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Medical Imaging in Low-Income Countries · Acedra
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Medical Imaging in Low-Income Countries
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0:01
Although we'll be discussing the important role radiology & medical imaging play toward improving health outcomes in low-income countries, it's very important to appreciate the context in which this talk is occurring... in a setting where more basic healthcare issues also simultaneously need to be better addressed... issues like clean water, better nutrition, better housing, and better delivery of medical treatments.
0:28
So why do I believe it's important to discuss the role of medical imaging in low-income countries? Well, there's traditionally always been a strong focus on striving to improve the delivery of primary care, obstetrical services, surgical services and therapeutics in low-income countries, but sometimes an under-appreciation for how much these services & therapeutics rely on diagnostic imaging to be effective. Without x-ray imaging capabilities, you can't tell if a patient's TB
0:58
treatment is working. Without ultrasound imaging capabilities, you can't monitor pregnancies well. Without CT imaging capabilities, you can't tell if a patient needs surgery to intervene on internal bleeding from an accident. Public health in these nations relies on medical imaging and radiology, and critical access issues currently exist in many low-income countries. To better understand the state of medical imaging in low-income countries, we'll focus on 5 topics...
1:31
...the spectrum & overall burden of disease in low-income countries, vis-a-vis middle-income and high income countries... the essential imaging requirements in low-income countries, physical capital and human capital issues low-income countries face, and finally... potential solutions folks have proposed to improve the public's access to medical imaging and radiology in low-income countries. When compared to the United States...
1:59
Low income countries experience a different spectrum of disease, and also a higher overall burden of disease. To better appreciate this, we'll first look at how relative death rates from... 6 different causes vary around the world: deaths from TB, influenza and pneumonia, HIV/AIDS, birth trauma, traffic accidents, and violence. The first 3 items on this list are infectious diseases and sometimes behave synergistically... as lung infections are one
2:32
of the most important causes of morbidity and mortality in patients with HIV/AIDS. We'll begin with TB and look at how relative death rates from TB compare between... ...low-income countries - particularly those in Africa and Central Asia, versus high-income countries in regions like the United States, Canada, Western Europe, Australia, and Japan... AND also versus the middle income "BRICS" countries: ...Brazil, Russia, India, China, South Africa.
3:03
Relative death rates from TB in Africa are substantially higher than in most of the world... ...and at 127 deaths per 100,000 people is over a thousand times higher than in the United States. Relative death rates from TB in middle income BRICS countries vary greatly, ranging from high in India to moderately high in Russia, to moderately low in China and Brazil.
3:30
Relative death rates from influenza and pneumonia are also dramatically higher than in high-income countries, China, and Russia. Relative death rates from HIV/AIDS are dramatically higher in Africa than in most high and middle income countries. Relative death rates from birth trauma in low-income countries are substantially higher than in most high and middle income countries. Relative death rates from traffic accidents in low-income countries
3:59
are substantially higher than in most high and middle income countries. Relative death rates from violence in low-income countries are also substantially higher than in most high and middle income countries, with the noticeable exceptions of the Russia, Brazil, and... the United States. The United States is an outlier amongst high-income countries, and sees significantly higher relative death rates from violence than practically any other high income country, China, or India.
4:29
Now let's look at relative death rates from 5 other causes, which are perceived to be among the leading killers in high-income countries: coronary artery disease, stroke, all cancer, lung cancer, and breast cancer. If we look at coronary heart disease, which is the number 1 cause of death here in the United States, it's readily apparent that relative death rates from coronary heart disease are, in comparison, substantially higher in most low-income countries and middle
4:55
income countries elsewhere in the world, than in the United States. Relative death rates from coronary heart disease are two and a half times higher in Africa, twice as high in India, and almost 3 times higher in Russia.
5:09
Relative death rates from stroke in low-income countries are substantially higher than in most high income countries. Middle-income BRICS countries, like China and Russia also experience dramatically higher relative death rates from stroke than most high-income and other middle-income countries. Relative death rates in low-income countries from all cancers combined are generally lower than in most high-income and middle income countries.
