Fueled by Frustration in Africa

Mindy Licurse, MD

I will confess my venture into global health first began as a college student with the selfish hope to fulfill a childhood dream to go to Africa, with an idealistic naivety that I was about to change the world with a single visit.  I packed my bags full of limited medical supplies, lightweight clothes that could be rolled up to save room, plenty of bug spray, and hopped on the plane for a three week trip to Tanzania.  Before I left, I remember a friend distinctly saying, “That will be an eye-opening experience.”  I smiled and agreed, feeling a warm rush of pride that is unique to self-promoted altruism when you have no idea what true altruism actually is.

Here is how it actually went. We visited three rural villages including Bumbuli, Rombo, and Faraja.  I got accustomed to not having hot water (or light when I showered), using Band-Aids to fix up the holes in mosquito nets, and the casual slang including “Mambo” (“What’s up?”) in Swahili.  We spent the first part of every visit walking miles around the villages, evaluating and triaging local residents.  This included seeking out patients with acute or chronic illnesses as well as evaluating their housing situations and sanitation.  Days later, we would set up a clinic in the center of the village.  Patients would come to us, most of whom we had seen during our triage visits, from the very young to the eldest.  With the coordinated help of local translators and local doctors, we would perform general physicals, draw blood for malaria tests, and hand out the limited medical supplies we had including short-term anti-malarials.

What did I learn during this? When we had no electricity one day and relied upon the sun to look through microscopes for malaria in the blood of our patients, I learned that having technology means nothing when you do not have electricity or infrastructure to uphold it.  When a child had a dental problem but lacked the five dollars to get to the city for proper treatment, I learned that I had just started to peel away the first layer of complexity involved in global poverty and underserved health access.

My eyes were opened.  I was seeing red.  Frustration at the inequity and lack of resources made my blood boil.  However, retrospective reflection has brought me to understand that having frustration is a good motivator.  It is that frustration that led me to medicine and what continues to light a fire beneath me in an effort to unravel and solve these problems.  This is why I will continue to travel, to seek what is unfamiliar, difficult, and learn a thing or two. As Henry Miller says, “One’s destination is never a place, but a new way of seeing things.”  Hopefully, when we put our heads to rest in our comfortable beds and take our heated showers, we will not forget where we have been.

Resident Rotation at Princess Marina Hospital in Gaborone, Botswana

Amana Akhtar, MD

The Hospital of the University of Pennsylvania radiology residency program offers a six-week rotation through Princess Marina Hospital in Gaborone, Botswana.  I was fortunate enough to participate in this elective from January-February 2014.  The following is a short summary of my experience.

A little background:  The Botswana-UPENN Partnership was established in 2001, with the goal of preventing and treating HIV/AIDS related complications.  BUP hires medical staff physicians for Princess Marina Hospital (PMH) and outlying village clinics; these physicians work in complement with PMH hired physicians. Penn residents from different disciplines are chosen to rotate through for up to 8 weeks.

I arrived in January 2014 after flying from New York City to Johannesburg, and then on to Gaborone, the capital of Botswana.  My flatmates included medical students, dermatology and internal medicine residents.  We stayed in flats rented by the university. In order to practice medicine in Botswana, we had to apply and undergo a vetting process, after which we were issued temporary medical licenses.

PMH is an open air ward, designed to mitigate the spread of TB. Every day at 7 am, we would walk to the PMH to attend morning rounds.  The call teams from overnight would present two admissions. As part of the diagnostics component of the presentation, I would assist in reviewing the plain films or CT images printed on film on the light box.

For the first few days during my time at PMH, I attended medicine walk rounds with my Penn internal medicine flatmates. I was able to review films at the bedside with the team.  After walk rounds, I would head to the radiology suite, at which time I would review film, CT scans (PMH has a 16 slice CT scanner), ultrasounds and basic fluoroscopic examinations.

After reviewing my findings with my attending, I would generate a handwritten report, to be typed by the transcriptionist. The reports would return to me for editing and re-review.  Additionally, medicine and surgical house staff would filter in and out of the radiology suite, requesting review of images and discussion of differentials. In this era of PACS, visitors to the radiology department in the US are rare.  However, in Gaborone, house staff routinely requested radiology consults.

The pathology at Princess Marina was fascinating.  Florid imaging manifestations of tuberculosis and HIV sequelae were topics I had only come across in textbooks.  I will also never forget a case we had of a 23 year-old woman with multifocal cannonball pulmonary metastases and brain metastases of unknown primary. Biopsy was not readily available. An astute physician recommended obtaining beta-HCG: 60,000. The patient passed shortly thereafter from choriocarcinoma.

As a women’s imager, I was interested in their utilization of mammography, but unfortunately the unit was not functioning during my time there.  However, I was able to perform breast ultrasound. At Princess Marina, the technologists issue a written read, rather than the physicians. Dr Sesay, my attending radiologist, originally from Sierra Leone, trained in Nigeria and South Africa.

Outside of work, my flatmates and I were able to explore Capetown, South Africa; Victoria Falls in Zimbabwe; and Kasane safari in northern Botswana. Off the coast of South Africa, we visited Robbin Island, where Nelson Mandela was imprisoned for 18 years.

