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The Tanzania Interventional Radiology Initiative: An Update From the Road2IR Global Outreach Program
Road2IR began in 2018 as a collaboration between the Yale Department of Radiology and Biomedical Imaging and Muhimbili University of Health and Allied Sciences (MUHAS) in Tanzania. It soon grew to include the Emory Department of Radiology and Imaging Sciences and other partner institutions in North America. The goal of the program is to build self-sustaining IR training programs in East Africa. IO Learning spoke with Road2IR co-founder, Dr Fabian Laage Gaupp, about the current status of the program, as well as challenges faced during the COVID pandemic.
How did the Road2IR initiative originate?
Dr Frank Minja is a diagnostic neuroradiologist and a native of Tanzania, East Africa. Dr Minja has been traveling to Tanzania every 6 months and has been instrumental in building diagnostic radiology services and a diagnostic radiology training program in Dar es Salaam, Tanzania’s largest city. Before 2007, there was not a single diagnostic radiology training program in Tanzania. By 2014, Dr Minja oversaw the implementation of a picture achieving and communication system (PACS), allowing Muhimbili to provide a modern diagnostic radiology department. By the time I arrived at the Yale School of Medicine in 2016 to start my interventional radiology (IR) residency, Dr Minja was the director of Yale’s Global Outreach Program for the Department of Radiology & Biomedical Imaging. At this point, he and his colleagues in Tanzania had successfully created a fairly large diagnostic residency program, with about 25 residents per year in a 3-year program. In 2017, Dr Minja and I traveled to Tanzania to perform an IR readiness assessment to determine the need for and hurles to starting an IR program, which resulted in the formation of the Road2IR initiative. Dr Minja recently moved to Emory University in Atlanta, Georgia, where he is continuing with global outreach, and has brought Emory and Yale even closer together for this ongoing collaboration.
How did you perform the baseline assessment?
We used the IR Readiness Assessment Tool for Global Health,1 which is a basic questionnaire used to evaluate the environment of a medical institution for IR services given an existing infrastructure. It assesses the availability of imaging equipment, disposable supplies, and manpower. The survey showed that Tanzania had much of the needed equipment, such as computed tomography scanners, magnetic resonance imaging, fluoroscopy, and ultrasound. However, they had no disposable equipment or faculty. Dr Minja had established the diagnostic radiology program at that point, but there was not a single radiologist in the entire country who could perform a basic IR procedure, such as a core needle biopsy, nephrostomy, or a biliary drain, let alone transarterial chemoembolization or ablation. It was astonishing to think that in a country of 60 million people, there wasn’t a single person who could drain an abscess or place a nephrostomy in a uroseptic patient. It’s hard to imagine the impact of this lack of IR availability. For example, a young Tanzanian woman with metastatic cervical cancer might develop bilateral hydronephrosis. Without placement of a nephrostomy tube, she will likely become uroseptic and die within a few days. Given this immense need for IR in Tanzania, we aimed to establish a competency-based residency program, as well as to train the necessary support staff (nurses and technologists) required to run an IR room. We knew that building local capacity was the only way to meet this extremely high demand.
How is the Road2IR initiative structured?
Road2IR is a 3-year program. The first year focuses on four simple procedures: core needle biopsy, nephrostomy, biliary drain placement, and abscess drainage. We began with core needle biopsy, because pathologists in Tanzania were performing fine-needle aspiration (FNA) biopsies and weren’t using image guidance; they were basically putting a needle into any part of the mass they could see. FNA is not ideal, because it only yields a cellullar sample; it doesn’t have the same diagnostic yield as a core needle biopsy, since it doesn’t offer any detail on the architecture of the tissue.
Each following year offers progressively more difficult procedures (Table 1). We set a goal of 10 trips each year (monthly from February through November, with December and January off), with a Road2IR team traveling to Tanzania for 2 weeks each, followed by a 2-week gap to allow the Tanzanian staff time to recruit patients, restock supplies, etc. After the first 3-year program is completed, the hope is to pull back and send a team every 6 months or so, and to have the program run more independently.
Can you talk about the reasoning behind your training strategy?
