Dr Rijo Mathew 
Introduction
The population of India exceeds a billion people. The large population offers several interlinked opportunities and challenges for healthcare. These include the opportunity to develop models of healthcare that can sustain health and wellbeing for a large population and the challenges therein, and the opportunity and challenges to provide diagnostic and therapeutic care for a large population. The large population translates to more numbers of people affected by illness or disease (even if the proportion of disease may be lower) and translates to stressors on the healthcare delivery system.
Healthcare delivery in India is provided as a mix of primary, secondary and tertiary care models. These models exist in the private, not-for-profit and public sector, and models that include hospitals, institutes, healthcare centres, and individual or group practices. There is wide variation in the resources, infrastructure and practices between each level and even within each level. The variation exists as a pragmatic reality even though guidelines for clinical practice may exist for several disciplines. The variation can be attributed to variations in training, available resources including infrastructure and human resources, access to higher-level care, affordability of care and differences in socioeconomic and demographic characteristics in a vastly diverse country like India. These variations offer opportunities to develop low-cost alternatives that are cost-effective and can have a wider reach and utilization but also raise challenges in the reach and adoption of the best locally relevant clinical practices.
The impact of epidemiological transition on the health profile of India is a major consideration as we plan for healthcare delivery. There are 5 stages of epidemiological transition that include
- Age of pestilence and famines-malnutrition, infectious diseases, and high infant and childhood mortality with low mortality from CVD (<10%)
- Age of receding pandemics-when better public health systems lead to decreased mortality from communicable diseases and emergence of CVD as important, with 10%-35% mortality
- Age of degenerative and human-made diseases is characterized by mortality from CVD surpassing mortality from communicable diseases and leading to 35%-65% of all deaths
- Age of delayed degenerative diseases, when cancer and CVDs are predominant causes of deaths and CVD leads to >40% of all deaths but there is a declining trend in death rates
- Age of inactivity and obesity, when declining physical activity leads to epidemics of diabetes, hypertension, and lipid abnormalities, with increasing CVD deaths rates
The large population of India and its diversity of terrain and resources translate to differing, yet significant levels of these 5 stages of epidemiological transition, between and within states in India.
Medical care is evolving rapidly with technological solutions offering the potential for better care models. A major limitation with technology is the ability to scale these advancements to reach a wider section of the population. Technology advancements often translate to costly interventions when scaled up to clinical practice before they reach a critical sustainable level that is affordable, accessible and available and yet retains high quality. More often than not, technology advancements remain the preserve of tertiary care or advanced centres till such a critical mass is achieved. More often not, the technology becomes obsolete even before a critical mass is achieved as rapid newer advancements turn existing technology into non-viable models of lower quality.
Radiology
Radiology is a discipline of medicine that has the potential to integrate with preventive, screening, diagnostic, therapeutic and interventional models of care. There is increasing recognition of the expanding role of Radiology (that is viewed primarily as a diagnostic discipline) in preventive, screening and interventional medicine.
Radiology has several advantages
- Objective evidence image based approach
- Technology advancements in image quality, acquisition, storage and interpretation
- Minimally invasive and relatively painless approach
- Pool of trained experts with a base of undergraduate medical training (Radiology is a post graduate medical program with super specialization) and hence an increased awareness of the basics of several medical conditions
- Existing resources including infrastructure
The challenges are to
- Optimize the use of this highly trained pool to provide healthcare services to a larger section of the population
- Integrate radiology services with primary and secondary care health services
- Integrate radiology with preventive and screening models
- Optimize radiology to triage patients that need higher levels of care and for clinical practice algorithms at different levels of healthcare
- Optimize the potential of radiology to derive population based “normal” parameters and nomograms
- Develop low cost point of care and portable equipment that can allow image acquisition even from populations in remote areas
- Develop networked image interpretation services that can allow for the provision of high quality care without the necessity of “physical transportation” of radiological expertise.
Radiology can
- Be used for Functional assessments- Organ Functions & OMICS- genomics, proteomics, lipidomics, metabolomics, and epigenomics
- Integrate information to predict the onset & Progression of disease
- Localize the disease,
- Identify the spread of the disease to adjacent or distant tissues, organs, and structures
- Assess the physiological environment and conditions of disease,
- Plan and guide surgical or minimally invasive surgery,
- Assess perfusion of lesions or diffusion in tissue as well as the vulnerability of adjacent organs to predict the success of interventions
- Screen using Imaging Biomarkers-Proactive Screens/Diagnostic Testing
- Radiology OPDs
- Therapeutic & Follow Up Protocols
We will explore the use of Radiology for these purposes in the next series of posts with a focus on the practical and pragmatic integration of Radiology Services at different levels and models of healthcare in India.
Dr. Rijo Mathew is a Member , Scientific Advisory Committee, IRIA, Member in Charge of Ultrasound, Career Assurance Program, IRIA, & In Charge, National Fetal Radiology CME Programmes of IRIA. Dr Rijo is the National Coordinator for Samrakshan, an IRIA program of IRIA that aims to reduce perinatal mortality in India.
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