5:35
Some of the highest relative death rates from all cancers combined currently occur in China, Russia, and Eastern Europe. If we look at different types of cancers, a more heterogeneous picture emerges however. Take... Lung cancer. The lowest relative death rates from lung cancer are encountered in low-income countries in Africa and Central Asia, while the highest relative death rates in the world from lung cancer occur in the United States,
5:59
Europe, Russia and China. It's different story, however with... Breast cancer. With the exception of Russia, which sees some of the highest relative death rates from breast cancer in the world, relative death rates from breast cancer appear to be relatively heterogeneous, whether your lens in low-income countries or high income-countries. Looking at these statistics, we learn that, number one.... the spectrum of disease in low-income
6:23
counties is different than in high-income countries. Fetal & newborn conditions, infectious diseases, road accidents, and HIV/AIDS are - relatively speaking - among the leading causes of morbidity and mortality. And number two... the overall disease burden is higher across the board in low-income countries. While heart disease may kill 79 in 100K people in United States, where it's the top cause of death, heart disease kills two and a half times
6:52
more people per 100K in a country like Nigeria, where it's not even the top cause of death. Compared to low-income and high-income countries, we also see that the picture in middle-income countries may be complex. Wide disparities in personal income exist in middle-income countries like India... China... and Russia... ...which can contribute to a substantial bifurcation in health outcomes, where populations
7:20
with high personal income resemble populations in high-income countries from a public health perspective, while populations with low personal income resemble folks in low-income countries from a public health perspective. This can put middle-income countries in a tricky bind, where leaders need to address both critical issues like TB, malaria, high neonatal death rates and also things like cancer and COPD, all in the context of an often compromised health care market.
7:50
Now... let's talk about... the what the essential medical imaging requirements of most low-income countries are. We've learned that... 5 of the most pressing health care issues in low-income countries are TB, AIDS related lung infections, maternal-infant health, trauma, and breast cancer. While the complete medical imaging arsenal is composed of these 5 major imaging modalities... The WHO estimates that X-ray and Ultrasound alone can probably address 80 to 90% of diagnostic
8:24
situations in low-income countries, which probably isn't surprising when you consider that... X-rays are an important tool in the diagnosis of many traumatic injuries, TB, and lung infections in the setting of HIV/AIDS. And that ultrasound is an important tool in the diagnosis of fetal and neonatal problems, not to mention some breast and vascular issues too. Plus, ultrasound can be a very useful tool
8:51
for guiding procedures that need to be done to treat patients with some of these conditions. And that's only the tip of the iceberg when it comes to what you can do with the combination of x-ray and ultrasound imaging... Besides conditions directly associated with trauma, TB, and lung infections, chest x-rays can also help diagnose other conditions like pleural effusions, emphysema, asthma, occupational lung disease, and heart failure, in resource-constrained settings.
9:17
In the case of pneumothoraces, pleural effusions and hemothoraces, chest x-rays are also an important means of identifying immediate post-procedure complications. Besides conditions directly associated with trauma, bone x-rays can also help diagnose conditions like osteomyelitis and some dietary deficiencies that affect the bones, in resource-constrained settings. Besides conditions directly associated with obstetrics and with trauma,
9:43
ultrasound can also help diagnose common conditions like cholecystitis, hydronephrosis, and abdominal masses, in resource-constrained settings. In the chest, not only does ultrasound help diagnose conditions directly related to trauma, it's a versatile tool in diagnosing cardiovascular conditions too, like DVT, heart failure, cardiac valvular disease, and pericardial effusions... Not to mention some orthopedic and neurological conditions too.
10:11
Besides diagnosis, ultrasound can also be a valuable tool guiding many common medical procedures in resource-constrained settings, too. The essential medical imaging requirements of most low-income countries can be pretty modest. Access to modalities such as x-ray and ultrasound alone can be dramatic game changers. So let's talk about the physical capital involved in improving people's access to x-ray and ultrasound in low-income countries.