All in all, I had an incredible experience. The people of Botswana were kind and generous. The support staff in radiology, from the technologists to the transcriptionists, was amazing. The warmth and kindness in the hearts of the people I met--I won’t ever forget that feeling.

Our Common Language

Mary Huff, MD

Dr. Huff (far right) with staff in the mammography dept at Pontificia Universidad Católica de Chile

I was fortunate enough to receive the Goldberg-Reeder Resident Travel Grant in 2012 where I studied the barriers and facilitators for mammography screening compliance in Chilean women alongside the Departments of Family Medicine and Radiology at the esteemed Pontificia Universidad de Chile in Santiago, Chile.  The radiology program director was kind enough to allow me to rotate through the department with his radiology residents to gain a better understanding of the practice of radiology in Chile.  I learned more than I ever anticipated.  I am including here an excerpt from my journal from my first day in the department.  I hope other international travellers can relate to my experience.

My main mission the first day was survival. I had an appointment with my supervisor at 09:00 at the university hospital, and I didn't want to be late. My first tasks of the day including riding the metro, finding the hospital and navigating to the office were remarkably easy. In fact I arrived about 30 minutes early. At the entrance to the office was a call box. This was my first anticipated challenge. I had been rehearsing how to introduce myself and ask to speak with my supervisor in Spanish. I must have sounded legitimate because the secretary let me in right away and started talking to me at full speed in Español. I almost immediately went into system overload. All of the words blended together into an incomprehensible song punctuated by a silence anticipating my response, “te entiendo” (do you understand)?

Uuuh, uuh...no.

Habla Español?

Solo un poquito.

She spoke again, slower, and I again did not understand. She just smiled at me and gave me a big hug. Then she said something else that an onlooker in the hall translated for me, "Wait."

Soon one of the residents came to give me a tour of the hospital and the department. She was very kind and spoke perfect English—to my delight. She introduced me to all of the residents in various stations throughout the department. That went well because all I had to say was, "Hola!" However then came the scariest part: she had to leave to go to work. I was on my own.

I quickly learned to follow the advice of my father, "Better to remain silent and be thought a fool than to open your mouth and remove all doubt."

I sat down at the reading station and began to listen to the conversations surrounding me and to observe the images on the monitor. Finally some common ground! CAT scans (called TAC here) look the same in Chile as the do in the United States. Moreover the medical vocabulary is very similar. For example:

pancreas = páncreas
lungs = pulmones
hypoattenuation = hipoatenuación
scattered diverticulosis = diverticulosis dispersos
adenopathy = adenopatía

Surprisingly, the laborious task of learning an entirely new vocabulary in medical school was useful. It was a common language. I found a safe haven surrounded by diagnostic imaging and medical jargon. Finally a foreign language that I could understand! It was quite a revelation for me.

The remainder of the day I listened intently to conversations. Despite the fact that the medical terminology was similar, the sentence construction was scrambled and there were many intervening words that I did not understand. Still, by the end of the exhausting day I was proud of myself for the ability to point to the images and recognize diagnoses:

Apendicitis!

Quiste renal Bosniak dos!

Lemierres!

Identifying the ‘Imaging Gap’ in Global Health

Supriya Gupta MD and LaDawn Hackett MD

Taken from http://www.huffingtonpost.com/2013/08/29/most-efficient-healthcare_n_3825477.html , Accessed on 10/21/2014

Radiology has the potential to contribute an important component to evidence-based medicine in United States (US). It is intriguing to know the way medicine is practiced in other parts of the world, especially in resource-restrained countries. Do they rely more on radiographs and ultrasound, or do they depend mostly on the disease endemicity, medical history and physical examination? Empirical literature is available on health care gap across the world, but the literature is severely limited when it comes to imaging resources, their availability and utilization. This raises the need to identify this gap in radiology healthcare and literature to help us build a strong foundation on which we can judiciously and effectively allocate resources for global health.

In most areas of the US, the ability of a primary care physician to utilize any imaging modality instantaneously to diagnose disease or to generate a differential diagnosis is taken for granted. In resource-restrained countries, the problem is multifaceted.  The disease burden is heavy and diverse. Additionally, populations in these countries typically have little income and no health insurance.  Due to the absence of medical screening, patients usually present late in the disease cycle. The absence of resources only contributes to the challenges a physician may face. Emergency physicians themselves usually lack proper facilities, supplies and equipment to effectively manage trauma and treat disease.  This is compounded with the shortage of imaging equipment, trained staff, equipment maintenance, and quality and safety standards.  Radiological imaging is an essential component in the management of trauma, obstetrical and gynecological issues, HIV/AIDS, tuberculosis and cancer, just to name a few. 

In resource-restrained settings, patients presenting with right lower quadrant pain maybe denied a basic computed tomography (CT) scan or even an ultrasound due to absence of imaging resources. This may be further accentuated by the absence of trained radiologists in settings where the resources maybe available. Moreover, even if there is a radiologist available, he or she may not be equipped with sub-specialty knowledge. It becomes an essential first step in outreach efforts to understand the current health care system including the distribution of imaging resources, presence of radiologists per population segment and the availability of sub-specialty radiology services. While we are struggling with the question of imaging utilization in developed countries, the gap is enormous compared to other countries where the imaging resources are not even listed.    

