are three tiers of medical insurance, the cheapest of which was already mentioned and patient’s payment of 10% of the total cost, government’s payment of 90%. Comparison from the district hospital level, even the tertiary referral centers where some district hospitals were superior in terms of donated/new medical equipment, to the private King Faisal Hospital was profound. Taking into account the gross national income of just a few hundred dollars a year, difficulties with clean water, the vast majority who use walking as their primary transport outside of the capital city, and reliance on agriculture for all life activities, the basic services provided are undeniably a step in the right direction.

• Education: Beyond training, nothing formal (as we think of CME). Radiologists complete 6 years of medical school (to include 1 year internship), 2 years practicing in hospitals, and then a 2 year radiology residency (in a non-Rwandan country; most commonly Tanzania, South Africa, and Kenya). Radiographers have three years training as mentioned before. General practitioners have no required, formal training in ultrasound. Which lends itself to many practical questions: How does one maintain skills? How does one learn how to use imaging modalities? How does one refine their knowledge base through feedback? Even without the medicolegal environmental mess that is the USA, how can one make the right diagnosis? There are many missionary, ex-pat groups doing work, some individuals and some teams – specifically, Israeli OB/GYN teaching radiographers by laptop to the very comprehensive Emergency Sonography manuscript and associated trainings at Parters-in-Health affiliated hospitals. To my great surprise, there were no overt radiologists/radiology groups teaching about imaging. Rather, it was the ED and OB/GYN physicians teaching relevant, basic ultrasound. Ultrasound – ostensibly the hardest imaging modality (as there is a great art in creating images in addition to interpreting the images), only second to Nuclear Medicine. In my opinion, I saw this as a missed opportunity for the global radiology community and promised myself to raise awareness of it upon my return. Especially given…

• …Future endeavors: Impending projects/developments include the formalization of the Rwandan Radiology Association, 64-slice CT for CHUK (currently 1/8 radiologists is in India completing a specific CT training), digitization of CHUK radiology department, activating the already laid down governmental cable to permit about 30 hospitals in Rwanda to be linked for teleconferencing purposes.

Don’t get me wrong, all the travel for my site visits was more than worth it, with the only real challenge being whether or not the car I relied on would 1. Be delivered and 2. Be functional enough if there was a mechanical problem. The rides through the countryside were breathtakingly pretty. Rwanda, known as the “Land of 1,000 Hills”, was more like the “Land of 1,000,000 mountains”. I thought this was stiff competition as compared to Charlottesville. Particularly gorgeous was the north, Ruhengheri hospital, as we approached Volcano National Park (where the mountain gorillas are) and the west, Kibuye hospital, adjacent to Lake Kivu (competition for any of the nicest resorts in the world).

Ruhengeri District Hospital near Volcano National Park

I actively/?obsessively took short videoclips to help convey my experiences better once home. Children running up, furiously waving with huge grins asking for pens and water bottles, passing genocide memorial after genocide memorial, and observing what the life of most Rwandese is like – peasants, working their own land with very crude/non-machinery tools, with no dearth of opportunity to socialize and participate in the overt commotion of very busy village life.

When not obtaining my data, other non-medical highlights included many work meetings with other ex-pats at various restaurants around the city, all cuisine available except surprisingly for Mexican food, with “claim” of chapatti as African (not Indian?!); exploring the city market which undeniably outdid the organic produce of Whole Foods! (if you wanted ANY kind of ingredient, you could get it, at your own barter); visiting the mountain gorillas thankfully (and safely) within a few feet so we could really see their expressions, identified not by finger print, but by nose print and the associated arduous journey through potato farm land, bamboo forest, and stinging nettle brush ending with a heavy rain (with delivery of twin gorillas for the 5^th time ever in history within a week of my being there); Ivuka Arts gallery, a co-op of Rwandese self-taught artists whose delightful work is only compounded by their art outreach programs at local orphanages; salsa dancing with our friend Jimi, as some call the “Congolese Patrick Swayze”; going to the National Genocide Museum, to include walls of photos of child victims and mass graves, as well as to Ntarama memorial church with the chilling evidence of victim’s bones organized by type, neatly displayed clothing and items, and even blood-stained walls of children victims; meeting Rwandese friends and bumping into ex-pats in such a way that it seemed everyone was related to one another, no matter how remote the environment; new experiences to include going to the American Embassy for social hour, eating beef brochette, traffic jams with road signs/signals as a mere suggestion at best; and so on… More than anything, I was profoundly moved by how warmly I was received by all the people I met, in general, soft-spoken, with kind smiles and engaging eyes, committed to helping me navigate this new world that is Rwanda.

