History of Radiography in Ghana: development, Challenges and the way forward.
PREAMBLE
The practice of radiography and radiology began, just after X-rays were discovered by Professor Wilhelm Conrad Roentgen, a German Physicist, in 1895. It was employed in the medical field by the military, especially during wars to detect embedded bullets or pellets of gunshot wounds sustained by the combatant soldiers.
DEVELOPMENT OF RADIOGRAPHY AND RADIOLOGICAL SERVICES IN GHANA
The advent of radiological services in Ghana was barely thirty-two years after the discovery of X-rays when Korle-Bu Hospital was built by the then colonial Governor, Sir Frederick Gordon Guggisberg, precisely in 1927. By 1929 and with a nationwide outbreak of tuberculosis, especially among miners in the mining areas, the colonial government requested for the establishment of an X-ray Unit at Korle-Bu Hospital for screening the citizens for early treatment. This was under the management of British radiographers who later co-opted some nurses to train them as their assistants, namely Messrs Thompson and Asiedu, both of blessed memory.
ACKNOWLEDGEMENT AND DEVELOPMENTS
A formal training School under the Ministry of Health was established at Korle-Bu Hospital for local training while a few people like Mr. C.S.K Ocansey, who became the first Chief Radiographer in the country and Mr. E. B. Ephson, who also became the first Ghanaian Training Officer of the School in 1951, were sent to the United Kingdom to train as Radiographers. Since then several people passed through the School and the products were designated as “X-ray Operators” (a misnomer) which changed to later Radiologic Technicians. Products were awarded a Proficiency Certificate by the Ministry of Health.
Other people of reckoning include Mrs. Francois (the Proprietress of New Horizon School at Cantonments) the first female Ghanaian Radiographer, late Mrs. Elizabeth Nyarkoah Lewis, Mrs. Victoria Mills, Mrs. Agnes Odonkor and Mrs. Harriet Duah, the latter four all becoming Chief Radiographers while Mrs. Duah also became the Principal of the Training School taking over from Mr. Adjei Buady, through its transitionary periods of Certificate-awarding and Diploma-awarding and as well becoming instrumental in the drawing of the Curricula for both the Diploma and BSc Programmes. She also held fort at the inception of the BSc Programme, until the younger generation came over from their postgraduate studies. She continued to lecture and finally bowed out in 2010. Let me also add that Mr. Ephson continued to teach till a ripe age of 80 years.
Other senior members like Mr. John Quaye who taught in the Training School and Mr. John Gakpetor, both becoming Acting Chief Radiographers, must be acknowledged. On the Technician side, there were two admirable ladies who contributed tremendously to the formation of most of us, the late Mrs. Dorcas Yeboah (nee. Dorcas Nunoo,” May her soul rest in perfect peace”) affectionately called Sister Dorcas or Auntie Dorcas and Mrs. Grace Nkum (nee Grace Adu). In fact space and time will not permit mentioning all, but we need to doff our hats to all who have contributed in no way to the development of radiography in Ghana.
Among the Radiologists, the late Dr. Frederick Ferdinand Christian was the first Ghanaian trained Radiologist to be appointed after the British team had left around the late 1950s and headed the Radiology Department of Korle-Bu Teaching Hospital and the entire radiological services in Ghana until the late 1980s. He was succeeded by the late Dr. Kofi Jumah Boateng who retired in 2001 as the first Professor of the Department of Radiology at the University of Ghana Medical School. Both contributed a lot to the development of the Radiological services in the country, especially in human resource development and equipment. It was during the headship of Professor Jumah Boateng that the first CT Scan equipment in the country was installed at Korle-Bu Teaching Hospital and the Curriculum for the undergraduate programme was developed for the School of Allied Health Sciences. He, together with Mrs. Agnes Odonkor, the then Chief Radiographer, served on the taskforce that developed the modalities of the establishment of the School of Allied Health Sciences.
