Maurice Haddad, Shukri Loutfi, Jean Tamraz, Aghiad Al-Kutoubi

From the Departments of Radiology, American University of Beirut Medical Center,
and CHU Hôtel-Dieu de France, Université Saint-Joseph, Beirut, Lebanon

About the authors:

• Professor Maurice Haddad, Former President of Lebanese Society of Radiology (LSR)
  and Pan Arab Association of Radiological Societies (PAARS)
• Dr. Shukri Loutfi, Chief Resident
• Professor Jean Tamraz, President of Pan Arab Neuroradiology Society (PANRS)
• Professor Aghiad Al-Kutoubi, President of Pan Arab Interventional Radiology Society (PAIRS)

Abstract

This is a first world report on the status of radiology in the Arab world. It discusses
briefly the history, radiological associations and staffing, healthcare systems and
equipments, radiation protection and control, training and qualifications, diseases and screening programs, and future directions for radiology in Arab countries.

Introduction

The aim of this world report is to give an overview on the practice of radiology in the Arab countries, with emphasis on the progresses that have been achieved and the problems encountered in this part of the world. The data are sparse and some of the information is based on personal recollections.

Historical Background

Shortly after the discovery of X-rays by the German physicist Wilhelm C. Roentgen in
November 1895, the first X-ray apparatus was installed in 1898 in Beirut at the Prussian Hospital affiliated since 1887 with the Medical School of the Syrian Protestant College founded in 1867 (later American University of Beirut in 1920). The first chest radiographs were produced after a long exposure time in 1900 by Reverend Père Maurice Collangettes at the Faculté Française de Médecine in Beirut and by Dr. Arthur Bacon and Mr. Brahim Youssef Succar the first X-ray technologist at the X-ray laboratory of Prussian Hospital. In Sudan, the first X-ray was performed in 1898 during British invasion battle of Omdurman. The first Lebanese specialized roentgenologist was Dr. Toufic Hajjar who trained in Paris from 1910 to 1912, and returned to Lebanon to stay for two years at the American University Hospital which was built in 1905 (later American University of Beirut Medical Center in 1970) as chief of the X-ray laboratory and then left to Egypt. Subsequently, Dr. Naadir Qadduwra (MD 1921 from Syrian Protestant College) who specialized in roentgenology in France and Germany (1921- 1923) came back and opened a private office in Beirut [1]. In neighbouring Damascus the X-ray facilities were limited and operated by physicians and surgeons like Dr. Nazmi Khani. In 1943 just before Syria’s independence from France, the first trained roentgenologist Dr. Muayyad Azm started practicing at the University Teaching Hospital but it wasn’t until 1950 when Dr. Wahid Sawwaf who had finished a full residency training in the United States, that the modernization of expansion of facilities started spearheaded by the building of the new teaching hospitals and Watani Hospital. In
Aleppo Dr. Tahsin Masri is credited with the establishment of the first radiological clinic.

The first Saudi Arabian radiologist was Dr. Mohamad Khalid Kashogi who graduated
from Damascus School of Medicine in 1921 in Syria, and certified as specialist from
University of Paris in 1932. In 1933, he installed in the “Holy city of Mecca” the first Xray machine in Saudi Arabia. Information on the history of radiological services in other Arab countries is not available.
In the last three decades modern imaging has found its way into the radiological practice throughout the region with increasing subspecialization. Interventional radiology, a specialty that started in academic centers like the American University in Beirut in the early 1970s has expanded extensively and enjoy a protected status in some countries like Kuwait but face the same challenges from other specialties just like in other parts of the world.

