The History and Advancements of Radiography in Different Countries

Wilhelm Conrad Roentgen, a professor from Germany, is credited with being the original founder of radiography in 1895. He stumbled upon this observation while experimenting with a cathode-ray tube. Through his experimentation, he observed crystals that gave off a fluorescent glow near the tube he was using, and from this, he was able to discover a ray that had the capability of passing through a heavy sheet of paper, creating a fluorescent green light. (History of Radiography, 2001)

Roentgen was able to conclude from his observation that this was actually a new type of ray being emitted and found that this ray could also be passed through numerous substances and would then create shadows off of solid objects. Through further experimentation, he discovered that even though the ray could not pass through bones or metal objects, it could in fact pass through human tissue. This experiment was actually tested on his wife, when an x-ray image was produced of her left hand as she wore her wedding ring.

The discovery gained a lot of interest from other scientists as well. Even though he was the first to discover this, the experiment was very easy to replicate because the cathode tube he used was common during his time period. Many scientists left their own discoveries to embark on this new, extraordinary one brought to life by Roentgen. Only six months after Roentgen first announced his discovery, medical radiographs were being made by physicians on the battlefields in Europe as a new way to locate bullets in wounded soldiers. (A History of Radiography, 2009)

During this time period, there was no way of knowing or testing the risks of radiation on human participants. Because they did not know that there could be risks involved, some people often thought x-rays could be beneficial for the body. Eventually, x-rays did in fact lead to serious injuries, but the symptoms were much delayed, so it was hard to tell for certain. Some experiments did in fact tie x-ray exposure and skin burns together. Today, with thorough experimentation, it is proven that radiation is among the most common causes of disease and damages the molecular, cellular, and organ systems if the correct dosage is not used.

Radiographic Capabilities in Developing Countries

Unfortunately, in today’s world, less than two-thirds of providers lack access and capabilities to perform basic x-ray procedures. Due to these circumstances, around 60 percent of medical anomalies are overlooked because they cannot be accurately diagnosed. A non-profit agency known as Healthgreen began to bring crucial screening and diagnosing capabilities to a hospital in Rio Hondo, Guatemala. Previously, the hospital was relying on film radiography, which lacked functionality due to a lack of digital capabilities. The financial burdens of film and the lack of ways to transfer films to experienced doctors also caused a roadblock for the hospital.

Seeing the hospital struggle, Healthgreen decided there was something they could do. They installed a computed radiography system that was fully functional, which was a huge step for medicine in this country. A group of doctors arrived to ensure patients throughout the country could finally receive the necessary medical care. According to Remis (2012), "Without a functioning X-ray system, the mission would not have been possible. These children could not walk, attend school, or leave their homes prior to treatment. With the computed radiography system, 440 X-rays were taken, and 28 of the more complex cases underwent surgery." Because of this new system, the hospital continues to impact affected patients and performs at least 60 to 70 x-rays a day, deeming it a huge success. (Remis, 2012)

History of Radiology in China

Radiology in China is continuing to advance, which plays an extremely prominent role in the medical field. Because of these accomplishments, the country is one of the most advanced in care and treatment in this field. In 1911, a clinic in Hebei Province run by Kailuan Hospital used the first x-ray machine that was imported by a missionary hospital. Many well-known radiologists contributed to the successes that led to the continuous development of Chinese radiology, including Zhi-Guanf Xie (C.K. Hsiech). Professor Xie, through all of his studies under an American radiologist named Paul C. Hodges, became the pioneer of Chinese radiologists. He was also named chairman of the department at PUMC Hospital, from which he graduated in 1923. On top of all these prestigious achievements, he also obtained membership in the American College of Radiology, making him the first Chinese doctor to hold this title. After collecting all of these accomplishments under his belt, he returned to Guangdong Province, which was his hometown.

For obvious reasons, there are varying differences in x-ray equipment throughout the urban and rural areas of China. These reasons simply mean that the rich, urban areas have a larger surplus of equipment than the rural, more poor areas of the country. As stated by Baishideng Publishing Group (2000), "general, large hospitals such as university hospitals, teaching hospitals, and provincial hospitals have all been equipped with DS A, CT, MRI, ECT, color Doppler US, etc., and some of them are state-of-the-art (e.g., spiral/helical CT, ultra-fast CT, PET, and super magnetic strength MRI)". This is not to say that the medium-sized hospitals lack these capabilities, because they are also equipped with CT, MRI, ECT, and DSA, just not to the extent of the larger hospitals.