While there are wonderful outreach organizations, such as RAD-AID, that come in and train aspiring radiologists mostly for a few weeks per year, our model is based on the fact that IR requires constant practice to maintain any level of skill. High-intensity, high-frequency trips are essential to successfully train IR residents. If we did only one or two trips per year, there would not be enough retention of skill for someone to become a fully qualified interventional radiologist. IR procedures require certain equipment and resources, such as fluoroscopy, ultrasound, computed tomography, disposable equipment, etc. The severe shortage of IR practitioners in sub-Saharan Africa doesn’t lend itself to an approach like Doctors Without Borders and other organizations that often focus on directly helping or training people in a rural setting. Tanzania has 60 million people and 60 diagnostic radiologists — the bare minimum should be at least 600 diagnostic radiologists for that many people. Rather than going into a small village and training 1 radiologist and 1 technologist, I believe it makes far more sense to focus on the big cities and train larger groups of people at academic centers with the same standards as in the United States. In the following years, the knowledge will slowly dissipate and eventually reach the rural areas. In terms of IR, the Society of African Interventional Radiology & Endovascular Therapy (SAFIRE) has proposed a minimum goal of 1 IR per 1 million people. Therefore, we need at least 60 IRs in Tanzania, but we are currently training only 3 per year. However, the program is already growing, and the class starting this October has 5 people, so we will soon have 8 trainees there in total. One trainee from the incoming class is coming all the way from Nigeria, which demonstrates the complete lack of any IR training programs across sub-Saharan Africa.
Who is typically included in each Road2IR teaching team?
We ask each faculty member who travels to Tanzania to bring a team of at least 1 nurse and 1 technologist. If they don’t have anyone interested in joining at their institution, we connect them with nurses and technologists from other institutions and put together a team this way. IR is a team sport, and it’s not possible to do our job without knowledgeable support staff. The fourth person is usually a resident or medical student to assist with research and organization. Our first teaching trip was in October of 2018. I traveled with Dr Douglas Silin, the director of the IR program at Yale. Since then, we have organized a total of 14 trips, the last one been in February of 2020 (subsequent trips were cancelled due to the Covid pandemic).
Does the Road2IR program offer a certification program to the trainees?
Yes, accreditation is a vital component of the Road2IR program. To be specific, the accreditation is provided by the local university, MUHAS. We supply the expertise and they supply the university infrastructure. Certification is required to practice IR in most African countries, so we submitted a Masters of Science in Interventional Radiology curriculum to the university in April of 2019. The curriculum was approved in October of 2019, which is when our first 3 fellows enrolled into this 2-year course. Surprisingly, this is actually the very first accredited IR training program in all of sub-Saharan Africa, and the only IR training program in all of Africa outside of Egypt, to my knowledge.
You mentioned that one team member is often a resident or medical student to facilitate research. What sort of research are you conducting?
We are conducting research to evaluate the impact and effectiveness of our training program. In order to expand this program to other nations and continue to obtain funding, we must answer the following questions: (1) Is a training program like this feasible? (2) Can the residents achieve competency from 20 week-long teaching trips over the course of 2 years? (3) Can addition of IR significantly improve patient outcomes? (4) Can IR provide cost-effective and affordable treatment options in a setting like Tanzania? To answer these questions, it is necessary to compare our outcomes with current outcomes in Tanzania from non-IR procedures. For example, we’ll compare the outcomes of basic procedures such as nephrostomy versus surgical management (which is virtually nonexistent), biliary drain placement for abscess drainage versus open washout, and uterine fibroid embolization versus myomectomy and hysterectomy. The idea is that once we have this initiative bolstered by proper research, it will be easier to make the case for establishing similar programs in neighboring countries. For example, one of the current trainees in Tanzania is from Rwanda. Once he completes his training next year, he plans to return to Rwanda and start an IR training program there. We hope that many of the faculty who have already been to Tanzania would also be interested in making a 2-week trip to Rwanda. If our Rwandan trainee is able to show the research from Tanzania to the Health Minister in Rwanda, it will be much easier to obtain the necessary funding, establish the program accreditation, etc.
