Report from

Nuclear medicinein Latin AmericaA review of its development, impact, and potential

by Dr Eduardc Tcuya

Nuclear medicine in Latin America has reached aremarkable level of development — 42 years after thefirst medical applications of radioisotopes were carriedout in the region. What is the present situation and whatare the future prospects in terms of nuclear medicine'srole and practical impact on the promotion, preserva-tion, and restoration of health in Latin America?

Nuclear medicine and health care

Medicine in developing regions has characteristicfeatures depending essentially on organizational struc-tures that are not always capable of coping with thehealth needs of the majority of the population. Economicconstraints on health budgets mean that there is often asimplistic confrontation between the concepts of primarymedical care and more "sophisticated" medicine entail-ing highly developed technology and consequentlyinvolving great expense in terms of unit cost.

Everyone has a right to health and society has a dutyto provide health care to all its members on an equalbasis. In actual fact, opportunities for enjoying health indeveloping regions differ within the population and as ageneral rule depend on each person's social and eco-nomic background. A health programme nowadaysshould aim at stepping up those activities that help topromote the health of all members of the community onan equal basis and in the shortest possible time.

In Latin America, there is a diversity of healthpolicies and a wide spectrum of needs that have not been

Dr Touya is President of the Latin American Association of Societiesof Nuclear, Biology and Medicine (ALASBIMN) and Director of theNuclear Medicine Centre, Hospital de Clinicas in Montevideo. Theauthor wishes to acknowledge the assistance of Dr Fernando Mut,Secretary of ALASBIMN and Assistant at the Nuclear MedicineCentre. -

satisfied. The programmes are inadequately planned andimplemented and do not ensure equal opportunities ofhealth for the whole population. Typical of the economicsituation in Latin American countries is a seriousaccumulation of difficulties that include familiarproblems of foreign trade protection and cancellation offoreign debt, which is becoming impossibly heavy interms of interest payments alone.

A major effort is being made to restimulateeconomies in the region. Although this should includemore attention to health programmes, it probably alsomeans postponing better allocation of resources in manyareas in accordance with prevailing political and eco-nomic considerations.

Levels of health care

Health care is classified in three levels (primary,secondary, and tertiary) to ensure that everyone receivesattention and that account is taken of all existing diseasesor risks. The health administrator, faced with insur-mountable economic constraints, is obliged to allocateavailable resources to projects of greatest benefit to thehealth of the largest number of people.

By virtue of the fact that the primary level of careinvolves basic but simple activities of low unit cost, itmust spread like a sheet over the entire population of agiven country or a region. It then becomes clear just howvital and urgent it is to have enough resources to be ableto extend primary care in a horizontal direction.

The value of secondary and tertiary care should notbe underestimated. This care is concerned with restoringthe health of a large proportion of the population not inrelation to social and economic conditions, but rather interms of the growing complexity of biological changescaused by various types of disturbances that modifynormal bodily functions.

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Increasing primary care means a reduction in thedemand for secondary and tertiary care, since byremedying malfunctions at an early stage one can avoidthe appearance or development of more complexdiseases.

Against the hasty conclusion that developing coun-tries are not in a position to hope for proper levels oftertiary care, one can argue that this level is just asessential as primary care. But an additional factor has tobe borne in mind: It is vital that all such activities bestrictly and comprehensively balanced in terms of costand benefit.

Nuclear medicine's role

Nuclear medicine certainly forms part of that set ofspecialized medical fields that are quickly assessed interms of their cost versus the manpower employed andthe equipment and materials required. The first require-ment of any nuclear medicine examination or treatmentis that it should be really effective and efficient in attain-ing its final objective, which is to ensure health.

It is true that a large number of nuclear medicinetechniques have demonstrated beyond any doubt, froma scientific point of view, that they are very useful foridentifying origins or changes during various stages ofdisease and that they are a valuable basis for therapy toensure a quicker and fuller recovery. It is also true thatprevious levels of effectiveness and efficiency should beborne in mind if nuclear medicine evaluation procedures

for a given clinical situation are the only means availableat low cost in terms of risk-benefit for the patienttreated.

How can the continuation of nuclear medicine indeveloping countries and its further development bejustified today against the background of the aboveideas?

