When Frank Minja, a former associate professor of neuroradiology at the Yale School of Medicine (YSM), traveled to Tanzania, East Africa in 2014 to help set up a modern radiology department on the Muhimbili National Hospital (MNH) campus, he knew the task would be complex and demanding. That same year, Minja established the Yale Radiology Global Outreach Program to help address the shortage of well-trained diagnostic and interventional radiologists in Tanzania.
Minja, who was born and raised in the former Tanzanian capital of Dar es Salaam, where the campus is located, traveled to the United States for college and medical school at Harvard University. He came to YSM in 2004 for a diagnostic radiology residency, followed by a neuroradiology fellowship.
But even before completing his fellowship, Minja had begun collaborating with radiology colleagues in Tanzania who were establishing the first diagnostic radiology residency training program on the MNH campus.
After becoming a member of the YSM Radiology & Biomedical Imaging Department in 2009, Minja joined the faculty of Emory University School of Medicine’s Department of Radiology and Imaging Sciences in 2020. He remains dedicated to providing radiology training to physicians in East Africa.
Melissa Durand, MD, an associate professor of radiology & biomedical imaging at YSM, became interested in a medical service mission a few years ago after she attended a grand rounds lecture. During the talk, Durand heard about volunteer opportunities with RAD-AID.org, the nonprofit group that works to improve medical imaging and radiology in developing and emerging countries. After meeting one of RAD-AID’s breast program directors, Durand, who joined the department as an attending physician in 2012 after a breast and body fellowship at Yale, signed on as a volunteer for a 2019 mission to Ghana, West Africa.
For a week in early June of that year, Durand volunteered at Ghana’s second-largest teaching hospital, the 1,200-bed Komfo Anokye Teaching Hospital (KATH) in Kumasi, the regional capital of the Ashanti Region that serves a population of about 5 million people.
Cicero Silva, MD, associate professor of radiology and biomedical imaging, and chief of pediatric imaging at YSM, led an outreach team from 2015 to 2019 on behalf of the World Federation of Pediatric Imaging (WFPI). In those parts of the world that are short of qualified medical staff, radiologists, and especially pediatric radiologists, are rare. Most countries in Africa have fewer than 30 radiologists, and 14 have none, according to a 2016 article in Pediatric Radiology. To address this shortage, the WFPI created a pro-bono second-opinion teleradiology outreach team to assist referring physicians.
Tanzania’s Interventional Radiology Initiative
In addition to also supporting the diagnostic radiology residency training program at Muhimbili University of Health and Allied Sciences (MUHAS), Minja led the successful effort to establish a Picture Archiving and Imaging System (PACS) at the Muhimbili Orthopaedic Institute (MOI), also on the Dar es Salaam campus. In 2018, with assistance from Fabian Max Laage Gaupp, MD, who is now an assistant professor at YSM, Minja established the Tanzania Interventional Radiology Initiative.
Laage Gaupp performed an IR readiness assessment in 2017, which found that most of the imaging equipment needed for IR was already available at MNH, such as ultrasound, X-ray fluoroscopy, and CT scanners. The critical missing component was the lack of IR training opportunities.
In a country with limited resources such as Tanzania, patients have little or no access to the benefits of interventional radiology because not a single radiologist in Tanzania had been formally trained to use it, said Minja. The Tanzania Interventional Radiology Initiative provides within-country training for the first generation of interventional radiologists in Tanzania.
“If we are able to do that, we will produce locally trained IR physicians who understand the necessary workarounds in a resource-limited setting, as opposed to training them at Yale or elsewhere abroad where more resources are readily available,” Minja said.
Goodwill and funding are both essential for the continued recruitment and support of the best teams for the Tanzania Interventional Radiology Initiative, Minja said. “Many countries around the globe face an acute shortage of diagnostic and interventional radiologists, especially in Africa, and could benefit from efforts similar to the Yale Radiology Global Outreach Program,” he said.
“The problem is not very complex, but the scale and urgency of the need is quite enormous,” Minja said. “That is also the opportunity.”
Radiology to Improve Breast Cancer Outcomes in Ghana
Breast cancer is the most common cause of female cancer deaths in Ghana, where the five-year survival rate is estimated to be 25%. In the United States, the survival rate is 90%. Many of the breast cancer patients treated at Kumasi’s KATH are young women in their 30s and 40s.
“The survival rate is low; people were presenting in late stage,” Durand said. “At Yale, we have a weekly tumor board with surgeons, radiologists, and oncologists to talk about cases that are 1 centimeter in size. There, we saw tumors that were 10 centimeters, and in younger women.”
Often, a woman will not come to the hospital until she feels a lump, she said.
One of the challenges to improving breast cancer outcomes for African women is overcoming traditional beliefs and cultural barriers, Durand said. Transportation and long travel distances also are barriers to receiving care, she said.
Still, the hospital is busy, with up to 50 patients visiting its Breast Care Centre each day. But the process can be time-consuming. If an examination shows the need for an ultrasound, the patient must return to the center for a follow-up appointment a week later. And if the ultrasound reveals a tumor that requires a biopsy, the patient must return for a third appointment.
Less than half of the patients who need an ultrasound or a biopsy return for these procedures, Durand said. Cost is one reason. While the national insurance program covers breast cancer treatment, the work-up to get a diagnosis of breast cancer is not. “As such, the cost of the tests can be prohibitive,” she said.
Durand conducted a radiology readiness assessment survey for RAD-AID, outlining the hospital’s breast imaging needs.
“What’s so attractive about the experience is that you feel you are changing something for the better,” Durand said.
Global Pediatric Radiology Service
Silva’s work with the WFPI has touched various parts of the globe. For example, in 2015, partnering with RAD-AID, the WFPI sent a pediatric radiologist from the U.K. to the Lao Friends Hospital for Children, in Laos, to educate pediatricians on the basics of X-ray interpretation, and radiology technologists on radiation safety. From 2014 to 2018, the hospital was responsible for 82% of WFPI’s teleradiology cases.
During Silva’s tenure with the WFPI, the majority of teleradiology outreach cases that were reviewed were from Asia (Laos), and Africa (Mozambique and South Africa), as well as from India, Peru and Jamaica. In that period, WFPI volunteer pediatric radiologists read 668 cases; the median age of patients was 1 year, 4 months.
Silva also traveled to his native country of Brazil in 2018 to help conduct pediatric radiology training classes in Belém.Although the city has about 1.5 million inhabitants, there are few radiology residency programs and none dedicated to pediatric radiology.
Silva also assisted in creating WFPI pediatric radiology three-month mini-fellowships in Africa, Asia, and South America, in partnership with the Shiels Foundation.
Originally published Dec. 16, 2019; updated Oct. 25, 2022.