How has the program been received by the Tanzanian trainees?
The entire program was built together with Tanzanian trainees, and much of this is based on their ideas and suggestions. There is great interest in the Road2IR program in Tanzania from junior trainees. I believe our success is due to our efficiency and to our close relationship with the team in Tanzania. The first group of 3 trainees is now starting their final year of IR training (like myself), and they will soon be the first class to complete the entire course. The trainees perform many important roles in addition to the typical training regimen, such as welcoming our teams at the airport and introducing them to the staff at the hospital, and are immensely helpful in coordinating the program from their end. Furthermore, they play a big role in the procurement of equipment, expansion of the IR department infrastructure, recruitment of patients, etc. They essentially do the work that would be done by an entire department with administrative support staff in the United States.
What is your current role in the Road2IR initiative?
My main role is now to coordinate the teams and to build a network of people who are interested in global outreach. About 50 people have now travelled to Tanzania over the past 2 years, and we have about 30 additional medical students and residents here in the United States and Europe who are involved in the research and education aspects who haven’t traveled there yet. Essentially, we are now running an entire department, including training, patient care, procurement, and research.
How has the Covid pandemic and the resulting travel restrictions affected the Road2IR initiative?
There is definite frustration, because the program was proceeding quite well and 2020 would have been an amazing year for us given that we are finally well funded now, thanks to the RSNA. We sent 1 team each month from October 2018 through February of 2020, which is a total of 14 teams, with most teams consisting of 1 faculty, 1 nurse, and 1 technologist, in addition to trainees and medical students. On occasion, we were short 1 nurse or 1 technologist due to scheduling conflicts, but >90% of teams were complete. We had really streamlined our processes and nailed down every detail, and the machinery was working quite smoothly. We were able to send a team every 2 weeks as planned and had essentially no travel mishaps or other complications. No injuries, no illnesses, nothing stolen that I know of, so we were really quite fortunate overall.
How has the program adapted to this challenge?
The last trip was in February of 2020, just before the Covid travel restrictions went into place. At that point, the trainees were quite adept at several basic procedures (core needle biopsies, abscess drainage, nephrostomy, etc) and they are now doing them independently. I would say that they’re probably actually better at doing biliary drains than most IR fellows in the United States, because they’ve done a far greater number of them. The endoscopists in the United States are so good at endoscopic biliary drains that IRs don’t do as many of them here any more. At this point, we have done about 450 procedures with the Tanzanian trainees, with about 100 of those having been done independently since the teaching trips stopped.
They are not doing any arterial procedures independenly yet, but they have done some venous interventions, such as permacath placement and central lines. The trainees have already learned how to perform uterine fibroid embolization and splenic artery embolization over the past year. Uterine fibroids are common in black women; they present at a younger age and are more symptomatic. Fibroids can cause infertility, and the inability to have children carries a stigma in many African cultures. One of our goals is therefore to establish uterine fibroid embolization as a potential treatment for infertility. Since they have not yet done a sufficient amount of arterial procedures to be comfortable with potential complications, the trainees have not done any of those arterial procedures since February, and we probably won’t resume that until the trips start again. However, there has been a great deal of online education available, so the trainees join many different webinars as guests, and the Society of Interventional Radiology and many others have offered online meetings. Each week, we also have at least 2 or 3 dedicated Zoom teaching sessions with the faculty who have been to Tanzania. These sessions consist of presentations, journal clubs, research discussions, etc.
In addition, we are developing a virtual reality (VR) teaching platform. We received a grant for the VR platform from Yale. One of our medical students, Shin Mei Chan, received 2 grants — an RSNA medical student grant for $6000 and a Yale Global Health grant for $10,000. We were then able to purchase a GoPro camera, which the faculty can wear and film in 360° or 180°. We are now filming procedures at Yale, and will send the video files to Tanzania. The focus here is on procedures that the trainees have performed a few times, but are not yet fully comfortable doing on their own. Our hope is that allowing them to review the videos will allow them to more confidently do those procedures independently. We also plan to send one GoPro camera to Tanzania so the trainees can wear the camera while they do the procedure and stream it live via Zoom for real-time feedback from the faculty here.