As far as the classification of the health programmeinto three levels of care is concerned, nuclear medicineshould be visualized in the form of a wedge introducedfrom the tertiary level into the primary level. This meansthat two criteria have to be taken into consideration: oneis centralization and the other is response to a "criticalmass" of requirements. Both these criteria seek topreserve the necessary balance between investment andmanagement. All types of unnecessary duplication ofservices leading to inadequate operational levels as aresult of under-utilization of investment in facilities,equipment, or radioactive material should be avoided.

Impact of nuclear medicine

The impact of nuclear medicine studies on theprimary level of medical care is undoubtedly muchweaker in comparison to the tertiary level if we consideronly the diversity of studies. It is a different matter if weconsider the number of patients; here the evaluation hasto be changed insofar as nuclear medicine is by naturesimple to introduce at the primary level and responds toa highly prevalent pathological condition among thepopulation.

Among other medical appli-cations, radioisotopes are.being used in Latin Americafor diagnosing coronarydisease. Shown is an imageusing a scintillation camerasystem. (Credit: E. Touya).

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One example of this is the determination of thyroidhormone levels; this, study can be begun by means ofblood samples that can be taken using any basic healthequipment. They can then be sent to processing labora-tories operating to some extent at the regional level. Thistype of arrangement can be fully applied in a zone wherethyroid disorders are extremely frequent.

Another example is the scheme for a national orregional project aimed at detecting neonatalhypothyroidism at an early stage and thereby avoidingresultant cretinism. This is basically an ethical obliga-tion, but the cost-benefit ratio is also favourable if onecompares the cost of maintenance and care of a thyroidcretin with the cost of hormonal assay in all newbornbabies.

Nuclear medicine at the level of secondary careshould maintain a balance between the pathology ofgreatest prevalence in the region where the hospital issituated and the resources of manpower and equipmentneeded for genuinely useful procedures.

In a small country such as Uruguay, the tertiary levelexists in practice at very few hospitals; this means thata complete nuclear medicine service, at this level, canplay the role of "centralized parent service" at the topof an organization shaped like a pyramid in terms of thecomplexity of its functions. The tasks of this service willbe, first and foremost, teaching, medical care, researchand development, and standardization of new diagnosticor therapeutic procedures.

In larger Latin American countries with more terri-tory and bigger populations, units organized at the threelevels should be established for effective coverage ofrequirements. There should be co-ordination betweenthese units and a common programme that subsidizestheir major requirements in manpower, equipment avail-ability, and radioactive material.

Any real effort made by countries to decide on effec-tive health policies, programmes, and projects designedfor the whole population on an equal basis will lead tothe indispensable reorganization of the nuclear medicinefield in the region. It will become involved more directlyin the process of economic and social development. Itspresent predominance in private medical care schemesthat are limited to a particular sector of the population,defined by its social and economic level and able toafford complete medical attention, will be reduced.

Contributions of nuclear medicine

It is not possible to list in detail all the contributionsmade by nuclear medicine in the region during the last40 years, but three major points should be singled out:

• The multidisciplinary nature of nuclear energyapplications. This led to the establishment of workteams composed of people with various kinds oftraining. Nuclear medicine brought together doctors,chemists, and engineers during the initial years, to

which nurses and technicians were added gradually inrecognition of the need to improve the organization ofthe work. Furthermore, the need to incorporate hospitalphysicists and personnel trained in computer studies wasrecognized as a result of. the growing complexity ofnuclear equipment.

The emergence of interfaces permitting integrationand communication between professionals is a verypositive element. This resulted inevitably from theexigencies of the work and overcame barriers that tradi-tionally still separated departments in the majority ofLatin American universities. Despite this development,the process of including the hospital physicist, above all,should be speeded up significantly. This post does notexist in the majority of nuclear medicine services,although such professionals are essential for advising onthe purchase of equipment, for carrying out qualitycontrol of the instruments, and for ensuring more effi-cient management of many procedures based on com-plex mathematical models. These areas are not coveredin the more biologically oriented training of doctors.

• Radioisotopes. They have made it possible to gainreliable knowledge of blood disorders and diseases ofthe thyroid gland that are highly prevalent in the region,to improve the management of patients during the diag-nostic and treatment stages, and to devise preventivemeasures to cut down the incidence of .these diseases andpromote health. With regard to diagnostic stages havinga pronounced effect on treatment, one should mentionthe contribution of scintigraphy in cases of hydatidosisand amoebic abscess, as well as Chagas' disease towhich a population of 65 000 000 is exposed. It isreckoned that some 28 000 000 people could be infectedby Tripanosoma cruzi, which is the agent causing thisdisease.

