The Economics of Medical Imaging in Africa

Submitted by Saurabh (Harry) Jha, an Associate Professor of Radiology at the Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA. Dr. Jha is also a member of the Applied Radiology Editorial Advisory Board, a writer, and a global radiology enthusiast. He can be reached on Twitter @RogueRad.

Unlike the Radiological Society of North America (RSNA) annual meeting, where vendors are separated from academics, vendors and radiologists participate together in scientific sessions at the Association of Radiologists in Nigeria (ARIN). At the 2022 edition of the meeting in Lagos, Nigeria, a radiologist asked why vendors don’t lower equipment prices for African markets.

Guy Poloni, a product specialist at Siemens Healthineers, responded that the challenge with lowering prices for African markets is the uncertainty impacting the ability to project demand. Demand is an important factor in planning sales, which in turn require training and engineering support teams to address equipment problems. Small markets present a significant planning challenge, he said, and vendors prefer to market in wealthier countries not because they are wealthier, but because their markets are more transparent, making equipment demand more predictable.

Poloni’s concern comports with economic theory. In his book, Risk Uncertainty and Profit, economist Frank Knight distinguished between risk, which can be quantified (eg, the chance that a coin toss will land head’s up) and uncertainty, which cannot be quantified (eg, the chance that one country will invade another). Uncertainty is never zero; it’s just not known how are from zero it lies. As a result, most corporations prefer risk over uncertainty because risk gives them the illusion of control. In his view, Knight believes entrepreneurs should be rewarded for uncertainty, as it is riskier than risk.

Uncertainty is a particular issue in Africa because the continent isn’t an economic monolith. West African countries such as Nigeria are economically ahead of sub-Saharan and East African nations. Nigeria’s economic growth increases uncertainty, not just because its growth is uneven, but because one doesn’t know when demand for medical imaging, an inevitable result of rising prosperity, will rise or fall. With considerable investment in Nigeria, mostly from China, medical imaging may become both abundant and scarce. There may be CT scans without radiologists to interpret the images, and patients who cannot gain access to CT scans.

Godwin Ogbole, MD, professor of radiology at the University of Ibadan, Nigeria, wants vendors to acknowledge local nuances when marketing their technologies in Africa. The continent’s nations have more in common with each other than they do with Europe and North America. For one, they endure intermittent power outages. Superconducting magnets, the lifeblood MRI scanners, require continuous electrical power.

Dr. Ogbole advocates for low-field MRIs, whose magnets don’t rely on cryo-freeze. He likens them to the Volkswagen Beetle, the cute, hump-backed automobile of years gone by. The more powerful MRIs, he says, are like Bentleys, and vendors have two options: to either make the Bentleys cheaper or make the Beetles more sophisticated. The latter, he believes, is the more sustainable, Afro-centric option. Dr. Ogbole wants vendors to innovate for Africa rather than to force overpriced Bentleys on Africa. He wants Beetles to be so good that they’re mistaken for Bentleys.

If necessity is the mother of invention, I would argue that scarcity is the mother of necessity. Africa’s needs have encouraged MRI physicists to innovate within the imaging reconstruction space rather than within the hardware space, with techniques such as compressed sensing, de-noising, and K-space undersampling, with the goal of boosting the quality-to-price ratio. Low-field MRIs are lower maintenance, safer, and more portable. In a sense they are Africa’s MRI.

However, from a different perspective, they are merely a Band-Aid, a temporary fix in a dynamic economic environment; a technology that undervalues Africa’s potential. They work because patients with neurological disease, for instance, often present late in the disease process. Patients with stroke typically present beyond the third day, when they’re outside the treatment window and it is easier to detect stroke because plenty of neurons are dead and the brain has been replaced by water. To detect hyperacute stroke while it’s still treatable, more sophisticated pulse sequences such as diffusion weighted imaging, which need stronger gradients — basically, stronger magnets, are needed to detect the subtler signs.

Low-field MRIs are noisier and have more artifacts. In another manifestation of the Inverse Care Law, the poorest get the cheapest MRI scans which, paradoxically, require more skill to interpret and are more prone to false negatives and false positives. These limitations notwithstanding, Dr. Ogbole believes the strengths of low-field MRI outweigh the weaknesses. He cautions that we should not let perfect become the enemy of the good.

Indeed, cheap can be costly. One example: equipment purchased on the open market.  Private companies often sell cheap, refurbished scanners to African buyers. They often work but they also often do not. Vendors are reluctant to solve technical issues with refurbished equipment because they are removed from the purchasing loop. The free market does provide service engineers, but with no pre-specified expectations, the quality of service varies. So-called “bargains” can have expensive tails.

To avoid the changing weather of free markets, radiologists and purchasers must form relationships with vendors. Vendors reduce prices for bulk purchases. This sounds like simple economics,  but it isn’t so simple. For a start, bulk purchases need a guarantor — demand. Anyone working in US hospitals knows that demand isn’t the same as need. That Africans have considerable medical need is indisputable. What’s disputable is that need always translates linearly to demand.

Consider the late presentation of stroke patients: why do patients typically present late?  The tempting explanation, which is partly correct, is cultural resiliency — the reluctance to bother doctors. Resiliency is an endearing trait. Who would you rather have a beer with, the battle-hardened Appalachians or the Moaning Manhattan Myrtles? But culture doesn’t arise in a vacuum. Africans may be reluctant to seek medical attention when they should because they often can’t. As nations prosper, access to medical care improves and culture changes. As culture changes, demand increases and patients want more.  “Get me an MRI stat!” a common demand from American physicians, signals impatience more than it does the immediacy of medical doom. Impatience is a surrogate for prosperity. Impatience will arrive in Africa.

None of this will happen linearly; it will occur gradually for a time and then suddenly explode. Africans will present with stroke within 24 hours for a time, and then within a few hours. Then they will go to the hospital with symptoms suspicious for stroke. Many won’t have stroke, but many will want and/or need MRI for reassurance. Demand will increase and then skyrocket, just as it has done in the US.

The only uncertainty in all this is timing. For vendors, the timing of the demand explosion in Africa is the billion-dollar question, but it is the wrong question. The vendors that will succeed in Africa are those that will assume the demand will increase and will not fret about timing. Instead, they will ensure they’re on the ground helping Africans build their imaging infrastructure. Its faith in underdogs that should be rewarded.

Thanks to Moore’s Law, computer chips have rapidly become less expensive. But they also have rapidly become obsolete. In an ironic twist, Moore’s Law has reduced the shelf life of equipment that relies on chips, such as CT and MRI scanners. This is just as well, because transience is the business model of imaging vendors. They must continually build new stuff. We, the consumers, must continually demand new toys.

Transience is the right assumption to make in Africa’s dynamic economic environment. Vendors must innovate, remaining aware of the present while also anticipating the future. Equipment contract negotiations should foresee the probability of equipment upgrade. If MRI field strength is a proxy for prosperity, then low-field MRIs are currently appropriate. But their permanence shouldn’t be assumed. Because one day Africans will demand Bentleys.