10:41
According to the WHO, 2/3 of the world's population have no access to basic medical imaging, which they define as x-ray and ultrasound... and this is a situation that hasn't changed meaningfully in decades. Even where x-ray or ultrasound are available, quality and safety to patient or to staff can often be questionable. Availability alone does not equate to access, and the WHO has in fact, formally defined access to medical imaging as medical imaging that fulfills...
11:13
6 criteria. Medical imaging must be... ...available... the x-ray or ultrasound equipment equipment needs to be physically purchased or acquired by facility and WORKING. Medical imaging must be... ...affordable... the x-ray or ultrasound imaging services need to be both cost-effective for the patient and the health-care facility providing it. Medical imaging must be... ...accessible...patients must be geographically
11:42
in reach of the x-ray or ultrasound machine. Medical imaging must be... ...appropriate... the x-ray or ultrasound equipment must be applied in scientifically valid applications, addresses local needs, and usable in affordable manner... meaning that plopping down a 3 Tesla MRI may not be appropriate! Medical imaging must be... ...acceptable... provided in a way that respects cultural beliefs and individual attitudes. Finally, medical imaging must be of...
12:13
...quality... safe & efficacious to the patient and safe to the staff providing it. Low-income countries may face many challenges in achieving the criteria, for example... Affordability. While the average cost of an x-ray or ultrasound exam is substantially less expensive than for advanced imaging studies... These costs can be a substantial hurdle if your average monthly income may be less than 86 US dollars, where national health care systems are often poorly funded,
12:44
and little or no health insurance exists. Accessibility can also be a significant problem in low-income countries. What imaging equipment that is available tends to be clustered in urban locations and where the wealthiest folks live... which leaves the majority of people underserved. For example, a person living in rural Nepal may need to travel 1-2 days and sacrifice 1 month's worth income just to get an
13:12
x-ray or ultrasound. Even if folks in low-income countries could afford the x-ray or ultrasound, they might not be able to afford to take the time off to travel for the study, which contributes to more delayed diagnoses, more costly treatment when they finally are diagnosed, and poorer outcomes. The maintenance of X-ray and ultrasound equipment maintenance is often also a problem in low-income countries. It's estimated that between 50 and 70% of x-ray equipment and at least 40% of
13:42
ultrasound equipment in low-income countries are not fully functional... and the cause is not necessarily poor maintenance either. Since much of this equipment may have been donated when end-of-life, if a part breaks, a replacement part may not be obtainable.
14:00
Infrastructure can be an obstacle in low-income countries. Not only are electrical grids sometimes unreliable, with wide voltage fluctuations that can damage electrical gear, the form of electricity some x-ray machines require may not always be available. X-ray machines are often built with modern hospitals in mind... and modern hospitals often run on 3-phase power, where 3 alternative currents are provided out of phase of each other,
14:29
unlike conventional residential AC current. Poor roads impair travel and service support may be limited. And even if the equipment is working perfectly, inadequate IT systems and network bandwidth can impair the use of whatever medical images are created. And then there's the matter of QC. In some low-income countries, national guidelines may not exist for medical imaging, and do constraints in resources - physical and human,
14:59
and in demands - SOPs and safety norms may be challenging to implement. Low-income countries also face an uphill battle when it comes to... Human capital. There's a major shortage of radiology technologists to take x-ray and ultrasound images, and of radiologists to interpret x-ray and ultrasound images. Technologist, medical school, and radiology residency programs are scarce, and many locations are unable to financially reimburse the few radiology technologists
15:34
and radiologists who are around. To put the shortage of radiologists into perspective... ...consider that while there's less than 1 radiologist serving every million people in Liberia, there's over 125 radiologists working at Massachusetts General Hospital in Boston alone. A shortage of radiologists exists in many middle-income countries as well. While radiologists are less scarce than in low-income countries...