Another goal is to develop a VR simulation with the Oculus Quest headset, which is more of an “augmented reality” that allows one to put a “virtual patient” on an empty table. This allows the trainee to track the procedure with their hands and practice the steps.
What are your current financial needs?
Funding is always a large concern, and we are often short of capital. We were initially funded by donations. We raised about $50,000 through Yale and the Dox Foundation generously covered the flights for many of the faculty through the first year of the program. Guerbet and Cook have donated products, and Burlington donated leads. Last year, we received a $75,000 grant from the Radiological Society of North America (RSNA) called the Derek Harwood Nash International Scholar Grant. It costs ~$4000 for airfare to send each 4-person team, so we allocated most of that money to cover flights for the second year of our program, with the rest going toward a $250 monthly research stipend to support our Tanzanian trainees, who don’t receive a hospital salary and pay for their own training. Additional funds would allow us to send more than 10 teams per year, and additional disposable equipment is always needed.
What are your current non-financial needs?
We urgently need industry to get engaged and expand their market to sub-Saharan Africa. We have been struggling for 2 years now to procure equipment directly in Tanzania. The big equipment companies urgently need to start selling their products there. We understand that there are some hurdles with establishing business relationships in Africa, but they have to put in an effort and do it, because there is no alternative. There are 60 million people in Tanzania alone that need access to the many live-saving procedures IR can offer. Of course, this applies not only to Tanzania, but to essentially all other countries in sub-Saharan Africa with the exception of South Africa, which has a well-established equipment market from what I know. In addition, we always need more people, of course, and our volunteer requirements will likely increase as we expand to other countries going forward.
Any final thoughts on the future of the Road2IR program?
At this point, we’re ready to upscale the program. We’ve shown that our initiative works, and have published a study on our model in the Journal of Vascular and Interventional Radiology.2 As I mentioned, the next step is Rwanda, likely followed by Uganda in collaboration with folks from the United Kingdom, and then we hope the program will spread out and essentially become self perpetuating.
The hope for future Road2IR initiatives is that the faculty from the United States will be joined by the new IRs we are training in Tanzania. We plan to have the current Tanzanian trainees visit the training program in Rwanda every few months to share their knowledge once things get started there. We have overcome certain limitations in disposable equipment and other supplies in Tanzania, which has led to a lot of innovation, and I think the exchange of ideas between African countries will be an important part of this process.
According to the World Health Organization, half of the global population has inadequate access to diagnostic radiology, and the situation for interventional radiology is even more dire. Sub-Saharan Africa alone has a population of 1.1 billion; of those people, essentially nobody except perhaps a few extremely wealthy people has access to IR. There is a huge need, and I think it calls for a revolution of procedural medicine in Africa. Currently, everything is done surgically, with techniques we used in the United States in the 1950s, which is really not acceptable given the advances that have been made in IR. Therefore, I think that IR is going to have a huge impact in Africa. The interventional oncology (IO) component of IR, in particular, has the potential to be even more important in Africa than it is here. In the United States, surgical techniques are very refined — we have laparoscopic surgery, robotic surgery, etc. — so a lot of things can be done surgically here that cannot be done in sub-Saharan Africa without very high complication rates. IO techniques would therefore offer a greater relative advantage over surgical oncology procedures in Africa. For example, a patient with a single hepatocellular carcinoma who lives in the United States could have a surgical resection with a very low complication rate, or could also have an ablative procedure, which is considered an equivalent to surgical resection. In Tanzania, the two procedures are not equivalent, because a surgical resection likely has a much higher complication rate than here. The ablative procedure would therefore have a higher relative advantage over surgery, because ablation complication rates are quite low as long as the procedure is performed properly and under sterile conditions.
References
1. Kline AD, Dixon RG, Brown MK, Culp MP. Interventional radiology readiness assessment tool for global health. J Glob Radiol. 2017;3:Article 2.
2. Laage Gaupp FM, Solomon N, Rukundo I, et al. Tanzania IR initiative: training the first generation of interventional radiologists. J Vasc Interv Radiol. 2019;30:2036-2040.