• Diagnostic studies. Given the contrasts existing inLatin America, the diseases that are most prevalent indeveloped countries are also fairly common in LatinAmerica. Mention should therefore be made of nuclearmedicine in the study of coronary disease, cancer, andinjuries to organs and transplants, particularly kidneytransplants.

• Radioimmunoassay. Apart from studies of thethyroid, radioimmunoassay has made it possible tomanage, in a more scientific manner, patients with dis-eases affecting other internal secretion glands, such asthe pituitary, parathyroid, pancreas, suprarenals, andgonads, both in cases of dysfunction and localizedneoplasms.

Present needs

In view of the region's current situation, the mainrequirement, to be given absolute and mandatorypriority, is to optimize all utilizable means, starting witheconomic and financial resources and ending withinstalled capacities in terms of their operational levels.

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Using radioisotopes andrelated equipment to diag-nose thyroid disorders hashelped contribute to healthcare in developing coun-tries, such as Uruguay and,as shown here, Kenya.(Credit: CGEA, CREN-Kenya)

It is essential to improve outputs by insisting onimproved quality through more efficient and responsiblehandling of financial outlays in relation to aims. In thisrespect, all the efforts to train people are significant,particularly programmes aiming to keep up and improvethe knowledge of experts already trained and playing achief role in nuclear medicine.

Quality assurance of diagnostic and therapeuticprocedures will become a reality to the extent that itbrings together educational programmes and makes itpossible to additionally influence the attitudes and perso-nality characteristics of different professionals andexperts of the multi-disciplinary nuclear medicine team.It is equally necessary to increase levels of responsibil-ity. This is so that concern to improve efficiency in themanagement of the health services becomes natural —keeping in mind measures suited to the procedures, andtheir value in relation to the environment in which theyare used. Two phrases appear to give a stamp of validityto these ideas: "Science in poverty, yes, but poorscience, no", and "research and technology appropriateto each individual region".*

It is a duty for Latin America's scientific communityto carry out research and to recognize that doing so isthe best way to speed up regional economic and socialdevelopment. The same is applicable to the group ofexperts working in nuclear medicine. But it is also quiteclear that there must be accompanying political decisionsat national and regional levels to make these activitiespossible. Support must be given to the universities aswell as to public and private institutions endeavouring to

* The first quote is from a statement by the President of the Republicof Argentina, Dr Raul Ricardo Alfonsin, at San Carlos de Bariloche,May 1985.

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cope with these tasks. Co-ordinated action by nationalatomic energy commissions, universities, scientificinstitutions, and scientific societies at national andregional levels would create a better framework formaking use of available resources. In this respect theLatin American Association of Societies of NuclearBiology and Medicine (ALASBIMN) could continue toplay a similar role.

International organizations, among them the IAEAand the Pan American Health Organization of the WorldHealth Organization (PAHO/WHO), together withgovernments and institutions in developed countriesproviding technical co-operation for the region, shouldcontinue to give substantial support to national andregional programmes. However, they should seek toimprove them by optimizing the use of economic andfinancial resources and adapting them to the region'spriority needs. Improved collaboration between coun-tries outside the region, and those within it, should makeit possible to improve international input to LatinAmerica by mobilizing new resources likely to promoteand accelerate socio-economic development. Health is afundamental part of this development and the right tolive is unchallenged. Efforts made to eliminate differ-ences between north and south are based on political,social, even economic factors. But in terms of healththey are a categorical imperative. Life expectancy fromthe moment of conception should be identical for allhuman beings. The peaceful applications of nuclearenergy in biology and medicine are ends in themselvesand should never be allowed as a pretext for the use ofnuclear energy for military purposes. Latin Americaneeds development and peace, and nuclear medicineshould play its small part by promoting the health of thewhole of its population.

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Atoms in Latin American health care:Historical perspectives

The first medical applications of radioisotopes in LatinAmerica were carried out some 43 years ago by theUniversity of Brazil's Institute of Biophysics in Rio deJaneiro, using phosphorus-32 to study patients with hae-matological disorders. A little over a decade later, agroup at the Thyroid Institute of the University of Cuyo inMendoza Province in Argentina began studying endemicgoitre in the Andean region using iodine-131.*

The second stage of development was marked bytraining abroad of distinguished scientists. Those scien-tists, motivated by a belief in the potential of radioiso-topes, went mainly to centres and laboratories in theUnited States, the United Kingdom, France, and Italy. Ontheir return to Latin America, they joined the group ofpioneers who were promoting greater use and popularityof this special field.