Now, the city and county hospitals lack these exquisite capabilities and are limited to conventional x-ray machines and ultrasounds. According to the statistics given by Baishideng Publishing Group (2000), "there were approximately 100 thousand X-ray machines of all kinds, 3 thousand CTs, 3 hundred MRIs, and 2 thousand Doppler US machines by the end of 1997 in China". In China, ultrasound and nuclear medicine are self-reliant and not included in the department of radiology. This is because ultrasonographers are educated much differently than radiologists. The radiologists in China have made tremendous strides within their country's hospitals and have obtained prestige research in CT and MRI. (Group, 2000)

X-ray capabilities in Africa

Compared to China, the resources in Africa are limited. The population in Africa is estimated to be around 190 million citizens, and there are only 60 known radiologists to work within the country. In Nigeria, the city itself only has CT, MRI, and point-of-care ultrasound, which is said to be their primary modality for imaging. There is one functioning CT machine per one of the large cities, and access to MRI is even more scarce. As a result, MRI scans are more expensive and are typically used only as a last resort or by those with a higher income. In Africa, surgeries actually cost less than x-ray scans, so exploratory surgeries are performed rather than a scan of the affected part of the body.

Very few citizens in the country have a means of insurance, so they are required to pay out of pocket for any type of scan. With a monthly average income of only 50 dollars, most people do not receive proper treatment, all because they cannot afford the costs. With this being said, many people are left undiagnosed and eventually die because they had an underlying disease that could not be diagnosed unless the scans had taken place. Also, most people do not live close enough to the hospitals in rural areas, and it would take them days to travel to a hospital to be seen. On top of all else, the radiologists are only making average monthly salaries of around 2,000 dollars, making it very difficult for the field to thrive due to such a low income payout. (Fornell, 2017)

Haiti

In 2006, a native of Haiti decided it was his chance to make a difference. He traveled to America to learn more about the field of radiology in hopes of bringing it to life in his country. Dieuseul Saint-Ange contributed greatly to the success of his country by aiding in the opening of the University Hospital in Mirebalais in March of 2013. The University Hospital is the first place in the country to own a CT scanner. This hospital now has the ability to store their x-rays, CT scans, and ultrasounds on a PACS system, which enables them to send the images to reading radiologists anywhere in the world.

Most hospitals have already had PACS implemented, but for something like this to be possible in such a poor, rural area is groundbreaking and a huge step for the future of medical care in Haiti. This is very beneficial for the doctors due to the fact that there are no radiologists in the country. Because of the lack of radiologists, the hospital relies on American volunteers from the Mayo Clinic, Massachusetts General Hospital, and the University of California to interpret the images and create a report for the doctors in Haiti. The ability to perform x-rays has saved many people who may have experienced trauma, chest pain, or even a change in their mental status and who would have probably died if it had not been for the ability to catch it so soon. (Avila, 2015)

Germany

In Germany, two separate systems were created for medical imaging reimbursement. Because of this, the medical imaging market has been moving at a much slower pace, which is deteriorating the investment in medical imaging equipment. CT and MRI are currently the preferred modalities across clinics in Germany. Angiography has also become a dominant modality within the country. Within the past couple of years, there has been a tremendous decline in the need for x-ray equipment due to the beneficial tendencies that interventional radiography brings (this includes angiography). The majority of the decline has been due to the use of the equipment by "non-radiologist users". In Germany, anyone who has the necessary knowledge on how to operate the medical imaging equipment may be authorized to do so. Often times, this can include work from cardiologists and orthopedic surgeons, which diminishes the need for x-ray technicians.

