Defeating Diagnostic Deserts in Conflict Zones and at Home

By Matt Phillion

A pilot project has brought together American and Canadian doctors to remotely train medical personnel in Yemen on patient diagnosis using a portable ultrasound device. Bridge to Health Medical and Dental, an organization empowering low-resource settings to establish low-cost, sustainable solutions for care, teamed up with Butterfly Network to use the latter’s portable ultrasound to help providers improve care for their patients.

Before their work in Yemen, the two organizations worked with organizations in Africa, explains William Cherniak, MD, cofounder and chair of Bridge to Health and founder and CEO of Rocket Doctor.
“When we started 10 years ago, our partners in East Africa had not come across a portable ultrasound. As technology evolved, we gave them a follow-up survey for the things they could use this for. One of the things that rose to the top was diagnosing pneumonia in children,” says Cherniak.

They formed a partnership and taught mid-level providers how to use the portable ultrasound, called the Butterfly iQ+, in the field for pneumonia diagnosis. The two organizations also set up a cloud-based teleradiology system, enabling doctors in the U.S. and Canada to review the results and give feedback to remote providers. “They were able to diagnose this illness from the other side of the world,” says Cherniak.

They then began to consider ways they could use this technology to train doctors and providers elsewhere. “We asked: Could we use it in a conflict zone?” says Cherniak. “Could we provide some sort of healthcare in a conflict setting?”

Dr. Nahreen Ahmed, the co-lead with Cherniak on a grant from Grand Challenges and the head of ultrasound at Bridge to Health, is a pulmonary clinical specialist who had worked with a group in Chicago that had a project on the ground in Yemen. The grant was applied for and won, and work began—but then the COVID-19 pandemic hit.

“We had thought we’d go into the field and start training for the first week, then flip back to a cloud-based system,” says Cherniak. “But when the pandemic hit, we couldn’t travel, we couldn’t get into the country.” Thankfully, Butterfly had released a teleguidance program that enabled the team to redesign their initiative, thereby allowing clinicians to train their counterparts without having to be on-site.

“It took us a while to figure out how to ship lithium-ion batteries into Yemen and how to work with our partners on the ground. We funded the hospitals to put up satellite internet to enable video calls,” says Cherniak. But they were able to get the ultrasound probes into the country and set up a robust virtual curriculum.

One of the most frequent problems with training for low-resource settings, Cherniak explains, is that the trainers may only provide on-site supervision for a few weeks out of the year. “The beauty of this setup is that we’re able to provide continuous feedback so you can always learn and improve,” he says. “Internet permitting, you can get online in real time to see the images.”

The hardest part, Cherniak says, is teaching the technique for holding and adjusting the probe, since small adjustments can significantly improve the quality of the image. “With traditional ultrasound, we call it knob-ology, but with the Butterfly it’s more app-ology, changing and adjusting the settings to improve the end result,” he says. “We got lucky with this program and partnership in that we had folks on the ground to support the initiative. There was a vascular surgeon in Yemen who was available to work with our trainees and help them in person to move the device” to improve their overall training.

Disruptive technology for better diagnostics

This sort of action—putting tools into the hands of providers who might otherwise not have access to them—is part of why Butterfly Network was founded, says David Walton, MD, senior director of global health for Butterfly Network and a physician with Brigham and Women’s Hospital and Harvard Medical School.

“We want to democratize imaging everywhere,” Walton says. “Part of that is miniaturizing the old systems. It’s very disruptive—taking the old tech and digitizing the probe. With the old cart-based system you have different probes for different parts: a cardiac probe, a linear probe, a pediatric probe. But when you digitize ultrasound, you can have one probe and toggle which body part you’re about to image, easily, from the palm of your hand.”

The Butterfly iQ+ is the world’s first handheld, single-probe whole-body ultrasound system using semiconductor technology. It plugs into devices such as smartphones. “This enables you to use it in any setting in any part of the world,” says Walton. “Places with years of significant conflict can be diagnostic deserts, often without plain film radiology, 3D imaging, or any kind of cross-sectional imaging like CTs or MRIs. But when you put this kind of device in a clinician’s hands at the bedside, they can make the right decision for the right patient at the right time.”

This impact can be seen not just in remote areas or diagnostic deserts, Walton explains—the device is useful at home too. “I’m in an academic, Harvard teaching hospital, the antithesis of a diagnostic desert, and I have it with me on rounds and use it to help make more-informed, real-time decisions,” he says.

And while having that option is a plus at a place like Brigham and Women’s, Walton says, “in places like Yemen or Uganda, there is no other option. You have a stethoscope and that’s it. What this brings to the clinicians there is incredibly powerful.”

The challenge, Walton says, is the training to get those clinicians up to speed. The ability to offer teleguidance during the pandemic was a game changer. “With the teleguidance feature, you’re looking at the phone with a split screen—half of the screen is what my hand is doing with the probe, and the other half is the image,” says Walton. “You can guide and help interpret the image in real time.”

Alternately, he says, there’s the option to do quality assurance asynchronously: The imaging is uploaded to the cloud and a trainer can look at it, provide advice, and send annotated results back to the clinician. “We’re also able to have extended offline mode—we recognize that they’ll be using the device in a very austere environment and don’t have high-speed internet,” says Walton.

The program operates in environments that rely on gasoline-powered generators, in areas with food or water shortages, where it’s difficult for clinicians to even get to work in the first place. To have internet up and running is remarkable. “We’ve prepared for this, and this is what it’s designed for,” says Walton. “We understand the realities of these environments.”

The collaboration is allowing both sides to push portable ultrasound training to the limit, making this diagnostic capability more accessible to the places that need it most. “What are the challenges Bridge to Health [is] facing, and how can we continue to improve so we’re making it even easier to use from the UI perspective?” says Walton. “That helps everybody. They’re doing some of the hardest work anyone is doing with it, and that flows upward—a novice user at Brigham is able to learn faster based on this.”

Butterfly is developing deep learning and AI tools to help with skill acquisition, cutting down on the amount of training new users need. “This enables the clinicians on the ground to invest that energy and money elsewhere, to leverage it even further,” says Walton.

As the program is coming to the conclusion of its grant, Cherniak says, the goal is to work with Grand Challenges to win a transition-to-scale award to roll out the program across Yemen and beyond. “We’ve already had signals that there are a lot of doctors that want this and a lot of hospitals that need it,” says Cherniak.

Bridge to Health is already working with a new clinic in Peru, on the Amazon River, that services remote fishing villages. “They have no diagnostic imaging right now,” he says.

Improving diagnostic imaging isn’t just for remote places in the world, both doctors say: The U.S. and Canada have their own diagnostic deserts that can benefit from new, disruptive technology.

“My title is director of global health, and people draw the conclusion that that means non–North America, but that’s not true,” says Walton. “I’m in Boston, and not a mile away there are places that lack access, despite being surrounded by academic teaching hospitals. Our collective challenge is: How do we think about global health with a truly global vision and create the equity we believe our patients deserve? Lack of access doesn’t mean they should get lesser care, especially when we’ve enabled an advanced clinical assessment tool for every caregiver pocket.”

Matt Phillion is a freelance writer covering healthcare, cybersecurity, and more. He can be reached at matthew.phillion@gmail.com.