In 1956, training courses began in the region andduring the ensuing decade were concentrated in the fol-lowing six places: the Puerto Rican Nuclear Centre; theArgentine National Atomic Energy Commission; theUniversity of Brazil's Institute of Biophysics; the NuclearMedicine Centre at the Medical School attached to theUniversity of Sao Paulo, Brazil; the Radioisotope Labora-tory of the Department of Endocrinology at the SalvadorHospital of Santiago, Chile; and the Mexican NationalNuclear Energy Commission.

In 1966, the first congress of the Latin AmericanAssociation of Societies of Nuclear Biology and Medicine(ALASBIMN) took place in Lima, Peru. The associationwas founded in Sao Paulo, Brazil, on 21 September 1964by Dr Tede Eston, who chaired the first congress. Paperspresented reflected standards attained by various groupsof specialists from Argentina, Bolivia, Brazil, Chile,Ecuador, Mexico, Puerto Rico, and Uruguay. Theycovered the introduction of diagnostic procedures, thebeginnings of research into regional pathology, anddescriptions of experiments conducted with largenumbers of patients. A sound basis was thereby providedfor their original conclusions or findings, similar to thosewhich were at that time being discussed in other areas.

IAEA and national support

The IAEA played a clearcut role in this initial period byproviding training for the first national groups under itstechnical assistance programmes, by subsidizing visitsof experts to the region, by financing regional coursesand fellowships abroad, and by providing equipment,radioisotopes, and consumable materials. Agencyresearch contracts supplemented national efforts toapply radioisotopes in the study of problems typical ofthe region.

The national atomic energy commissions and otherofficial bodies, especially those in the region's moredeveloped countries, such as Argentina, Brazil, and

* Work at the Institute of Biophysics at Rio de Janeiro wasunder the direction of Dr C. Chagas; in Argentina, researchencompassed Dr A. Pawlowski's studies, and the work done byDr Hector Perinetti's group in Mendoza in association withDrJohn B. Stanbury of the Massachusetts General Hospital,Boston.

Mexico, gave priority support to biological and medicalapplications at national levels. Interregional co-operationactivities took the form of manpower training, particularlyin the six centres which organized formal courses, andalso through bilateral agreements designed to benefitservices being set up in neighbouring countries lessdeveloped in nuclear medicine. Progammes includedexpertise, equipment, and radioisotopes which weresupplied cost-free, thereby making it possible to put intoeffect international co-operation programmes estab-lished by the IAEA. Other United Nations organizations,such as the Pan American Health Organization of theWorld Health Organization (PAHO/WHO), as well asnational atomic energy commissions, official bodies, ariduniversities in the United States and Europe, also playeda part in this.

The next decade

From 1966 to 1976, nuclear medicine's developmentin Latin America showed a marked upward trend. Theimproved standards of the groups meant that qualifiedpersons were able to serve as experts under IAEA andPAHO/WHO programmes in other Latin American coun-tries. Interest in receiving experts from the United Statesand Europe was maintained. However, it was recognizedthat there was advantage in using Latin American scien-tists who were best suited to programme requirementsand who had had experience with problems common tothe area. Service centres that were more developed inradiopharmacy and in vivo and in vitro applications, andwhich had more experience in Latin America, began totake fellows from other countries in the region who werefinanced by international organizations. Thus, they couldreceive a complete course of training in 1- or 2-yearcourses, or advanced training in specialized fieldsthrough shorter courses lasting one to six months. Dur-ing these 10 years, ALASBIMN held congresses everytwo years.*

Concurrently, this period saw the organization ofregional meetings and the establishment of the nuclearbiology and medicine review committees on radiophar-macy, instrumentation and radioimmunoassay, andworking groups on radiation protection and training.ALASBIMN played an important role in bringing togethervarious nuclear medicine working groups in LatinAmerica, as well as in facilitating communication andexchange of ideas and experience obtained duringexpert visits and interregional fellowships. Thisincreased significantly the channels of communicationbetween different, sometimes distant, services. It allproceeded in a friendly atmosphere and thereby helpedto cement stronger and closer links between LatinAmerican specialists.

