There are many potential avenues to engage in global health work, be it as an individual or a group, as a trainee or a practicing radiologist, technologist, medical physicist, or radiology nurse, through de novo partnership or preexisting ones (i.e., NGOs or university affiliations), direct (on-site) or indirect (i.e., Internet-based image interpretation or equipment donation) involvement, short-term or long-term engagements, etc. While these variables each have their pros and cons, one advantage of group or organization-directed efforts (i.e., through a university or NGO partnership) over individual-driven efforts is that the former lends itself more easily to sustainable and responsible imaging implementation due to the number of people involved. Furthermore, early exposure to global health work during the formative years of training may serve to inspire future volunteer efforts when these health care workers have more experience to share.

What follows is a brief overview of considerations in designing a structured global health imaging experience, keeping in mind the principles of responsible, sustainable program development as well as the more specific education objectives set forth by individual certification and specialty governing bodies. The concept of sustainability here refers to the ability to develop and maintain knowledge, equipment, skills, and other resources as part of an enduring radiology infrastructure that addresses the healthcare needs of a community by integrating with existing healthcare infrastructure; in this construct, sustainable radiology development can occur at any level, from a single clinic to an entire nation [19].

There are many important considerations when deciding on a location or site to establish a global health imaging elective experience. Chiefly among them is deciding on a country, hospital, clinic (with or without a radiology training program), or community with whom to partner. Factors to consider include language, stability and safety of the area, and existing infrastructure. Creating a de novo international partnership can be a daunting and difficult feat without the right connections. Fortunately, in today’s world, with the ease of international travel, telecommunications, and increasing globalization, it is far more common than not that preexisting partnerships (or at least attempts at partnerships) exist. There is no need to reinvent the wheel, but instead it may be possible to steer the wheel in a new direction and build off of what has come before. It is often the case that training programs affiliated with large academic institutions have unprecedented access to well-established partnerships with a wide variety of institutions all over the world. These relationships may be managed by a dedicated global health committee or department, and in partnership with clinical and nonclinical global health institutional colleagues, much of the difficult relationship building and contact development is already in place. Oftentimes the most useful guidance comes from physicians and other healthcare volunteers who are already directing established global health education and outreach programs, most commonly in other disciplines such as surgery and internal medicine. For example, the Emory University Department of Radiology is currently home to one of the few established international elective imaging experiences in the USA for radiology resident physicians, located at Addis Ababa University (AAU) in Addis Ababa, Ethiopia; in choosing a site for the rotation, they built off of preexisting international connections established by other specialties in their academic center [20].

However, the presence of a preexisting relationship to a medical community in the developing world may be the exception, rather than the rule, for many individuals, organizations, or training programs interested in incorporating medical imaging outreach. Alternative strategies in site selection for establishing or participating in a developing world imaging education program may include partnering with an international clinical or nonclinical nonprofit organization, researching contacts or opportunities via a national specialty governing body or society, researching and reopening communications with prior international short-term image equipment donation or other efforts, or establishing new ties to a specific medical community via personal contacts or initial in-country visits. Oftentimes much of the most useful guidance comes from physicians and other healthcare volunteers who are already directing established global health education and outreach programs, most commonly in other disciplines such as surgery and medicine.

Once a group of sites are chosen and all partners identified, it is important to balance the priorities among the specific geographic locations, the objectives of the program, safety, and funding. As an example, the cost differences for travel alone between the USA and candidate locations in Haiti versus locations in Tanzania are substantial. Also, some funders or institutions will not provide resources for efforts in certain locations due to liability or safety considerations.

No matter how well established the relationship is between home institutions or organizations and the host site, a comprehensive imaging-related site assessment is critical to the development of a responsible and targeted imaging outreach education and training program. The WHO asserted that there is a “prevailing but mistaken belief that anything is better than nothing… [and that] unsolicited and unnecessary health care… is wasteful.” Site and country-specific assessments must be completed before the design and promotion of new initiatives. An example is the RAD-AID Radiology-Readiness™ assessment tool, which provides an analytic framework for the structured assessment of local disease epidemiology, facility physical and technology infrastructure, clinical referral networks, access to medications and clinical consumables, availability and training of local healthcare personnel, availability of complementary laboratory testing, existing radiology infrastructure, and institutional financial health, among other areas. To date, the Radiology-Readiness™ tool has been used in multiple locations around the world as part of collaborations between RAD-AID and other partnered organizations such as Project HOPE, Imaging the World, and the WHO [19]. The assessment process is designed to aid program design and identify important barriers in a given location before planning a sustainable clinical radiology program.