Other Radiologists to be remembered are the beloved late Dr. Kotei, Dr. W.O Brakohiapa (Retired), Dr. A.A Yeboah who took over from Prof. Jumah Boateng and the present crop of Radiologist, including Dr. V.K Hewlett, who took over from Dr. Yeboah and the current HOD, Dr. Yaw Mensah Boateng, affectionately called Dr. Yaw B. Others are Dr. Samuel Asiamah, currently, the Director of Medical Affairs of the Korle Bu Teaching Hospital, Bishop Dr. E.M Ogoe (with the Lighthouse Church Hospital and an Evangelist) and Dr. E.O Brakohiapa (a Lecturer with the Radiology Department of UGMS) and Dr. Col Kaminta of the 37 Military Hospital were the first locally trained Radiologists by the UGMS while Dr. (Mrs) Klenam Dzefi Tettey, is the first female locally trained Radiologist.
Radiography worldwide, in both education and practice, has developed from simple and primitive technology to computerized technology. It has developed from the time when only X-rays were used to produce images to using high frequency sound and magnetic resonance to produce images. We have moved from the production of unidimensional images to the production of 2- and 3-Dimensional images with the ability to demonstrate soft tissues which had hitherto been a mirage. Radiography has indeed developed so fast that we can now use it for forensic investigations to assist in criminal prosecution.
The same development in technology transmits to the classroom for training radiographers since they have a lot more to perform in the clinical area than is seen now, especially in our side of the globe. Radiographers not only produce the images, but they have the additional responsibilities of ensuring that what they produce provides the appropriate information for the management of patients. They have to ensure that their clients go through the correct procedures, receive quality care, protected from unnecessary irradiation, have the appropriate information as to what examinations and procedures they will go through, and therefore provide avenues for informed choices. Radiographers also are required to protect the clients’ rights as regards privacy and confidentiality, and also have to bear the responsibilities of their own actions and decisions taken when providing services to their clients.
Radiography education has evolved through the ages. With the advancement in healthcare delivery coupled with the principle of evidence-based medicine and enhanced by modern technological advancements, the level of knowledge and skills required to practice as either a Diagnostic Radiographer or Therapy Radiographers also changed dramatically. In the United Kingdom and other jurisdictions the programme changed from awarding higher diploma to a university bachelor’s degree of minimum 4-years duration. This was because much was required of radiographers, as imaging and radiation therapy professionals. Radiography now entailed application of much knowledge and skills in the care of the patient. Radiography evolved to include complex diagnostic investigations and application of newer technologies to treat patients. Messrs. James William Ampofo, Samson Awuni Aweligiba and late Steven Kudjoe Kudiabor were beneficiaries of Ghana government-sponsored training programme in BSc Diagnostic Radiography in Cuba. They returned to Ghana in 1997. They had benefited from the new trend in radiography education and clinical application in the newer modalities, namely Medical Ultrasonography, Magnetic Resonance Imaging, Computed Tomography and Digital Subtraction Angiography. More radiographers were to follow suit from then, some receiving their training in South Africa, others in the United Kingdom and finally most of the rest from Ghana, when the School of Allied Health Sciences of the University of Ghana was finally established in 2002. This was indeed a new generation of Radiographers, built from the solid foundation laid by the older and faithful generation.
All through the years of radiography and radiology services in the country, it had been limited to the diagnostic area while patients who required therapy had to travel outside the country for such services. The Government, the Ministry of Health and the Ghana Atomic Energy Agency found it prudent to establish the National Radiotherapy Centre to take care of radiation therapy services. This materialized with the support of International Atomic Energy Agency (IAEA) to establish the National Radiotherapy Centre in Korle-Bu Teaching Hospital in 1997 and the second one in Komfo Anokye Teaching Hospital in Kumasi, Ashanti Region.
Personnel to man the centres were initially taken out from serving professionals to include doctors, nurses and radiologic technicians who were sent to the Republic of South Africa. Names to be mentioned include Doctors Joel Yarney and Verna Vanderpuye as Oncologists, Messrs. Michael Mordey, Julian Kumah, Samuel Denyoh, Mr. Kwaku Duah (in KATH) and Miss Stella Asieduwaa Danso as Therapy Radiographers (among them, only Mr. Denyo is presently serving in the Centre) and some Therapy Nurses. Dr. Samuel Yaw Opoku did his BSc in Therapy Radiography in the USA and the PhD in London. One name worth mentioning is Mr. Eric Torgbor of blessed memory, who was so helpful in the practical training of the first, second and third batches of Therapy Radiography students. He was called to his maker just before his final examination results were released as he joined the third batch of students. The School and the Department of Radiography have since between 2003 and now graduated six cohorts of Therapy Radiographers manning the two centres with one of them, Mr. Kofi Kyei Adesi, now a Senior Member of the Department.