In 1970, at the third ALASBIMN Congress in Mexico,the World Federation of Nuclear Medicine and Biology(WFNMB) was founded and held its first congress in

• They took place in 1968 in Mar del Plata, Argentina; in 1970 inMexico City, Mexico; in 1972 in Santiago, Chile; in 1974 inLa Paz, Bolivia; and in 1976 in Quito, Ecuador.

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1974 in Tokyo and Kyoto, Japan. This meant that newlinks were now forged between Latin America and Asiaand the Pacific; these were gradually strengthened insubsequent years.

The last years of this period were marked by political,social, and economic changes in the region, which led toincreased emigration of Latin American scientists to theUnited States and Europe and a major turnabout in thepolicies of the national atomic energy commissions. Thecommissions, faced with the oil crisis, began to placemore emphasis on energy programmes, to some extentneglecting their support for biomedical applications.

Recent advances and trends

During the years 1976-86, progress continued to besupported through international co-operation, mainlyunder programmes co-ordinated by IAEA in variousareas, particularly nuclear equipment maintenance,standardization of in vitro studies, and quality assuranceprogrammes. The WHO sponsored studies on the effi-ciency of techniques, on evaluation of cost-benefit andrisk-benefit ratios, and on the design of flow diagrams orguides for the possible uses of radiation in diagnosis inthe most frequent clinical situations. The impact of newradiation diagnostic techniques and the limitationsimposed by the high cost involved made the policynecessary.

Period of expansion and constraints

. Regional economic trends during the late 1970s andearly 1980s brought about an expansion of nuclear medi-cine in the private sector. This was the result of thereduced role played by national authorities and the factthat financial institutions provided funds for specialists topurchase equipment, especially scintillation cameraswith different computer data processing systems. Anotable development was the introduction of cardiovas-cular studies, which became widely used in the majorityof private centres and also in many public ones. Theinfluence of national centres for production of radiophar-maceuticals declined due to imports of radioactiveproducts, which came on the market during the period oftemporary economic prosperity in the private services.

Although research groups continued, the main effortof the region's specialists was focused on the introduc-tion and standardization of diagnostic and therapeutichealth care procedures, particularly in the private sector.

In the early 1980s, the region's economic situationchanged suddenly and foreign debt incurred by Latin

American countries became an obstacle to continuedequipment investment and severely reduced availableresources for health care. Owing to the lack of availableconsumable materials, spare parts, and domesticradionuclides and radiopharmaceuticals, the servicecentres had difficulty in continuing to operate.

The public services, which had lost some of theirinfluence during the period of false prosperity, continuedto be short of funds and were unable to play the sameleading role that they had during the early years ofnuclear medicine's development. No PET system(positron emission tomography) has yet been installed inthe region, and the SPECT system (single photon emis-sion computerized tomography) is being introduced veryslowly. So is the use of tracers known as MIBG, or thosebased on monoclonal antibodies. It is still not possible touse Pharmaceuticals labelled with iodine-131 since nocyclotrons have reached the stage of normal production.

During 1976-86, ALABISMN held three congresses:in 1979 at Punta del Este, Uruguay; in 1981 at Rio deJaneiro, Brazil; and in 1984 at Montevideo, Uruguay.Contact between groups was maintained, and thesimilarity of problems was more clearly recognized, aswas the possibility of finding common solutions. Somegroups co-ordinated their clinical research work andthese were the first attempts at multi-centre and multi-national co-operation.

It was recognized that interregional co-operationactivities had to be increased and that it was also neces-sary to promote further mobilization of internationalresources for the region. This was reflected in the estab-lishment of the IAEA's ARCAL regional programme, aswell as in the report of the regional experts' meeting thattook place in Santiago, Chile, in April 1985 in preparationfor the United Nations Conference for the Promotion ofInternational Co-operation in the Peaceful Uses ofNuclear Energy (UNCPICPUNE).

Today, nuclear medicine in Latin America has ahistorical foundation laid by pioneers who are stillinfluencing its future. The names of scientists, no longerwith us, such as Jorge Varela of Argentina, Hugo Claureof Chile, Maximo Medeiros of Brazil, Berta del Rosario ofPeru, and Roberto Pieroni of Brazil point to the wayahead. Second and third generations of youngspecialists are now called upon to make their contribu-tion, to rethink ideas that serve as a framework and guidefor the present management system. In so doing, plansfor the next few years can be set with greater certainty tohelp ensure that by the year 2000 all inhabitants of theregion will benefit from and enjoy the same right tohealth.

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