Treatment, Not Terror: Time for Unique Problem-Solving Partnerships for Cancer Care in Resource-Challenged Environments.

Over the past few years, low- and middle-income countries (LMICs) have been increasingly plagued by two distressing trends: increasing numbers of deaths as a result of terrorist incidents and increasing incidence of noncommunicable diseases (NCDs),[1] including cancer.[2] The daunting and at times overwhelming nature of these issues provides the incentive needed to build uniquely effective global problem-solving partnerships.

The driving forces that bring the public health and security communities together are the real threat of dirty bombs (improvised explosive devices that include radioactive material) and other forms of nuclear and radiologic terrorism, and an enormous shortage of cancer care in LMICs. Effective multimodality cancer care requires radiation therapy, which can be either from a radioactive source—cobalt-60 or cesium-137—or from a linear accelerator that generates x-rays electronically. Terrorists could use radioactive sources to cause harm in several ways, such as placing them in locations that expose the public over a long period of time (radiologic exposure devices [REDs]), or by dispersing the sources through food or water supplies, or by contaminating an area to deny long-term access (radiologic dispersal devices [RDDs]). Unlike weapons of mass destruction, weaponized high-risk radiologic materials are not expected to cause mass fatalities, nor would they likely cause deterministic health effects (dose above 1 Gy.).[3,4] However, their use could generate substantial economic, social, and psychologic upheavals, including widespread fear and anxiety.

Although an RDD attack has not yet occurred, there is ample evidence that if such an event were to happen the effect would be devastating. In 1987, in Goiânia, Brazil,[5] a cesium-137 teletherapy device was left in an abandoned hospital and sold to a junkyard owner. The blue glow of the small cylinder of cesium chloride inside the device made it appear valuable; it was broken into pieces and used for decorative purposes, which included application on the skin. The incident led to four deaths and to the hospitalization of 28 people who had serious radiation burns. Two hundred fifty people were exposed to cesium, and as many as 150 of them suffered from internal radiation exposure because they inhaled or ingested the cesium powder. More than 85 residences were significantly contaminated; 41 of the residences were either totally or partially destroyed after the event. Buses and paper were contaminated, as was money, which had to be screened at local banks. The government lost public trust, because it was not able to account for 30% of the radioactive material, which led to protests where people even attacked a hearse that carried two of the victims. People whose homes had been destroyed in the cleanup were expelled from hotels, and six people were ostracized from the city of more than a million residents. Furthermore, the incident crippled the health care system. More than one tenth of the population sought medical attention although they were not in the vicinity of the incident. Finally, residents of the state of Goias were shunned even months after the incident in other states of the country. Terrorist exploitation of a source of cobalt-60 is more likely to be in the form of an RED than an RDD because of the difference in physical properties.[6] Nonetheless, the consequences of terrorist uses of such materials could still be significant in today’s LMIC cities, because of the high activity level of such sources and the widespread fear of radioactivity.

The International Atomic Energy Agency (IAEA) maintains an online, voluntary database of radiotherapy devices and the sources they house—the Directory of Radiotherapy Centres (DIRAC) database.[7] As an example, according to this database, at least 86 cobalt-60 medical devices exist in Africa; 75% of these devices are in seven countries: South Africa, Egypt, Morocco, Tunisia, Algeria, Sudan, and Nigeria. The others are distributed throughout more than 16 other countries. The sources in these machines are classified as category 1 sources—the highest risk classification level of the IAEA.[8] The concern is that some of these radioactive sources exist in countries that suffer from frequent terrorist activity and could be stolen and used for malicious purposes. Among terrorist groups of concern are Boko Haram (in the northern part of Nigeria, Cameroon, Chad, and the Niger Republic), Al-Shabaab (in Kenya), the Islamic State and its affiliates (in Tunisia, Egypt, and other parts of North Africa), and Al Qaeda.

The burden of NCDs, especially of cancer, is severe. Compared with a single infectious disease (ie, malaria or tuberculosis), cancer is highly heterogeneous, composed of hundreds of different phenotypes. Moreover, for effective diagnosis, therapy, or palliation, there is a need for radiologists, pathologists, surgeons, radiation and medical oncologists, highly trained nurses, and allied health workers. In addition, tumor registries and research in this area are critical to understand the burden of these diseases. The organizational structure needed to properly prevent, diagnose, and treat all or even some cancers is challenging. A collaborative effort is needed with government agencies, nongovernmental organizations, academia, and other volunteers to provide mentorship and education for individuals to build a sustainable career. There is a great need for financial support to attain this spectrum of expertise and its associated infrastructure. The investment needed to tackle cancer, especially the essential role for external radiation treatment, is not only a humanitarian requirement but also highly cost effective for a society. Moreover, the sustainable health care infrastructure and expertise needed to address cancer care in these communities will also help them cope with other diseases or epidemics that arise, such as Ebola, Zika virus, or other infectious diseases.[9]

The link between biosecurity and NCDs was recently emphasized by Allen[10] with WHO. The opportunities for research in this area include implementation science, health care delivery systems, new understanding of the etiology of cancer in these settings, and innovation in treatment paradigms that include innovative technology and telecommunications. To establish high-level security requires finding a way to advance cancer care while reducing radiation risks from misappropriated radiation sources.