Older equipment within the country is slowly being replaced with CR and DR systems, enabling it to stay current with technology. With the enhancements in technology, as stated by Doctor Bursig (2006), "Germany is in the process of establishing a national mammography screening program. The requirements for this program may lead to the replacement of a certain number of existing pieces of equipment." Also throughout the many advancements, ultrasound is becoming one of the most commonly used modalities within the country. The only struggle they have with ultrasound growing so quickly is that they lack enough qualified technicians to perform the job, so they are pushing for more education and training. In 2005, investments in equipment began to increase again, propelling Germany quickly to the larger marker.(Bursig, 2006)

Brazil

In 2012, GE Healthcare delivered and installed over 120 new systems to enable the performance of minimally invasive procedures in the hospital and clinical settings. This was an extraordinary advancement for the country and created a bordering platform. The new equipment is expected to enhance patient care, decrease the cost of exams, increase image quality, and lower patient dose. (Healthcare, 2012). In 2015, the country’s population climbed over 200 million, increasing the need for more equipment as well as clinicians to operate the equipment.

The country puts much of its focus around CR and DR capabilities (primary imaging), in order to make decisions more promptly. Brazil uses AeroDR in order to wirelessly transmit their image data between other hospitals or clinics. With the help of this company, Brazil plans to continue growing and find new ways to improve exams and patient care. (Imaging, 2015)

India

As of 2008, in India, there were between 1300 and 1400 functioning CR systems. Most of the hospitals within the country rely heavily on the use of CR, while some do use DR. Although some of the more rural areas have more than 50% of their hospitals relying on analog systems due to economic hardships, In the near future, India hopes to initiate a reliable PACS system as well as the ability to use teleradiography in small towns. Govindji R. Jankharia (2008) states that "in conventional radiology, 90% of the work is radiography of the chest, bones, spines, and sinuses, and only 10% of the work is, and will be, related to procedures such as barium studies, intravenous urograms, etc."

USG, which stands for ultrasonography, is the most commonly used cross-sectional imaging modality in India. In 2008, there were at least 50–55,000 ultrasound machines throughout the country, and this is expected to double within the next couple of years. In hospitals or clinicals with USG, there is only one radiologist reading all of those images, which makes for a very prosperous modality. CT is also used throughout the country, but with a lot fewer machines—about 3,000. Even though that number is low now, it is also expected to double in the next couple of years.

Even though MRI capabilities are easily more powerful than the other modalities, they have the least amount of scanners in the country, at only about 600. As well as all of the other equipment, the number of machines is expected to reach at least 1000–1200. The only reason that the number of machines will not increase is due to the extensive costs. Jankharia (2008) also states that "with the economy booming and the GDP growth at 8–9%, it may become possible to acquire MRI equipment more easily and ensure that its benefits become available even to the poorest in the land." The modality with the least amount of equipment is the PET scanner, of which they only have 16 in the whole country. It is expected that more systems will be installed as molecular imaging continues to grow. (Jankharia, 2008)

Italy

Augusto Righi, a physicist in Italy, was one of the first to follow in Roentgen's footsteps. Throughout 1896–1919, Righi published over 60 articles containing research he conducted. The first doctor to actually take an x-ray in Italy was Domenico D’Arman, which he accomplished in his own private laboratory. People started to realize how much of an impact this field could have on the country and began researching CT, MRI, and ultrasound. Bracco, a private, family-owned company in Italy, is responsible for the creation of many highly unprecedented contrast agents for almost all imaging modalities that are still being used to this day. Because of all the pertinent research that was conducted, a Museum of Radiology has since been established in Palermo, Italy.

Currently, radiographic procedures are housed within multiple institutions, including public hospitals, academic buildings, ambulatory structures, and private facilities. The country’s main task is to maintain consistency in cost reduction, efficiency, and competition. In 2000, at least 44 million diagnostic images were taken within hospitals as well as ambulatory structures (this number does not include any ultrasound exams). At least 1/3 of the 44 million images taken were done in an emergency-based setting. Since 2000, Italy has been swarming with qualified professionals, which, as stated by Stefania Romano (2009), included "5,354 radiologists, 1,041 chiefs of department, and 10,687 technologists." Because of continued interest and research within the country, the medical imaging field and Italy have high expectations to continue advancing in the years to come. (Romano, 2009)