Ivuka Arts Gallery orphanage art outreach program

I should not delay writing any further the extent of my gratitude to Robin. Not only was she my hostess and colleague, but she became a dear friend, quickly assuming the status of “sounding board” for everything that happened and that I was thinking during this experience. She conducted herself with grace, as she organized meetings with groups of, at times, seemingly competing/competitive agendas, demonstrated unyielding dedication to conscientiously corresponding in all forms no matter what time of day/night, and modeling the patience that is absolutely required for an American to be operating in at times, a Kafka-esque African environment. I am also thankful for my mentors, who know who they are, UVA, and RAD-AID’s assistance for their respective contributions to this successful experience.

As I stare out the window at the Atlantic Ocean near Reykavik, regretfully headed home after a full-bodied, exceeded expectations experience, I promise myself a few things to make sure my trip was not in vain. First and foremost, I plan to, as best I can, convey the current state and need of the Rwandan imaging world, through my reports, photos, videos, and impending teleconferencing involvements. Second, I vow to make myself available for continued correspondence with the various health professionals and new friends I have met while there. And thirdly, I want to go back, further along in my training, to work in some capacity as a diagnostic radiologist and educator. For now, I end on the note: Rwanda was just the “dawa” (medicine) the doctor ordered, to fuel my continued dedication to international radiology through investigation of the progress and promise of the Rwandese medical frontier.

RAD-AID has begun 2011 with a fast sprint to accomplish great progress all around the world, which is great news for our country partners, members, volunteers, and collaborating organizations. In January, RAD-AID sent a team to North India to work with Project HOPE and PGI Chandigarh as a follow-up to the Radiology-Readiness Initiative last July. The team worked on a mobile women’s health program development for North India. Joining the team were volunteer MBA students from Columbia University through RAD-AID’s partnership with Pangea at Columbia, a truly innovative program to bridge best-practice business knowledge with medical expertise in program development.

RAD-AID is also pleased to announce the completion and publication of its Pakistan Country Report. The Country Report Program at RAD-AID is designed to give volunteers all over the world the opportunity to research and analyze health care systems of developing nations to determine how radiology is currently used (if at all) and how radiology could be expanded or optimized for those regions. RAD-AID is working to further standardize these reports to streamline this important research process.

On the educational front, RAD-AID is working on launching an international exchange lectureship program with China in addition to online learning systems for educating imaging and health care professionals. Education is key to the advancement of international radiology. RAD-AID’s work with China aims to build advanced dialog and collaboration with China’s rapidly advancing health care system to produce innovations for the world.

RAD-AID is also in the process of launching its public health program, which was presented at the RAD-AID Conference on November 1st 2010. Linking radiology and public health programs is a key part of RAD-AID’s mission, as this link helps medical imaging to play a key role in population-based programs such as breast cancer screening, maternal infant health, infectious disease, and radiation safety.

As many of you know, RAD-AID has been working with multiple organizations to help Haiti, such as Project HOPE and the American College of Radiology (ACR). In September 2010, RAD-AID performed a Radiology-Readiness Assessment in Haiti to see how radiology could strengthen the health care system in Haiti, particularly in dealing with the aftermath of the earthquake. RAD-AID is currently working on several follow-up initiatives for Haiti, such as a next-stage return trip for further strategizing medical imaging. We will provide updates as these unfold.

So, we are off to a rapid start in an exciting upcoming year. We hope to provide more updates as we work hard to develop programs and initiatives.  Thank you for your ongoing support and interest in RAD-AID.

Now that I am already back in the comfort of home, I can step back and reflect on what I saw and learned in Haiti in the course of four days. I had the opportunity to visit two medical centers and discuss the future of health care in Haiti with hospital administrators, Project HOPE representatives and the head of UNICEF’s health program in Haiti. I also attended a “cluster” meeting of NGOs working on health care in the country. Without going to excessive detail, I will offer some of my impressions regarding radiology in the region.

Not surprisingly, I saw a general lack of radiology equipment in Haiti. Most hospitals are lucky to have a single analog radiography unit from the 1970s, perhaps in conjunction with an equally outdated ultrasound machine.

Even greater than the need for technology, however, is the need for maintenance and proper use of the technology available. One site I visited had a new digital radiography unit that had been donated by the manufacturer. Due to the lack of proper monitors and a functioning PACS, images could only be viewed on the unit’s tiny display screen and were erased in a matter of days. Another hospital had an intact analog radiography unit but was unable to obtain film, rendering the machine useless. The same medical center also had a mammography unit and a C-arm covered in dust; no one knew whether they worked or how to operate them properly.

Given these deficiencies, two potential areas for RAD-AID to focus its efforts in Haiti could include training for technicians as well as transitioning to digital radiology systems with PACS. Progress in these areas would allow further developments to have a more profound and sustainable impact on health care in the region.

Project HOPE is also particularly interested in developing mobile medical care, including mobile radiology units, as a means of extending the currently limited reach of regional health care facilities. This is a potentially promising avenue that, like numerous other topics, warrants further discussion… which I think I will leave for future blog posts!

(I will also try to include some photos in future posts — currently having technical issues of my own.)

Ryan Sydnor
Resident, Duke Radiology