Radiology in an international perspective

The ready availability of radiographical services is accepted as a normal part of life by those living in industrialized countries where the average member of the population undergoes 0.3-1.0 radiological studies per annum.

In such countries the most sophisticated imaging systems are available and there is one piece of radiological equipment per 1,500-10,000 of the population, one radiologist per 10,000-30,000 and one radiographer per 2,000-5,000.

Globally, however, radiology is a luxury. More than three-quarters of the world's population lives in circumstances in which the possibility of receiving even the most elementary radiological services is exceedingly remote. In developing countries this may mean that there is only one item of x-ray apparatus per 50,000-1,000,000 of the population, one radiologist per 100,000-2,000,000 and one radiographer per 50,000-200,000; the number of radiological studies under these circumstances may be less than 0.01-0.1 annually per inhabitant. These statistics underline the problem of health care in these countries and mean that the scope of delivering satisfactory radiological services is severely limited, particularly as standards of both equipment and radiology often leave much to be desired.

In industrialized countries specialized studies, including fluoroscopic and contrast medium studies, account for 20-30 % of all examinations (and this proportion is increasing), whereas they represent only 5-10 % of the total number of studies in developing countries. The distribution of radiological equipment in the latter is also different: in industrialized countries basic services are widespread and readily accessible, but in developing countries the available radiological equipment and knowledge is often confined to a few large centres.

Radiological performance in the developing countries is often hampered by the poor condition of equipment. Even basic radiological equipment is usually designed on the assumption that it will be used in a well organized system where technical maintenance is of a high standard and readily available. When such equipment is installed in a technically less advanced milieu a protracted break-down of activities usually ensues. The lack of maintenance personnel may result in the non-utilization of equipment that has been purchased at high cost with precious "hard" currency. These problems are exacerbated by other adverse factors such as extremes of climate, lack of clean water and interruptions in electricity supplies. In these conditions radiological services which, in theory, may have been well planned and structured, never practice in function, and the anticipated benefits of newly acquired technology remain unrealized.

Analysis of cost and benefit is an important process in industrial countries, and may show cost savings in health care by stimulating the acquisition and rational utilization of high technology modalities such as computed tomography and magnetic resonance imaging. For 75 % of the world's population, however, the problems are on a completely different plane - for instance, how to get a plain radiograph of the lungs or bones. In order to remedy this problem the World Health Organization (WHO) created the so-called Basic Radiological System (BRS), which has now evolved into the WHO Imaging Systems (WHIS). This is described in chapter 5.

A similar basic ultrasound unit is now also part of the WHIS. The use of ultrasonography seems certain to increase, because of the intrinsic advantages of the modality and the price and durability of the equipment.

Radiological activity is based on radiological education which concerns both radiologists and radiographers and is unfortunately also beset with problems despite its importance. The models for teaching have usually evolved in industrialized countries, which means that their organization and balance may be unsuitable for non-industrialized countries and imported experts and visiting teachers may have problems in adjusting to local circumstances and requirements. In expert groups, e.g. in the WHO, the prevailing opinion has been that teaching systems would be developed in their own surroundings giving due consideration to the prevailing realities in order to respond to the local needs. The level of radiology undertaken is to a large extent determined by its customers, i.e. the referring doctors and it is to these, as well as radiologists, that teaching programmes should be directed - a philosophy incidentally, that could be applied with benefit in every country.

The organization of teaching and education in radiology is a matter of concern to several international organizations. The European Association of Radiology, EAR, strives to coordinate education in Europe and similar efforts are made by the Radiological Society of North America (RSNA), The Interamerican College of Radiology, and the Asian Oceanian Society of Radiology (AOSR) in their respective areas of the world. The International Society of Radiology, ISR, being a global, non-governmental organization, aims at the global promotion of radiological education. This is done by arranging and accrediting courses and teaching programmes and by arranging the International Congress of Radiology. The ISR also sponsors teaching centres. There are several other first-class teaching programmes in various parts of the world.

Radiology is an expensive and capital-intensive modality and the radiological activity of any country is determined by that nation's economic resources. Significant differences in the availability of radiological services across the globe seem likely therefore, unfortunately, to remain for the foreseeable future.

Carl-Gustaf Standertskjöld-Nordenstam