This global challenge is addressed in the report Treatment, Not Terror,[11] which resulted from a series of discussions among nongovernmental organizations, the United States, developing-country government agencies, technology vendors, and cancer specialists concerned about nuclear proliferation. Simultaneously, the US Department of Homeland Security has chaired an interagency working group on alternatives to high-activity radioactive sources; the White House Office of Science and Technology Policy is launching a higher-level effort in this area;[12] and two dozen countries involved with the April 2016 global Nuclear Security Summit[13] are exploring incentives to phase out the commercial uses of high-risk radioactive sources across a wide range of industries, including medicine.

New technologies and practices could permit an effort to tackle both challenges simultaneously. These include development of innovative technology, including linear accelerators that can function in resource-limited environments; new financing mechanisms that make current and future nonisotopic technologies more affordable for developing countries; sustainable health care infrastructure, including physical centers and in-country careers for experts and workers; affordable and culturally appropriate interventions, including new and inexpensive diagnostic technologies; novel approaches to education, training, and mentorship to reverse brain drain; better understanding of the risk factors for disease development; novel cost-effective screening and strategies for prevention; and multimodality cancer care at international quality standards. Such solutions could also be applied to economically disadvantaged communities in resource-rich countries.

Ultimately, the full spectrum of cancer care, including prevention, screening, and treatment is necessary; therefore, Atun et al[14] for the Global Task Force for Radiation for Cancer Control assessed the magnitude of the shortfall in radiation oncology capacity and capability. Many countries have limited or no radiation oncology equipment or expertise. The common explanation for why this gap in radiation treatment persists is that it is too expensive, an argument refuted by Atun et al,[14] who note that their “results provide compelling evidence that investment in radiotherapy not only enables treatment of large numbers of cancer cases to save lives, but also brings positive economic benefits.”(p1153) What is needed to address this challenge is an interdisciplinary campaign that brings together medical professionals, social finance innovators, technology entrepreneurs and inventors, experts in oncology and infectious diseases, global health and health disparities visionaries and investors, and national and international policymakers. The policymakers would include the US Government; leading developing-country governments, such as those of Brazil and India; the World Bank; the IAEA; and WHO.

Indeed, there is a burgeoning interest in global health careers[15-17] that requires acceptance and support by academia; it also requires the business people who now run health care to establish a sustainable career path[12] so that person-to-person mentoring, and continuity of projects and partnerships, provide a strong underpinning for permanent change. That cancer care is indeed a component of public health and necessitates a systematic approach to health care has been discussed by Love et al[18] in the concept of public health oncology. Academics, private sector experts, and retirees who seek new career challenges form an emerging pool of experts who, primarily by using telemedicine, are willing to mentor health care workers in LMICs to improve cancer care in their countries. Two nongovernment organizations, the International Cancer Expert Corps[19] and Medical Physics for World Benefit,[20] are working together to address these issues. A key goal of their work is to make radiation oncology the cornerstone of a facility that would provide multimodality cancer care and support services. Such a center would be a sustainable program that would include oncology, general medical and surgical care, palliative care, and treatment of infectious diseases.

In recognition of the need for 5,000 or more linear accelerators in LMICs during the next two to three decades and of the limited infrastructure in most parts of those countries, in November 2016, the ICEC organized a workshop hosted by the Conseil Européen pour la Recherche Nucléaire—Design Characteristics of a Novel Linear Accelerator for Challenging Environments. The current-generation sophisticated linear accelerators in use in upper-income countries often do not function well in the adverse conditions encountered in LMICs. In addition to addressing the design characteristics of an affordable, reliable, robust, and easily repairable linear accelerator, an international group of experts discussed the economics related to the development of new equipment, the need for training of personnel, and the need for infrastructure requirements.

Establishment of effective cancer care in marginalized communities and countries requires on-the-ground expertise, facilities, and infrastructure to provide the spectrum of cancer care. Regional centers of excellence must be built and sustained to address the range of NCDs and communicable diseases, and provide surveillance for emerging epidemics and pandemics. Building and sustaining expertise on-site requires development of suitable technology; networking to share expertise and to close knowledge gaps as centers of care are established; and mentoring to educate, train, and sustain in-country expertise. Global institutions interested in the security of medical radionuclides and in cancer care are now working together to supply appropriate radiation treatment both to address the global inequality of health care and to prevent terrorism. Analysis by the Global Task Force on Radiotherapy for Cancer Control indicates that cancer care, including radiation therapy, is indeed affordable.[14] To address these issues in a sustainable manner, effective investment and collaborations among academia, government, nongovernment organizations, and global institutions are required. Valuation of global health as a bona fide component of a career path is essential. That treatment is foremost and the threat of terror is secondary is a unique formulation of the approach to global terrorism. Together, these unique partnerships could improve the quality and quantity of life for millions of people, establish common bonds and friendships that enhance understanding among peoples and nations, develop new knowledge about cancer etiology, and forge multisector partnerships where clever economic approaches and disruptive innovation to solve complex systems solutions can lead to understanding, caring, and compassion serving as a counterpoint to today’s grim headlines. We are at the early stages of a stimulating crossroads for the prevention of nuclear and radiologic terrorism and for the support of global health. This is a transformational opportunity not to be missed.