Canada

Currently in Canada, they have high-functioning CT scanners, MRIs, SPECT machines, and PET machines. Doctors are able to use these to diagnose underlying diseases such as cancer and internal injuries, and surgeons are actually able to use them as a guide during open surgeries. In the more urban areas with higher populations, there are obviously more machines, but in the more rural areas with lower populations, there are a lot fewer. Though rural areas are said to have less equipment, a recent inventory noted there are more CT and MRI scanners, but some of them are spread out over large circumferences, which make it difficult for some people to reach. Also during the inventory, it was found that there are at least 374 facilities within the country that house medical imaging equipment. Most of the housing exists within community hospitals, tertiary care centers, freestanding hospitals, and hospitals. Some of the MRI machines within these sites are actually mobile units that can be used in neighboring locations under contract. Recently, clinicians have been mentioning the need for more research to properly inform patients on the optimal use of medical imaging. (News, n.d.)

One of the recent goals for Canadian clinicians is to decrease wait times for patients because, in 2004, wait times for CT scans were about five weeks and those for MRI scans were about thirteen weeks. These wait times are not ideal, especially for patients needing immediate medical attention. The reason the wait times are climbing is because many doctors are relying heavily on medical imaging to diagnose their patients instead of basic clinical skills. The excessive usage of medical imaging is frowned upon by some clinicians; as William Evans (2005) states, "it may in fact have led to iatrogenic illnesses because of the workup of false positive results and diverted attention away from simple interventions that have been shown to be effective." Many supporters within the country mention that providers should begin expanding medical imaging capabilities in hopes that it will do more good than bad. They are working towards the goal of minimizing medical imaging in the hopes that it will only be used on a necessary case basis and not just for convenience. (Evans, 2005)

Latin America

With current economic growth in Latin America, medical imaging technology is continuing to thrive in order to adequately enhance the quality of life for patients. Latin America has many differences in the quality of equipment, most of which are because it is previously used equipment that has just been reconditioned. North American CT protocols previously used within the country are continuing to decrease, leading clinicians to manipulate their own protocols to fit their desired needs. The increase in technology also requires an increase in the number of technicians, physicians, and biomedical engineers. Latin America is very large, which means that the major cities house the higher, more specified diagnostic care centers. This causes an inconvenience for the people living in the poor, rural areas, as they have to travel far distances to receive the care they require. (Volpi, 2016)

Bhutan

As of 2016, Bhutan was equipped with functioning CT, MRI, DR, and ultrasound machines. The only problem before was that they lacked a PACS system to store and distribute their images to other facilities. Within a couple years, they came up with a cost-effective solution that would then enable them to view previous images, and this was all done within a three-day span once the funding became available. Once the software was installed, they began training the reading radiologists as well as the technical and IT staff within the departments. Even though they have the ability to view the images, the system does not work as a PACS in the sense that they cannot distribute radiographs to other locations.

With a population of around 700,000 citizens, there is only one CT, MRI, and DR scanner within the capital of Bhutan. While at these hospitals, it is discovered that the reading radiologists actually interpret the images directly from the screens within the imaging suite, making it a challenge due to the fact that they have to individually go to every room to interpret the images, as opposed to having them all located on the same monitor. In Bhutan, as stated by Osman Ratib (2016), there are "three board-certified radiologists, two radiology technologists (with bachelor's degrees), 14 radiographers (with certificate degrees), eight ultrasound technicians (with diplomas and certificate degrees), four CT technicians (with diplomas and certificate degrees), and three MRI technicians (with diplomas and certificate degrees), as well as support from a local IT team for support and management of IT infrastructure" within the entire country. Clinicians hope that in the future, they will have easier ways to access medical record histories and an increased amount of medical imaging equipment throughout the entirety of the country. (Ratib, 2016)

Conclusion

Through extensive research, it is evident that medical imaging capabilities within developing countries appear to be a work in progress. I do not think that this is something to be upset about or ashamed of; it is a huge step for the future of the field. The more people realize the benefits of medical imaging, the more prominent it is going to become in the future. Whether it be a chest x-ray to diagnose tuberculosis, a PET scan to diagnose cancer, or a CT scan on a small child that hit their head too hard when they fell off their bike, without the use of medical imaging to diagnose these patients, there is a good chance they could have been left to die. We need better healthcare, not only in North America but for all developing countries around the world. Regardless of the hardships, I hope countries continue to notice and utilize the benefits that could arise from this technology and allow it to pave a brighter future for our healthcare system.

Works Cited

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