Another problem resource restrained countries are currently facing is inequitable resource distribution within the health care system. This difference is not just in equipment but is also seen in terms of training. Not only must the radiological equipment be accessible and maintained, but also trained staff and skilled physicians must operate and utilize the equipment.   There are usually central or capital cities that are diversified with multiple resources including sub-specialty radiology services. Conversely, more remote locations have a significantly different set of resources and quality of care.

With this overwhelmingly obvious ‘Imaging Gap’ across the globe, what can be done?  Utilization of ultrasound is promising, as this equipment has no ionizing radiation, is portable, and provides real-time images that can instantly aid in diagnosis.  Who will interpret the studies generated?  Should the primary care physician be required to gain knowledge in image interpretation during their training?  This model is plausible as emergency medicine residents learn how to perform the focused assessment sonogram for trauma.  However, what about the complicated study?  Is teleradiology a possibility?  Would US radiologists volunteer services to assist colleagues in diagnosing disease overseas?  These learning opportunities would be extremely valuable for radiology residents to gain exposure to pathology abroad and generate a sense of global community that may foster increasing support for global imaging initiatives.  Significantly, there is also the critical question of sustaining the equipment, training and payment of radiology services over time. 

Gauging the wide gap in availability of imaging services on one end and dealing with appropriate imaging utilization on the other end helps us realize the efforts which need to be undertaken. Several efforts have been made by American College of Radiology and other organizations in radiology as first steps. However, such efforts need to be supported on a larger scale to mitigate the current existing gap. 

Challenges & Lessons Learned - Mike Dominello, MD

Dr. Dominello at Zomba Central Hospital in Malawi

This year, I had the opportunity to travel to two African nations, Malawi and Tanzania. While in Zomba, Malawi this past November, Dignitas International, and staff working at the Zomba Central Hospital kindly welcomed me to their facilities where I was invited to lecture on cervical cancer and participate in their clinic. With annual global incidence of cervical cancer over 500,000 and greater than 80% of these cases reported in developing nations, cervical cancer is a major cause of cancer-related morbidity and mortality in Sub-Saharan Africa. Lecturing at both Dignitas International's main office and Zomba Cental Hospital, I had a chance to interact with the clinical and office staff including physicians, nurses, medical officers, and researchers. Finally, I had the opportunity to work in the Zomba Central Hospital Kaposi Sarcoma Clinic which offered a unique snapshot of the type of oncology care available in Malawi.

Halfway up Mt. Kilimanjaro! #yesthereisafilter

In the Spring, I returned to Africa to present research at the Greater Horn Oncology Symposium (GHOS) held in Moshi, Tanzania. The conference was sponsored by Radiating Hope, a nonprofit organization that works to provide resources to improve oncology care and access to oncology care in developing nations. A Kilimanjaro climb and Safari were organized by Radiating Hope to raise money for a new cancer center in Moshi. The symposium had a strong radiology and radiation oncology focus and included sessions by notable leaders in international radiology and radiation oncology including Helmut Diefenthal and Mack Roach. While in Tanzania, I was fortunate enough to climb Mount Kilimanjaro…a life-changing experience. The next GHOS will take place Spring 2016.

Dr. Dominello and Mira Shah, PGY5 in Radiation Oncology at Henry Ford Hospital at the GHOS

Challenge: Both in Malawi and for a connecting flight in Nairobi, the airline had no record of my ticket and I was initially told I did not have a seat on these flights. With visits to the actual provider “office,” they were able to rebook my reservation and print my ticket, though they required the confirmation email, which I had luckily printed out and brought along.

Lessons learned: Arrive at the airport with plenty of extra time as neither visit to the provider office resulted in quick resolution; thankfully I did not miss my flights. Also be sure to have a printed your itinerary and receipt as proof of purchase.

Barranco Wall

Challenge: Kili

Lessons learned: Despite what one might read online, this is a difficult climb, not technically difficult but grueling, especially once you find that oxygen has become a commodity. I did take acetazolamide to help with acclimatization and made it to the top successfully. Finally, bring waterproof gear!

Uhuru “Freedom” Peak, the summit of Mt. Kilimanjaro

Welcome to the new ACR Foundation RFS International Outreach Subcommittee Blog   This blog is provided to facilitate discussion on issues involving radiology outreach in developing countries.  Residents have played a significant role in radiology outreach.  Through their involvement with the Goldberg-Reeder Travel Grant program, and their participation with NGOs like RAD-AID International and Imaging the World, radiology residents continue to provide both direct service as well as solve problems to facilitate sustainable radiology services to areas of the world currently lacking that access.  We hope you will fully participate in this forum.  Ask questions, add experiences, respond to inquiries and develop program initiatives and ideas to share.  We thank you for both your interest and ideas.  Rebecca Gerber, M.D. ACR RFS International Outreach Subcommittee