Scientific Forum in Vienna:
Better Health for the Poorest
J. Ford, IAEA Division of Public Information
The use of nuclear technology to improve human health was the underlying theme of presentations and discussions at the second morning session of the Scientific Forum. The challenge here is not just to transfer technology, but to ensure that any technology transferred is both relevant to local needs and sustainable development.
Screening newborns—an important public health tool
One important use of nuclear technology is in screening newborns for congenital disorders. In Thailand, there is a high prevalence of congenital thyroid disease, despite the fact that national programmes to provide essential iodine through salt and drinking water have been operating since 1962. To answer the question why and, more importantly, to prevent the mental retardation that can result, a pilot project was developed with Agency assistance to develop the tools needed to screen newborns for signs of hypothyroidism.
The thyroid is a small gland located at the base of the throat. It produces important hormones for growth and development that can influence how well the brain develops, organs function, and growth is achieved. Iodine deficiency, in the mother during pregnancy or in the first few months after birth, slows the production of thyroid stimulating hormone (TSH), the hormone that stimulates the thyroid to develop normally.
In parts of Thailand, the incidence of iodine deficiency is high. One in 900 babies are born deficient versus one in 3-to-4000 on average worldwide, and one in every 1,792 births has congenital thyroid disease, according to Dr. W. Charoensiriwatana of the Thai National Institute of Health. The pilot project initially used the radioimmuno assay (RIA) technique, where antibodies raised to identify specific molecules such as TSH are labelled using radioactive isotopes and measured to determine whether TSH in the blood is sufficient for normal thyroid development. With time and experience, local researchers were able to adapt the RIA method and develop a new method called immunoradiometric assay (IRMA) with locally developed reagents, rather than Agency-supplied ones. Based on this success, a full national screening programme was developed. Beginning in 1996, the government has provided some $15 million financial support over five years for four centres, including construction, equipment, and operating costs.
Today, the centres have screened some 1.4 million babies for these deficiencies. If detected and treated in the first month, the devastating effects on brain development can be prevented, and the financial and societal costs of the resulting unfulfilled potential, estimated to be some $129 million in Thailand alone, can be avoided.
But the human impact of this work can be measured in more than just dollars and cents; 430 children have had been treated successfully. The programme is also sharing its success by providing expertise and reagents with other developing countries in the region.
Health through proper nutrition
Good nutrition, especially in young children in developing countries, can mean the difference between life and death. Despite some progress in recent years, infection and parasitic diseases are the major cause of death during the first five years of life. According to Dr. R. Uauy, Director of the Institute of Nutrition and Food Technology, Chile, some 65% of these deaths have malnutrition as an underlying factor. Measles, for example, is more likely to be fatal in a malnourished child. In developed countries, poor nutrition is also a factor in early death of adults from cancer, diabetes, and heart disease. Nutrition is fundamental to health throughout life. Emerging problems in developing countries include stunting, where children fail to achieve proper height because of poor early nutrition, and obesity, where children receive too many calories for their needs.
Many countries have food supplementation programmes to address these nutritional problems. Through these programmes, staple foods such as milk or flour are supplemented with essential nutrients. Stable isotopes can help determine how effective these programmes are. Stable isotopes are completely safe, non-radioactive isotopes of nutrients of particular interest—like iodine, iron, zinc, and copper.
A regional project in Latin America has been using stable isotopes to evaluate the bioavailability of nutrients provided in supplementation programmes and to determine the calorie requirements of children receiving supplementation through school programmes. Similar projects are also being undertaken in Africa, where researchers in Senegal, for example, are evaluating the supplements provided to nursing mothers, by studying the quality of mother’s milk and evaluating the growth rate of their babies in the first year, according to Dr. S. Wade. And the results have been promising. In the Chile, anemia due to insufficient iron has been decreased by over 20% and in Senegal zinc supplementation has been shown to improve growth of babies.