Associations and Staffing

The first associations of radiologists were established in Egypt in 1949 under the
leadership of Professor Mustafa Ragheb, and in Tunisia in 1952 under the leadership of Professor Ali El Fourati [2]. Similar progress was observed in other Arab states with slower development of the radiology community, because of lack of medical schools in some countries and priority of career choices which were directed mainly towards surgical and medical specialties but not radiology [3,4]. Table l shows some demographic and workforce data collected by the “Pan Arab Association of Radiological Societies (PAARS)” which was recently founded in Beirut in September 2004, with the participation of eleven representatives of Arab radiological societies. From this data we realize the serious shortage of radiologists that affect all Arab states with some variability if we consider an acceptable world standard of 70 radiologists per million people [6,7]. For this reason, there was an influx of professionals migration in the early 1980s towards the Arabian Gulf countries where job opportunities were more available. In the early 1990s the drive towards training and employing local health personnel started in some countries particularly Saudi Arabia but according to the recent data from the“Radiological Society of Saudi Arabia (RSSA)” the non-Saudi to Saudi radiologists ratio is still high estimated at 2.86:1. However, there is still at least one Gulf country that relies exclusively on expatriates for radiological services. All these problems are compounded by the worldwide shortage of radiologists in the setting of rapid technical development and subspecialization. Unbalanced distribution of radiologists and clustering in major cities has led to the introduction of teleradiology services in 1994 to underserved especially rural areas with limited human resources in the United Arab Emirates, Kingdom of Saudi Arabia, Jordan and Lebanon with mixed success [8]. The teleradiology service which is relatively expensive was used primarily for subspecialized consultations and videoconferencing over international telephone lines. It did not last long with the advent of the Internet that has largely replaced it in most countries with the possible exception of Saudi Arabia. Attempts at creating association with international societies to further knowledge were started in 1990’s. For example, associations with the“Société Française de Radiologie (SFR)” established in 1999 and memberships with the
“International Society of Radiology (ISR)”, were initiated namely with Mediterranean
and North African Francophone nations. Regional associations of radiologists such as the “Fédération Maghrébine de Radiologie et d’Imagerie Médicale” was founded in Tunis in 2003 comprising all North African Arab nations, and the “Gulf Society of
Radiology” founded in Beirut in 2004 comprising all Gulf countries. Several Pan Arab
societies for radiological subspecialties were also created like the “Mediterranean and African Society of Ultrasound (MASU)” founded in the Greek Islands in 1986 and
member of the “World Federation of Ultrasound in Medicine and Biology (WFUMB)”,
the “Libyan Society of Ultrasound in Medicine and Biology (LSUMB)” founded in the
city of Misurata in 1991, the “Pan Arab Neuroradiology Society (PANRS)” founded in
1994 in Beirut in association with the “World Federation of Neuroradiological Societies (WFNRS)”, the “African-Middle East Association of Radiologists” founded in Cairo in 2001, the “Egyptian Society for Women’s Imaging and Healthcare” founded in Cairo in 2005, and the “Pan Arab Interventional Radiology Society (PAIRS)” founded in Dubai in 2006.

Healthcare Systems and Equipments

Healthcare systems in the Arab world are varied, but in general are either government- subsidized or free healthcare systems [9]. There is an increasing number of privately insured patients and private health institutions [10], but only a small minority of selfpayers. In Lebanon for instance the private sector is growing because although governmental healthcare expenditure is quite high (representing for example in Lebanon 12.3% of the national gross domestic product (GDP) compared to a world middle-income-country average of 5.7%), yet the standard of medical care in the public sector is low ranking poorly on the overall health system performance ranking scale because of wastage of financial resources resulting in a coverage of less than 18% of the healthcare market. The radiology and laboratory billing proportion has remarkably increased in the past few years from 6-7% to 17-18% of the total hospital bills because of the increasing demand on radiology and laboratory services particularly expensive cross-sectional imaging. These data and figures were recently published by the Lebanese Order of Physicians. Radiologists working in governmental hospitals are usually paid a monthly fixed salary, whereas those working in the private health institutions are reimbursed on the basis of fee-for-service according to a nomenclature for professional acts. Some specialists may
work in both the public and private sectors. From the technical resources viewpoint data about the provision of equipment across the Arab world is lacking and much variation exists. Data from Lebanon show the number of radiology equipment available per number of population, to be equivalent to or slightly exceed that of industrialized countries (in Lebanon, 1 MR/125.000 inhabitants and 1 CT scan/45.000 inhabitants). However, the quality of imaging services is much inferior
because of lack of evidence-based or standardized system, lack of accreditation and
quality assurance or governmental control. In private health institutions or even clinics competition can lead to the purchase of the latest advanced and expensive technology such as a 3 Tesla MR or a PET scanner before they are acquired by academic teaching institution. Reforms in the healthcare systems are taking place, even in oil producing countries where they are considering the option of relieving government budgets from healthcare financing through the adoption of user charges and private health insurance to individuals [11]. The health authorities in the future will have a new role of planner rather than direct provider of healthcare services [12].

Radiation Protection

Rising awareness among radiation workers about radiation hazards or concern and
application of safety standards in radiology is noticeable. In this regard, several regional initiatives and meetings on radiation protection against ionizing radiation took place since 1994 with the latest effort in July 2005 at the Beirut Governmental University Hospital, in collaboration with the Lebanese Atomic Energy Center and the International Atomic Energy Agency (IAEA) which is a United Nations (UN) organization.