16:01
...radiologists in middle-income countries are often in such high demand that they can often choose positions that favor the interpretation of more profitable of CT and MRI studies instead of bread and butter modalities like x-ray and ultrasound. In addition, in India, the availability of ultrasound imaging has been further constricted by the Pre-Conception and Pre-Natal Diagnostic Techniques Act, which has had the unintended consequence
16:27
of creating significant bureaucratic barriers to ultrasound use unrelated to prenatal diagnostics. These sort of market & regulatory headwinds have exacerbated the shortage of radiologists interpreting x-ray and ultrasound in middle-income countries.
16:47
So... ...how can we overcome some of the obstacles standing in the way of medical imaging access in most low-income and many middle-income countries? In a perfect world, enacting new government policies, modifying the distribution of public spending, training more medical professionals, and making big investments in infrastructure could work. Experience and history tell us, however, that accomplishing meaningful change within a
17:15
reasonable timetable would be extraordinarily difficult with these sort of strategies. So folks have been looking at more feasible strategies. Many of these strategies aim to... grow the physical capital required for medical imaging and to expand the capacity and capability for interpreting medical imaging. Expanding humanitarian efforts are a start. That can mean physical capital like donated radiology equipment or human capital like volunteer radiologists. We've seen a move
17:49
in this direction in some American radiology residencies, like at Penn for example, where radiology residents participate in increasingly formalized rotations overseas. Non-profit humanitarian efforts are a good start, but larger and longer-term strategies are also needed... ...such as more aggressively training local medical imaging entrepreneurs. Investments in business leadership and administrative training can help
18:16
create local imaging entrepreneurs who are more likely to succeed, mitigate risks, lower costs, stay in business, and improve health outcomes in low-income countries. This goes hand in hand with helping low-income countries secure better access to capital and financing for medical imaging and... ...incentivizing vendors to develop x-ray and ultrasound hardware that's designed for low-income countries from the get go... starting from engineering decisions like
18:47
housing complex circuitry elements in casing more resistant to water and physical damage, to building machines that function with simple maintenance, and with straightforward troubleshooting manuals usable by non-technicians. With ultrasound machines, systems that have the power requirements of a laptop - particular ones that can be easily charged and work off a battery - work much better than conventional ultrasound systems. A new emerging class of
19:16
ultrasound devices powered by smartphones, such as solutions from Butterfly, may be a game changer. Strategies for expanding the capacity and capability to interpret medical imaging may start with leaning on academic radiology programs in the United States to provide more resources to existing radiologists in low-income countries, by providing more opportunities for a few months of training stateside,
19:42
to providing on-site direct instruction, to expanding sponsorships to academic conferences. Continuing to expand the pool of non-radiologists trained to do and interpret bread-and-butter medical imaging can partly make up for the critical shortage of radiologists in low-income countries. Towards this end, the WHO has established ultrasound training recommendations for general practitioners and for midwives. WHO ultrasound training recommendations
20:12
for non-radiologist MDs is currently 300-500 ultrasound exams tailored to local disease patterns, while for midwives, is currently 250 abdominal ultrasounds, 50 pelvic ultrasounds, 50 first trimester ultrasounds, and 200 second/third trimester ultrasound exams. Digital imaging and teleradiology can also help, by decentralizing the interpretation of medical imaging studies. If the IT infrastructure hurdles can be tackled, digital imaging and teleradiology
20:46
can leverage the economies of scale, broaden access to experience radiologist interpretations, and enable effective QA and QC - but the bandwidth requirements will be substantial. Finally, don't underestimate the potential of technologies like artificial intelligence, smartphones, and social networking to entirely transform how medical imaging interpretation may be handled in low-income countries in the future.
21:19
So that's an overview of where things stand with medical Imaging & Radiology in Low-Income Countries, and we'll close with... these 6 take home points.
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