However the site assessment is conducted, the information gained in this process is important both as a starting point for collaborative discussions and data to be used in the development of future project metrics and research initiatives. The assessment data must be made available to the host institution leadership and any other partners so that a targeted project can be designed.

For example, based on data gathered from a targeted site assessment, RAD-AID engaged public health and medical institutions in Northern India to develop a strategy to improve access to medical imaging for the massive, impoverished slum population. The data indicated an overwhelming need for women’s health, in particular breast and cervical cancer evaluation as well as osteoporosis screening. In addition to these targeted epidemiological health needs, transportation and connection to clinical systems for follow-up were major obstacles to overall health care and were identified as reasons prior outreach efforts had failed. This work led to the implementation of a mobile women’s health outreach program. The mobile unit offers screening for breast cancer, cervical cancer, and osteoporosis as well as targeted health education. This partnership will aid data collection on women’s health, including barriers to engaging the healthcare system, obstacles to referrals, as well as patterns and rates of disease. In addition, the volunteer radiologists, technologists, nurses, and medical physics professionals will have the opportunity to practice medical imaging in a resource-poor setting and collaborate on research and imaging education projects with the partnered Indian medical center. Because there are multiple stakeholders, all with a well-defined targeted focus, this work will hopefully inform government partners in creating policies that will better incorporate radiologic services into public health programs [21].

An on-site assessment should also obtain detailed knowledge of the rules governing the scope of practice of foreign trainees, and ideally includes planning meetings with the host country’s ministry of health or equivalent governing agency. Otherwise, problems can arise to undermine the project. For example, a global health imaging program staffed mainly by US physicians and other imaging practitioners put in place unilaterally might possibly highlight the administrative failings of the host country’s medical delivery system, place non-partnered rival local medical practitioners and institutions in an uncomfortable position, violate local laws governing the privileges of foreign practitioners and trainees, or deliver services deemed inappropriate by the host country officials. Any of these scenarios could engender significant conflict despite the underlying good intentions. Therefore, it is important to fully engage both the partner and the host government representatives as part of an initial assessment to build trust, and obtain an understanding of the public health policies, local politics, and potential ramifications of the proposed program.

Though individual programs, stakeholders, locations, and objectives will differ, curriculum development can become critically hampered by a lack of standardized guidelines. In an essentially new field of study such as global health imaging, this concern becomes more important because there are no preexisting models, as there are in other clinical and nonclinical disciplines, to adopt. However, there are numerous existing competencies that may be used as a basis for the development of a targeted but acceptably inclusive curriculum. For example, core competency topics can be constructed within an established framework set forth by a national governing body, such as the American College of Graduate Medical Education (ACGME), the Association for Radiologic and Imaging Nursing (ARIN), and the American Society of Radiologic Techno-logists (ASRT) (Table 11.1). Collaborating with partnered institutions or colleagues in medical education can also help expedite the process of developing a comprehensive curriculum.

Because it is important to begin the process of curriculum design with a model in mind, a first strategy could be to develop or adopt specific competencies unique to the particular program or discipline. Ideally, global health imaging education should span the length of a given training program, not just the period of international travel to the host country. At the minimum, an educational curriculum should span a sufficient period of time before and after the international rotation, to gain the necessary skills in advance of the on-site experience and to later reflect on the experience with newer trainees to the curriculum. There are a variety of options with regard to methods of curriculum content delivery. An educational curriculum may involve regular (e.g., monthly) group discussions on required readings or brainstorming sessions. For example, discussions may focus on analysis of global health literature, work-shopping strategies for implementing imaging in a resource-poor setting, or didactic lectures on the clinical and imaging presentation of tropical diseases in the developing world. Resources for imaging presentation are currently scarce, but include this text as well as the comprehensive Reeder and Palmer volumes entitled The Imaging of Tropical Diseases [22, 23]. Many of the articles listed in this chapter’s bibliography may also serve as “journal club” topics for discussion. At institutions with established global health departments, public health schools, or resident global health electives in other medical specialties, multidisciplinary meetings and lectures are a particularly useful tool as they serve to develop a “global health community” with interdisciplinary cooperation and collaboration. These types of group sessions would allow trainees to explore global health systems at large and would serve as an excellent adjunct to imaging-specific didactics.