The first female Therapy Radiographer, Mrs. Vivian Atuwo (nee, Vivian Della) was locally produced by the Department and has gone on to pursue a postgraduate programme in Medical Physics at the School of Nuclear and Allied Sciences at GAEC, Kwabenya. A few others are out pursuing postgraduate programmes or have joined the Department as Research Assistants with the hope of pursuing postgraduate programmes to become full Senior Members.
It is also worth noting that a few graduates in Diagnostic Radiography have joined the Department as Research Assistants and Clinical Tutors and it is hoped that very soon they will become full Senior Members. Again two Senior Members of the Department are presently enrolled on to PhD Programmes in the UK and may soon complete the Programme. The first batch of post-graduate students, six of them, of the Department were admitted into an MSc Medical Ultrasonography programme in 2012 and graduated in July 2014. The third cohort are currently on the programme. The curriculum of the programme is under review to expand it to include other areas of specialization.
This so far is the development of Radiography in Ghana.
CHALLENGES
In Ghana many challenges have been faced in both the training and practice of radiographers, especially in the designation of graduates of the Training School by the Ministry of Health and the appropriate remuneration due to personnel; equipment and personnel attrition.
The designation of “X-ray Operator” or “X-ray Technician” of personnel trained in Ghana had been a misnomer and therefore had attracted fewer prospective personnel into the profession. Their placement on a scale on the Payroll made personnel inferior to their other parallel colleagues in the health sector till the early 2000.
Personnel designated as radiographers were trained outside the country, i.e. United Kingdom, Nigeria, Cuba, the Republic of South Africa and Algeria. This became a drain on the financial resources of the country since a number of such beneficiaries failed to return and the result was that the government stopped the award of scholarships to technicians desiring to pursue the professional practice. This problem was, however, resolved with the introduction of the Diploma and Degree Programmes in 2001 when the then Principal of the Training School, Mrs. Harriet Duah, together with her counterpart at the School of Medical Laboratory Sciences, strongly pushed for the upgrade of the Certificate Programme to the Diploma Programme. That eventually led to the development of the BSc Programme. One person, whose name needs to be mentioned here for such progressive developments, is Dr. J.D Otoo, who was the Director of Human Resources and Development Division (HRDD) at the Ministry of Health (now Human Resources and Health Development, HRHD). He was very instrumental in the establishment of the two Programmes. He was the one who approached University of Ghana on the establishment of the BSc Programme with a financial support to the tune of 2 million Euros from a German team from the University of Ulm and the European Union.
The Diploma Programme started in 2001/2002 academic year while the Degree Programme in the same year, under the School of Allied Health Sciences, had the first admission of students from the Medical Laboratory Sciences and the first batch of Radiography students been admitted in the 2002/2003 academic year. In 2006, the School of Radiologic Technology (and Medical Laboratory Technology) for the Diploma Programme became affiliated to the School of Allied Health Sciences to be awarded a Diploma Certificate by the University of Ghana. Admissions to the Diploma Programmes stopped by 2008 when the last batch of students passed out. The two Programmes helped to stem the tide of shortage of personnel as a result of some improved conditions of service.
On the part of equipment and other inputs, this became a serious challenge in the 1980s when almost all the equipment countrywide were broken down, with an acute shortage of film inputs due to foreign exchange crunch that the country faced when the Military took over the reign of government in 1979 and 1981. This culminated into a serious departure of a larger part of the workforce, especially in the academics and health sector, to the neighbouring countries for greener pastures. Almost a whole crop of newly qualified Radiologic Technicians and some old hands left to work in Nigeria. The Departments were so depleted that untrained person, especially Darkroom Technical Assistants took over and this has gone on till date when there are still pockets of untrained hands being employed by some hospitals, especially private and mission hospitals.
