Any radiotherapy treatment-planning system must be commissioned and tested before it can be used clinically, with one of the main tasks being the entering and testing of beam data for the local centre's treatment machines. I told those centres that requested copies of my program that I would be happy to visit and help with this commissioning work, in exchange for an air ticket and a place to stay – a licence to print tickets to exotic parts of the world that I would in all likelihood never have otherwise visited.
My interest in medical physics in the developing world was further encouraged by my attendance at a meeting run by the Institute of Engineering and Technology (IET, formerly IEEE) in 2006.3 A presentation on the implementation of telemedicine in the Peruvian jungle, given by a joint team from Lima and Madrid, provided an excellent example of the way in which medical images can be acquired at small remote health centres and then transmitted to university hospitals for reporting and analysis. The data transfer between the jungle health centres and Lima was performed using state-of-the-art WiFi with solar-powered repeaters.
Developing countries often have high levels of mobile connectivity, providing opportunities to exploit such technologies for medical applications. For example, programs have been written in JAVA that run on 3G/GPRS mobile phones; these programs help monitor HIV/AIDS patients.
Supply and demand
The keynote address at the IET meeting was delivered by the World Health Organization (WHO), which has invested a great deal in improving technology management in developing countries. This presentation highlighted the situation where a hospital in a developing country is given an expensive piece of medical equipment for which they do not have sufficient engineering or scientific support. As a result, the equipment can end up spending years in its packing crates.
Hospitals can also find themselves in an embarrassing situation if they receive second-hand equipment without the accompanying manuals. Local engineers cannot get the systems working and the redundant equipment simply takes up valuable space. In one case a mammography set was sent, without manuals, to a hospital in Bacau, Romania. The centre could not get the equipment working and put it into store. Some time later, the hospital was subject to an inspection by the Romanian Nuclear Regulatory Commission (CNCAN); as a result they were fined for possessing undocumented radiation equipment.
Organizations such as the Clinical Science and Education Foundation, established by physicists from St Bartholomew's Hospital in the UK, have addressed the quality issue. The organization will only supply second-hand equipment that is working, fully documented and that it would be happy to use at St Barts.
A further problem associated with medical equipment donated to developing countries is that the supply often only lasts a few months. This initial influx can help drive local manufacturers out of business. One recent success story is the Pan African Wheelchair builders association, which runs a wheelchair technologists training course in Tanzania. This course emphasizes the need for both professional wheelchair producers and wheelchair technologists attached to the manufacturers who can also serve in the clinical rehabilitation team.
Another amenity, and one that's taken for granted in developed countries, is access to stable electrical power for medical instrumentation. The problems of generating stable sources in remote rural locations to power sensitive equipment such as pulse oximeters and Doppler foetal heart monitors has been tackled by the Cape Town-based Powerfree Educational Trust. Complete mobile operating theatres have been designed that can be used in remote locations.
Train for gain
My own experience of radiotherapy physics in the developing world has been in the Far East, the Middle East and Eastern Europe. While the cost of radiotherapy equipment means that treatment facilities in these regions are generally located in major towns, power outage can still be a regular problem.
The standard of physicists that I have met along the way has almost always been extremely high. The problem is that medical physics is not taken seriously by hospital administrators and government funding bodies. I can understand this view; before I applied for my first job, I thought that all hospital staff were either doctors or nurses. Consequently, the medical physics profession suffers from poor pay and staff retention – and the result is a considerable brain drain. As a personal observation, most of the medical physicists I met in my early visits to Romania in the late 1980s have now left the country to work abroad.
Everyone recognizes the worth of a "medical doctor". However many developing countries do not recognize the equal importance of training radiographers, technicians, dosimetrists and medical engineers. High-quality radiotherapy is a team effort. However, until about 15 years ago, for example, Romanian radiographers were recruited from the nursing profession and could practise radiotherapy after attending a two-week training course.
Setting up a medical physics training programme can also be problematic. Some universities (such as Zarka in Jordan and Chiang Mai in Thailand) have offered medical physics courses. But when trainees are sent abroad to study for an MSc, it can lead to the loss of staff; some trainees may decide to stay and make the most of the available improved career and research possibilities in the host country.
The IAEA runs two-week intensive courses on radiation protection that are held in host countries, and the Open University offers a distance-learning MSc. In addition, Radiotherapy and Radiation Protection Environment – a new organization in which I am involved – aims to provide on-site practical medical physics training.4 A situation where the trainee receives such on-site training as well as academic lectures could prove the ideal combination.
I have found this work to be extremely rewarding. I have a great deal of respect for my colleagues in the developing world, who provide a safe, accurate service while understaffed, underpaid and under-resourced, thinking on their feet and often making crucial decisions in isolation. They deserve our full support.
I would like to thank the many organizations that helped fund the visits to Thailand, Romania, Albania, Jordan and the Baltic States.5 The Romanian Association of Medical Physics awarded me honorary membership for this work. I would also like to thank the International Atomic Energy Agency (IAEA) for inviting me to teach on their "Radiation protection in radiotherapy" courses that were held in Jordan, Moldova and Turkey.