Interventional radiologists call on WHO to address the “dramatic lack of IR services” in low income countries

The European Trainee Forum of the Cardiovascular and Interventional Radiological Society of Europe (CIRSE), the Residents, Fellows, and Students section of the Society of Interventional Radiology (SIR), the Society of African Interventional Radiology & Endovascular Therapy (SAFIRE), and Road2IR—a collaborative effort between several partner institutions aiming to build self-sustaining interventional radiology (IR) training programmes in East Africa—have published an open letter to the World Health Organisation (WHO) in CVIR Endovascular, calling for an increase in the efforts to understand the needs of low income countries regarding image-guided therapies.

In what participants hope marks “the beginning of a great collaboration between the WHO and the IR community”, several letter signatories first met with Adriana Velazquez Berumen, group lead for medical devices and in vitro diagnostics at WHO, online on 23 October to discuss IR and service development in low income countries. Interventional News understands that these remote conversations are ongoing, and that an online petition is in the pipeline “to continue raising awareness and increase the pressure on the WHO to do something about this [lack of IR provision in low-income countries]”.

First author of the CVIR Endovascular letter Yi Yang (Aventura Hospital and Medical Center, Aventura, USA) and colleagues say that the intent of the address is “to initiate a discussion on and collaboration in addressing the dramatic lack of interventional radiology services in low income countries and the lack of associated data”.

The letter is also approved and supported by Andrew Kesselman (RAD-AID International), Susan Jackson (Western Angiographic and Interventional Society), Kartik Ganga and Sreenivasa Raju (both Indian Society of Vascular and Interventional Radiology), Gerard Goh (Interventional Radiology Society of Australasia), Murray Asch and Kevin Shixiao He (Canadian Association for Interventional Radiology), and Karin Euler (Canadian African Health Care Alliance—Tanzania).

The authors write: “Prompt publication of countless dedicated research articles, public education through news outlets and social media on preventive measures, and initiation of vaccine development within weeks of the COVID-19 outbreak highlight the many benefits of global connectivity and collaboration. Yet, these times of fear and stress reveal the persistent chasm of racial inequality, healthcare inequity, and social injustice that have plagued humanity for centuries. These inequalities extend into almost every facet of medicine, but nowhere is the disparity more extreme than in minimally invasive treatment options available to patients in high-income countries and the near-complete lack thereof in most low- and middle-income countries (LMICs).

“[…] There are several hurdles to the implementation of IR in LMICs, including the sparsity of baseline data, limited access to equipment, and lack of training. In order to facilitate effective IR training and adequate supply of IR equipment, there is a critical need for improving and updating the ‘WHO Global Atlas of Medical Devices’.”

Speaking to Interventional News about the significance of a collaboration between the WHO and the IR community, immediate past chair of CIRSE’s European Trainee Forum and past chair of the British Society of Interventional Radiology (BSIR) trainee committee, Gregory Makris (Guy’s and St Thomas’​ NHS Foundation Trust, London, UK), a senior author of the open letter, comments: “This letter is part of an effort to increase awareness around this very important issue. During the last five years there has been significant effort in increasing the presence of IR in Africa, but we now need more structured support to take these efforts to the next level. We have to make people understand that even standard life-saving procedures like a nephrostomy insertion or a drain of a liver abscess are currently not possible due to the luck of expertise and kit. The scale of the problem, as well as its significance, is massive, and that is why it is important to have a collaboration between international IR societies, the WHO, and the medical devices industry to address the various issues in lack of training, manpower, and supply chain/kit. We are planning to start an online petition within 2021 in order to reach even more people and get people interested in our cause. Introducing IR in Africa can have a major impact in raising health care standards given the multidisciplinary nature of our specialty. We hope for your support.”

Updating the WHO Global Atlas of Medical Devices

The WHO Global Atlas of Medical Devices, the most recent iteration of which was published in 2017, is a report presenting the global status of national medical device policies and the availability of medical device information, regulations, assessments, procurement, and donation guidelines, as well as the density of high cost medical equipment and guidance documents available at country level.

Its authors say that the aim of the publication is “to raise awareness and bring evidence of the indispensable safe and good use of appropriate, affordable, and quality medical devices in health care delivery to achieve better health outcomes”.

Data included in the WHO Global Atlas of Medical Devices come from a 2013 Baseline Country Survey on Medical Devices (to which 177 countries responded), a 2015 global health technology assessment survey (conducted by government or national institutes), and a 2016 study analysing medical devices regulatory frameworks. The information collected by the surveys and studies was then processed into a comprehensive database that includes statistical analyses of more than 100 aspects related to medical devices evaluated with respect to welfare indicators, such as World Bank income groups, health expenditure, Human Development Index and WHO regions.

However, signatories of the recent CVIR Endovascular letter point out that the WHO document does not assess several medical device and equipment categories “that are integral for diagnosis, treatment, and follow-up of patients by minimally invasive means”. Specifically, they request the following be included in future versions of the WHO Global Atlas of Medical Devices:

“1. Ultrasound: As a non-ionising imaging modality, ultrasound is the ideal first-line imaging tool in obstetrics, paediatrics, trauma triage, and is essential for breast cancer diagnosis, biopsy, and follow-up. Ultrasound is used in over 90% of IR procedures to guide percutaneous biopsies, vascular access, and drainage procedures.

“2. Fluoroscopy: As a dynamic, X-ray based, real-time imaging modality, fluoroscopy is the other most essential imaging tool used in IR. With fluoroscopy, interventional radiologists can navigate wires and catheters to almost any place in the body in order to perform embolizations in the setting of haemorrhage, limb salvage from peripheral arterial disease, extract clot in the setting of stroke or pulmonary emboli, and administer radio- and chemotherapy locally. These procedures are often life-saving and significantly less invasive than their surgical alternatives.

“3. Systems for Reviewing Imaging: Determining the availability of PACS (Picture Archiving and Communication System), EMR (Electronic Medical Record), and/or access to a viewing box or written medical records which are paramount for initial evaluation and follow-up of the patient’s medical history, management planning, and disease status over time.”

They expand: “The availability of these data measures will clarify the global distribution of diagnostic and therapeutic imaging and procedural devices. This will allow IR societies, academic institutions, researchers, educators, and non-governmental organisations to strategise and prioritise where and how to best extend and implement minimally-invasive life-saving procedures in LMICs. Additionally, these data will facilitate industry growth and partnerships within the unique context of the LMIC setting.

“We believe that increasing the robustness of the ‘WHO Global Atlas of Medical Devices’ will contribute to increasing access to minimally-invasive procedures in LMICs. We want to be actively involved in this process to support the efforts of the WHO in this matter. For example, as trainees, we can assist with facilitating coordination with consultants and suppliers and lead research efforts in evaluating and guiding implementation. We appreciate your efforts in leading equity in global health and look forward to moving forward in our collective commitment to providing all patients with the care that they need and deserve.”