Training and Qualifications

Radiology education in Lebanon started in 1925 with the opening of “Institut de
Radiologie” at the Faculté Française de Médecine of Université Saint Joseph, it was
pioneered by Dr. Lamarche. In 1934, Professor Chaumet inaugurated the first course in radiology and radiotherapy at the same institute in “Hotel Dieu de France” university hospital. The second residency programme in radiology was established in 1950 in the department of Diagnostic Radiology at the American University of Beirut Medical Center attracting candidates from the region. The residency programme was initially for two years then extended to 3 years, and for 4 years training programme in 1997 with a very comprehensive curriculum that covers all aspects of conventional and advanced diagnostic imaging and interventional radiology. Integrated radiology teaching was also introduced into the basic medical school curriculum for education of undergraduate medical students in the United Arab Emirates [13]. Radiology teaching and medical reports are done in different languages e.g. Arabic (Syria), French (North African Francophone countries and Lebanon), and English in Lebanon and the remaining countries. Radiology residents obtain their national diplomas, certificates or fellowships, and then pursue higher education and qualifications in European and North American centers through links and affiliations with overseas universities. Accredited centers with the Royal College of Radiologists of United Kingdom and Ireland were established in 1973 in Lebanon and in 1986 in Saudi Arabia and Kuwait offering foreign qualifications prior to the uncoupling system adopted in 1995 with separation of the qualifying examination from training. The need for a unified qualification across the Arab countries was realized through establishment of “Arab Board of Radiology” by “The Arab Board of Medical Specializations” in Damascus in 2004 under the governance of the Arab League. Numerous radiology courses and conferences are offered by national societies, universities and teaching institutions [14]. The input and support of eminent immigrant Arab professors working in European and North American universities is of paramount importance in maintaining academic activities particularly in these difficult times when scholars from the Western hemisphere are discouraged from traveling to the Middle East for security reasons. The calendar for continuing medical education events is usually announced in local medical journals with little cross fertilization between the different countries in the region.
The only radiology journal that the authors know about is the “Egyptian Journal of
Radiology and Nuclear Medicine” which is not an indexed journal issued bi-quarterly.
Publication of radiological articles is limited, the majority of articles represent clinically oriented research directed to international journals for recognition and promotion purposes rather than pure funded research. Arabs produce less than 1% of the biomedical citations in the world [15].

Diseases and Screening

There has been a decline in the incidence of most infectious/parasitic diseases and malnutrition. However with the modernization and improvement in living conditions, traumatic particularly road traffic accidents, cardiovascular diseases and hypertension, obesity and hypercholesterolemia, diabetes, and cancer are on the rise [16,17]. Disease prevention is limited to vaccination programmes, while trends are towards curative rather than preventive medicine for other diseases. There are no national screening programmes for early detection of breast cancer and others in the majority of countries. Cancer databases from the Arab world have shown that breast cancer is the most common cancer in Arabic women and it presents at a younger age than in women of Western countries, which has led oncologists to recommend breast cancer screening starting at the age of 40 years. Only breast and prostate cancers awareness campaigns or studies are conducted for a short period of time [18]. In a survey conducted in the United Arab Emirates women lacked adequate knowledge about breast cancer screening, and only 10.3% of
women had mammography screening examination on yearly basis [19].

The Future of Radiology

The Arab world is rich in natural and human resources but has suffered for a long time from many devastating wars and sanctions that have hindered development and frustrated its people including radiologists. Major problems and challenges in health development remain to be addressed through thoughtful and appropriate planning and healthcare management. Radiology reflects the standard of medical care and one way to move forward is by increasing inter-Arab cooperation which is a giant step towards change.

Conclusions

We have tried our best to collect demographic data from all parts of the Arab world.
However, the collection of information from Iraq, Yemen, Oman, Somalia, Eritrea and
Djibouti was not possible despite an extensive effort to establish direct contacts and a search of the literature. The authors wish this first world report on Arab radiology with all its shortcomings to be a position paper for the Arab radiologists, junior and senior, and other health workers to strengthen their links and efforts towards improving the provision and standard of radiological care and training.

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Table 1. Demographic and workforce data of Arab radiological societies and states

– : No data available to the authors
N/A : No society is available
* : Data collected from ref. 5 in 1995 by N.M. Kronfol

ACKNOWLEDGEMENTS

The authors would like to acknowledge and thank Pr. Mahmoud El Meligy (Egypt), Dr. Adel Shannan (Syria), Dr. Bassam Sawwaf (Syria), Dr. Nouri Al Moudares (Syria), Pr. Mutasim Al Seed (Sudan), Dr. Mohammad Hiari (Jordan), Pr. Fathy Tantawy (Egypt), Dr. Nagib Al Marzoq (Kuwait), Dr. Abdul Hameed Al Awadhi (Bahrain), Dr. Sattam Lingawi (Saudi Arabia), Dr. Mohamed El Fortia (Libya), Pr. Najat Boukhrissi
(Morocco), Pr. Nabil Chikhaoui (Morocco), Pr. Salah Kechaou (Tunisia), Pr. Ridha
Mkaouar (Tunisia), Pr. Azza Hammou (Tunisia), Pr. Abderrahmane Fergani (Algeria),
Dr. Nabil Hijazi (Palestine), Dr. Ahmad Omar (Qatar), Dr. Mohamed Ould Beddi (Mauritania), Dr. Mohamed Abd El Bagi (Saudi Arabia), Dr. Mohammad Aabed Al- Thagafi (Saudi Arabia), Mrs. Zepure Mansour and Valentina Hamouche (Lebanon), Dr. Youssef El-Zein (Lebanon), Pr. Fouad Boustany (Lebanon), Dr. Bahij Arbid (Lebanon) and Pr. Sameh Morcos (United Kingdom) for providing information and reading the manuscript.

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