Progress travelled on the Road2IR in sub-Saharan Africa

Fabian M Laage Gaupp is assistant professor of radiology and biomedical imaging at Yale School of Medicine (New Haven, USA) and a recipient of the Yale Institute for Global Health’s winter 2023 Spark Awards. This monetary prize will see Laage Gaupp and his team at Road2IR make frequent trips to Uganda to help set up the country’s first interventional radiology (IR) training programme—based on the sub-Saharan region’s very first, which the organisation established in Tanzania in 2018. Laage Gaupp, who is one of Road2IR’s founding members, speaks to Interventional News about the challenges of growing IR in sub-Saharan Africa and the impact Road2IR’s work to date has had on healthcare in this region.

Road2IR started as a WhatsApp group in 2017 when I first visited Tanzania with my friend and mentor Dr Frank Minja, who is himself a neuroradiologist, originally from Tanzania. During that visit, I met three peers in Tanzania, who were in their second year of radiology residency at the time—Drs Azza Naif, Erick Mbuguje, and Ivan Rukundo. Together, we assessed the current status of IR in Tanzania—it was non-existent. We came up with the goal of establishing an IR service and training programme in Tanzania, which would make it the first and, at the time, only, IR training programme in all of sub-Saharan Africa (a region with over one billion people). In October 2018, we started doing a two-week teaching trip to Tanzania every month. Another year later, Muhimbili University of Health and Allied Sciences (Dar es Salaam), the university affiliated with Muhimbili National Hospital, where Azza, Erick, and Ivan were training in diagnostic radiology, started a two-year Masters of Science course in IR. Those three enrolled as the first trainees and graduated in September 2021. We have come a long way, with several thousand procedures performed, 10 interventional radiologists graduated (eight from Tanzania, one from Rwanda, and one from Nigeria), and growing demand and procedure numbers. The reason why I do this is because I see the extreme demand for IR in Tanzania and sub-Saharan Africa overall and I know that we can have immense impact, even with relatively limited resources. All the advantages IR provides in countries like the USA are even more pronounced in sub-Saharan Africa, where surgical and anaesthesia complication rates are often higher.

The COVID-19 pandemic only halted our progress for about six months (March until October 2020). We decided early on that we could not justify stopping an entire service line and training programme because of a viral disease with relatively low mortality. At the time, the IR service in Tanzania was already saving lives every day, so stopping it was not an option. We resumed our monthly teaching trips in November 2020, and have done at least one trip per month since. This is in contrast to many other global health organisations, who seemed to remain in a state of paralysis until recently. We graduated the first class of three fellows in 2021, the second class of seven in 2022, and are about to graduate the third class of three in August 2023. The reason why the second class was so large is that several Tanzanians, who were supposed to do IR training in China, got kicked out of the country when the pandemic started, and we took them into the programme in Tanzania. This should serve as a cautionary tale for countries relying on China and other nations to train their physicians. The safest way is always to train in-country and every country should aim to have at least one IR training programme of its own.

Our main challenge has always been, and remains, disposable equipment. This is an obvious problem, since there was never any demand and, therefore, nobody to supply equipment. Now that demand is growing, we are trying to convince equipment companies supplying this part of the world. So far, some companies have been eager to expand their market to sub-Saharan Africa, while others, not so much. This probably depends on their overall strategy, their willingness to take risk, and their size—some companies can barely keep up with demand in the USA. That being said, I do think it is important that companies make an effort to supply their products to sub-Saharan Africa. The demand is huge and we as IR physicians cannot do our work without equipment. If Western companies do not act, Chinese and Indian companies will certainly take the market. Tanzania is an example of how quickly a supply chain can be established—we can get a company’s entire device catalogue approved in a week by the Tanzanian health authorities, who have been supportive collaborators with us throughout the process. All we need is for companies to be open-minded.

 

To be honest, I have no idea. WHO never responded. Prior to the letter, we have reached out to WHO for several years. At one point, we had a Zoom call with some of their radiology and surgery leadership and discussed extensive plans and suggestions. After that, they never followed up and it went nowhere. Sadly, I think that WHO has no real understanding or appreciation of what IR is and how much impact it could have in resource-limited settings. I am hoping that with a growing body of evidence on IR in these settings, WHO will take note. We could greatly benefit from their support, but IR is still not a focus for global health, unfortunately.

I will travel to Tanzania and Uganda every few months in the coming year to help set up the partner programme in Uganda. We are essentially creating a copy of the Tanzania programme, but now have the advantage of having a regional partner programme in Tanzania. This means that we will not only have visiting teams going to Uganda from Europe and the USA, but also from Tanzania. This should help the Uganda programme evolve even more quickly and robustly. I am really excited for the next year and I am hopeful that, by 2024, we can do most basic IR procedures in Uganda and, by 2025 or 2026, we will be able to do most complex procedures there. In addition, Ivan Rukundo is now back in his homeland Rwanda and has started the first IR service in this country of 10 million. He is getting over 100 phone calls from referring physicians a day! As you can see, demand for IR is high everywhere, and we are trying to reach the goal set by the Society of African Interventional Radiology and Endovascular Therapy (SAFIRE) of at least one interventional radiologist per million people. This means we need at least 60 in Tanzania, at least 40 in Uganda, and at least 10 in Rwanda.

Probed further on SAFIRE’s role in expanding IR coverage in sub-Saharan Africa, Laage Gaupp states how it is a very new society, having had its first official meeting in 2021 in Cape Town, South Africa. Nonetheless, he asserts his belief that there is “lots of promise and potential” as far as the society’s work is concerned. Laage Gaupp suggests that SAFIRE plans to set up a continental examination board to allow for uniform IR training standards.

Regarding the continued work of Road2IR, the Spark Award is one of several funding sources that the organisation has secured, Laage Gaupp avers. For example, it has recently received £25,000 from the UK’s Academy of Medical Sciences, but in order to continue to gain much-needed financial backing, Laage Gaupp stipulates the need to tailor funding applications to the promise of solving disease-specific problems, as opposed to a larger gap in procedural medicine.