The most serious challenge was the absence of a Regulatory Body to regulate the practice of radiography and the other allied health professionals. Moreover these professions were not registered as Trade Unions and therefore had no bargaining power to ensure they had their maximum remuneration like other health professionals. They were erroneously grouped under the Health Services Workers Union which is a conglomerate of non-health professional personnel but working in hospitals and registered with the Ghana Trade Union Congress with a Bargaining Certificate to negotiate for Salaries and Wages levels. This seriously affected the integrity of salaries for not only Radiographers and Radiological Technicians but all other allied Health professionals. It seriously demotivated qualified personnel and a number of the younger generation found themselves moving to pursue courses in other areas they considered more lucrative.
One area of concern worth mentioning in the development of radiography is the acquisition of equipment. It was noted in the 1970s that in the procurement of equipment, the radiographer as the end user, was never consulted or completely left out which affected the quality use of the equipment. A recommendation was submitted through the Head of Department and general radiological services in the country to the Ministry of Health for the setting up of task force on procurement comprising of a Radiologist, a Radiographer, an Engineer from the Technical Division and a Technocrat each from the Ministries of Health and Finance to come out with proposals on equipment suitable for use in the country. This could enhance the efficient and effective use of such equipment and prolong their lifespan. However, this recommendation had never been implemented and pieces of equipment are being installed all over the country without personnel to manage them.
Another serious situation which has been a big disincentive is placement of personnel on the Payroll. Personnel who were already practicing Radiologic Technicians and went on to pursue the professional programme returned to a salary placement which made them worse off. The existing structure in clinical ranking and salary of the Ministry of Health does not have placement for personnel who decide to pursue postgraduate programme. For such personnel, the Academia is the current safe haven where their worth and skill are well appreciated
THE WAY FORWARD
With the introduction of the Diploma and Degree Programmes, more people have been trained to fill the vacuum that was created in th 1970s and 1980s and it is hoped that the gap could be bridged soon. However, the problem of placement on the Payroll is yet to be resolved and the worse is the government’s embargo on employment that has seen so many of the products without work. Though some have moved into private hospitals, a number is yet to be absorbed and are becoming frustrated. The setting up of a Diagnostic Centre is capital intensive, it could have been suggested that groups of qualified personnel could draw proposals to Financial Institutions to secure assistance to establish diagnostic centres in areas where the services are lacking.
The Ghana Society of Radiographers must seriously collaborate with the sister allied health professions to strengthen the Ghana Federation of Allied Health Professionals to vigorously pursue the course of becoming an independent member of the TUC and thus obtaining its Bargaining Certificate.
The GSR needs to strengthen its Secretariat and gets its offices outside Korle-Bu Teaching Hospital and employ at least a fulltime Secretary and ensure that the Secretariat is able to collaborate with all institutions that matter for members’ progress.
The Department of Radiography is reviewing the postgraduate programme in Ultrasound to include other areas of specialisation (including Therapy) and graduates must take advantage of enrolling on the various programmes, despite the cost involved. The Programme is for Radiographers and people should look at the enhancement of their future practice. The need for research activities, and in deed publications are necessary to enhance the profession’s image. Professionals should be encouraged to think of continuousprofessional development (CPD) and education (CPE).
The Government, as a matter of urgency, should strengthen the Allied Health Professions Council to establish the various Sub-Committees under the Council to enable it implement its regulation of practice since there are several facilities with unqualified personnel depriving the properly trained radiographers being employed. Moreover the Ministry of Health should as a matter of priority work towards establishing a salary structure for allied health professionals who pursue postgraduate programmes to enhance their practice as specialists in their fields but not see them as unwanted in the practical field, which has been the norm at the Ministry. This could go a long way to retain qualified professionals in the hospitals and as well enhance Clinical Supervision of students.
Finally, already practicing radiographers should have the vision for where they want their profession to be in the next decade. If we do not feel proud about our own profession and work towards making it highly appreciated by the public and raising its image, there is no one to do it. We must feel proud of our profession to the extent that we can recommend our own children to join but not feel ashamed of it when we are asked of our profession. We need to work towards the upliftment of the image of the profession by ourselves by doing research and publishing them.
By Mr. Lawrence Arthur (Lecturer)
Department of Radiography, School of Allied Health Sciences,
College of Health Sciences, University of Ghana, Legon