No matter the discipline or background of the trainees, dedicated coursework on the topic of cultural competency should be at the core of every global health education curriculum, and a requirement of all participants in a global health imaging outreach and education program (Table 11.2). Cultural competency training in particular is vital for volunteers traveling abroad, as it helps build the trust and credibility required for successful long-term collaboration. One in-depth cultural training resource presented at the 2010 RAD-AID conference is Aperian Global’s GlobeSmart^® Web tool [19]. Another resource which includes didactic case-based material is the Web-based Ethics of International Engagement and Service-Learning Project Web-Based Guidebook (EIESL)—an easily accessible resource that provides students, faculty, staff, and international organization members with materials designed to provoke ethical reflection on international engagement and service learning projects, and is particularly useful as part of a larger global health curriculum. The EIESL materials are designed to “challenge how we engage as global citizens committed to social and ecological justice.”

Within a radiology department, a global health imaging curriculum could be tailored to either the training program as a whole or simply to interested parties including not only residents but also faculty and other medical imaging professionals. Institutional support would be essential in order to provide faculty-protected teaching time, and a high level of trainee interest would be needed in order to incorporate global health topics into an existing residency lecture series framework, as the content may have limited applicability to those not interested in global health. As an alternative, an evening elective seminar series on global health imaging is perhaps a more feasible option and would require a commitment by faculty and trainees alike to dedicate time outside of routine training obligations to participate. This would allow for more freedom from daytime residency program restrictions, and course content would be directed by a core group interested in the subject matter. It should be noted that this strategy may cause conflicts with regard to call responsibilities and, potentially, work hour violations. Attendance may be sporadic due to personal or family obligations.

Another option in training programs with available elective time, or during “mini-fellowship” time, an entire elective “rotation” (lasting from one to several weeks) could be set aside as an option for those interested in concentrated global health imaging instruction; however, this strategy may cause difficulties in that the elective time may be limited and better served as the travel component of the global health program. Much of the content could be provided as part of the on-site field experience in which the faculty would have an opportunity to provide focused instruction to trainees from both the host and visiting partner institutions. Lastly, in programs with limited extracurricular time, informal self-study via journal articles, Web-based resources, and other global health text assignments may also serve as an alternative to formal didactics.

A global health imaging curriculum must also take into account the structure of the international, on-site experience. The on-site experience should be tailored to the host location and will depend on the available resources and imaging modalities. If visiting an imaging training program (or radiology residency program) in the host country, close coordination with host faculty will be necessary, as they will be responsible for supervising the visiting resident per ACGME guidelines if/when the resident is not traveling with a faculty member from the home institution. An example on-site curriculum may include spending 1 week with each available imaging modality (plain film, ultrasound, fluoroscopy, etc.). Due to potential legal restrictions by hospital or governmental/Ministry of Health regulations, the visiting trainee or faculty may be confined to a more observatory role during film interpretation, image acquisition, or during procedures, though this is entirely dependent on the location and specific context.

The visiting resident should be encouraged to save a certain number of cases with a digital camera, including clinical data and outcomes. Unlike in the USA, patients will often be directly available during imaging interpretation, and such interactions can provide invaluable insight into a country’s culture and health care. If traveling with another clinical service from your institution, clinical rounds with other specialties (e.g., in the emergency department, inpatient wards, or medical ICU) may prove fruitful for all parties involved, as shown by the Emory-AAU experience [26]. Given that PACS is often nonexistent in many developing countries, patients are often responsible for their own films, which are often interpreted by non-radiologist clinicians at the bedside. Thus, there may be ample opportunity for visiting trainees and radiologists to be involved in direct patient care and bedside teaching.