Ohio State University 2010

Radiography, Nepal Pokhara

Whilst researching global health and the quality imaging services available to those living in the developing world, it didn't take long for Jonathan to discover that two-thirds of the world’s population (approximately 4 billion people), have limited to no access to even the most basic of imaging exams. In order to learn more about this and aid in the issue of correcting it, Jonathan realised he would have to get some first hand experience.

As a radiologic technologist with over six years experience within the radiology profession, I have always enjoyed the comfort of job security. According to the World Health Organisation, approximately 60% of the reasons that a patient seeks medical attention subsequently require some form of medical imaging in order to obtain a diagnosis for their ailment. Whether an ultrasound, CT/MR scan, or radiotherapy treatment is needed, there is an equal need for a medical professional who is trained in the art of medical imaging. Furthermore, more often than not, we RT's are provided with state of the art equipment that enables us to produce high quality images with relative ease. Perhaps the above statistic is also the reason why most of us living in the industrialised world can drive just about any direction for a handful of miles and be certain that we will have access to these necessary health-related services...

It was this line of thinking that led me to question whether the abundant access to quality imaging services was a typical occurrence for the global community, or perhaps, and more likely the case, a unique perk to those of us living within the industrialised world. Well it didn't take too much searching to find another statistic credited to the WHO indicating that two-thirds of the world's population (approximately 4 billion people), have limited to no access to even the most basic of imaging exams. Although I was not entirely surprised by this finding, I could not help but wonder how it was that such a drastic global imaging gap could exist? Were there any non-profit organisations working towards correcting this massive imbalance? And on a more personal level, how could I learn more about this issue and aid in correcting it?

After contacting a few organisations (RAD-AID, WHITIA, Imaging the World) I was able to get a better sense of the hurdles that were associated with bringing radiology services to medically underserved communities. I learned of issues related to focused need, facility infrastructure, project funding, personnel training, governmental stability, etc, etc, etc. In fact, the more I learned about what was needed to develop a self-sustainable medical imaging program, the more amazed I was at the advanced health care network that had been developed within the industrialised world.

More importantly, I made two important realisations... First, if I truly wanted to help, I had to do my part to raise awareness of the access to imaging issue by colleagues and peers on a local level. Just as I had taken for granted the ease in which I could have an injured hand or a prolonged cough assessed with the aid of medical imaging, the case was no different for the other RT's I worked with on a daily basis.

Secondly, if my goal was to recruit others to spread the word, I was going to need to need more than two WHO stats of interest to share. I was going to need some firsthand experience observing routine radiology exams within a medically underserved community and personal stories/photographs to help put the problem into perspective.

Needless to say, fiscally conservative non-profits were unable to offer such an experience, saving their limited resources to make a larger impact than I could as an individual. This is when I turned to Work the World to help me coordinate my radiology experience abroad.

In only a month of initial contact with the company, I found myself starting a 7,650 mile trip to the Asian country of Nepal. Literally traveling to the other side of the world, it took three flights and a 7 hour taxi ride to complete my 38 hour trip to the city of Pokhara. Fortunately, a company liaison on-site guided me every step of the way, providing travel advice, connecting me with a hospital-based radiology department, as well as hosting me, along with other visiting medical professionals, in a community-style residence for the entirety of my two week visit.

Immediately upon arriving to the hospital in which I was assigned I could see the stark differences between the radiology work environment in which I was accustomed and the Nepali imaging department I was observing in. Placed in a privately run medical complex that was considered to be the best of the three hospitals that served the region surrounding Pokhara, a city of over 200,000 people, I was made aware that the government run facilities offered even fewer imaging services. The MR system consisted of a 0.35 Tesla magnet and was one of only two in the entire region

Although pleased to see that the hospital managed to offer magnetic resonance imaging, computed tomography, ultrasound and radiotherapy services, I soon realised that the equipment being used was far from anything I would expect to see back-home in the states. Especially considering that the hospital was a primary healthcare resource for a large region of the country. The MR system consisted of a 0.35 Tesla magnet and was one of only two in the entire region. The CT scanner was a single-slice model and did not have an automated power injector for contrast bolus studies. Although their single ultrasound unit was in good working order, the room with fluoroscopic capabilities was out of order, requiring esophogram exams to be performed using a blinded "swallow and shoot" method. Lastly, the linear accelerator used for radiation therapy treatments was run by a single therapist, and needed necessary, though costly advanced calibration tools to ensure greater treatment accuracy.  

Equipment limitations aside, I also had a chance to experience several other challenges that I was warned was to be expected when practicing radiology in a developing nation. "Load shedding", or sharing of electricity, was a routine occurrence in which there wasn't enough power for the entire country so energy had to be distributed regionally on what seemed to be a random basis. Hospitals were left to rely on generators for as many as 14 hours a day, consequently forcing the medical facilities to conserve their energy usage with dimly lit hallways, an absence of air conditioning, and further parsing of energy to departments with the greatest need. I was even told that radiology departments in the public medical facilities would be forced to temporarily discontinue specific exams so that in-patients' heart monitors or ventilating devices could remain powered.

Further complicating matters is the lack of local technical support for radiology departments in the developing world. In the industrialised West, when an imaging system goes down, the RT on duty typically contacts the local service engineer. We are accustomed to a service professional being on site the next day, often with part in hand; this is not the case for the few radiology departments scattered throughout Nepal.

For this reason, equipment maintenance is a key responsibility of Nepali radiologic technologists. For example, there is a constant concern for limiting tube loads to ensure an extended lifespan for the x-ray generating devices. Any equipment malfunction might lead to weeks of department downtime, and a further delay in much needed medical imaging services. On a personal level, it was humbling to see the level of respect and careful handling that technologists exhibited for equipment that holds a relatively low market value in the West.

Besides the differences in equipment and work environment, I also saw different types of cases than those that I am used to. These differences may be partially attributed to the inefficiencies of a relatively unstable government as well as the native culture of the local people.

First, approximately half of the patients that were sent to the radiology department had histories of traumatic injury, most often from motor vehicle accidents. With no apparent enforcement of traffic laws, the streets of Pokhara were packed with cars, scooters, bicycles, feral dogs and free roaming cows that made transportation a leading cause of hospital visits.

Secondly, of those seen for reasons other than trauma, it was rare that imaging did not present some form of gross pathology, indicating chronic conditions that had long gone undiagnosed. For a combination of reasons, including the default to home-based remedies for acute onset of symptoms, living in villages hours away from the closest hospital and a simple lack of financial means to pay for  medical costs, the patients that did finally show up for medical care were almost always too sick to be treated.

Overall, my radiology experience in Nepal provided me with the experience that I needed, and quite a bit more than I expected. Perhaps the most motivating aspect, however, was when I learned of efforts taken by a Nepali radiologist who brought an ultrasound machine to the outlying villages surrounding Pokhara in an attempt to encourage early disease detection. It was clear that without adequate funding, his good intentions were relatively futile in the grander scheme of things. However, perhaps if like-minded radiology professionals on a global level were to combine their efforts with a little guidance from established international non-profit organisations, I am confident that we could work together to produce a sustainable and meaningful answer to the global imaging gap.

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