Measuring stable isotopes requires specialized and often expensive equipment. While these tools can play an important role in developing and evaluating nutritional supplementation programmes, there is a significant investment of resources required, both human and financial. For its part, the Agency has been providing support to developing countries by providing training, control standards, and equipment to support several regional projects. Making effective use of any technology requires knowledgeable and trained personnel, but where radiation is involved, proper training is crucial to using the technology safely and effectively and preventing accidents.
Treatment of disease
Treatment of cancer was one of the first uses of radiation in the health field. Costa Rica obtained its first cobalt-60 teletherapy unit in the 1970s, according to Dr. R. Pardo Evans, Minister of Health. Teletherapy uses a complex system to deliver targeted beams of radiation from the cobalt-60. Using carefully calculated dose of radiation over time, tumour cells are killed, while healthy cells are not. By 1992, Costa Rica had three teletherapy units.
Despite the availability of this treatment, a group of doctors became concerned that the death rates from the most common forms of cancer had not decreased over the past 15 to 20 years. This was particularly worrisome because of the high incidence of gastric (stomach) cancer in the country. As an investigation into this situation was just beginning, there was a serious accident with one of the teletherapy units that resulted in 115 patients being overexposed to radiation during their treatments. With Agency assistance, the investigation into this accident found several serious shortcomings: the teletherapy units had exceeded their useful life, there was a lack of national treatment standards, and there was a shortage of trained personnel. In response, Costa Rica has established an agency to support and promote cancer prevention and control. Efforts are now developing an integrated national programme, including training the needed personnel, acquiring new equipment, and building new facilities. In the meantime, patients are receiving alternate therapy or receiving radiation treatment in other countries.
A similar approach to developing a national cancer programme is followed in Ghana, Africa, according to Professor J. Amusai. Currently, facilities for diagnosis and treatment are limited, but with strong government support, this will soon change. The goal of an IAEA model project is to establish a national network of centres to serve, not just Ghana, but also neighbouring countries like Côte d’Ivoire and Togo. The Agency is providing support to train three radiation oncologists in South Africa and the United States.
Developing countries are not alone in this effort. According to Dr. B. Cummings, of the International Society for Radiation Oncology, no country is self-sufficient in maintaining such programmes. And as technology continues to advance and computerize, the global demand and competition for highly qualified personnel is expected to grow.
The road ahead
Providing quality health care is about much more than buying expensive equipment. With the competing priorities for limited health funds, finding resources to develop and sustain national programmes can be a significant challenge in developing countries. This challenge does not mean that developing countries should be denied access to technology that can make a real difference. However, careful consideration must first be made to ensure that such technology is relevant and integrated into local conditions. There must also be sufficient need, not only so that the equipment will be well used, but also to ensure that those using it maintain their skills. In order to be successful, there must be an infrastructure in place—to support, to finance, to train, and to maintain.
Pooling resources through regional collaboration is proving to be successful in several regions of the world. The Agency supports training of qualified candidates at western institutes and provides specialized training courses. But is this enough to meet local needs and circumstances? As was noted during Forum discussions the discussion after the presentations, training in western institutions may not always prepare those who work in developing countries. For example, patients in developing countries may suffer from different forms of cancer and have more advanced disease when they come under treatment. Adapting to suit field conditions has been successful in some areas, according to Dr. A. Aznarez, Uruguay, where newborn screening has been successfully linked with the issuance of birth certificates across the country.
To further this promise, partnership opportunities, between private firms, institutes, and non-governmental organizations, must be sought. Novel approaches to training, between developed and developing country institutes and experts, must be explored. Hopefully, in the future there will be more opportunity to strengthen training, as the base of expertise expands in developing countries. Western institutions, especially those currently recruiting from developing countries, should be encouraged to share their time and expertise with training programmes in developing countries.
The Forum session clearly showed that, with proper training and infrastructure, nuclear technology is making a significant contribution towards improving human health. Regional collaboration, such as the nutritional projects in Latin America and the model project in Ghana, show that the challenges of establishing successful programmes to improve health in developing countries can indeed be met. Through parternships, they can be sustained.