Criteria for Teletherapy Unit Exchange
Prepared for
National Nuclear Security Administration
Office of Radiological Security
David Albino
Debaki Ale
Asma Easa
Matthew Mayeshiba
Alex Straka
Andrea Traverse
Workshop in International Public Affairs
Spring 2015
©2015 Board of Regents of the University of Wisconsin System
All rights reserved.
For an online copy, see
www.lafollette.wisc.edu/research-public-service/workshops-in-public-affairs
publications@lafollette.wisc.edu
The Robert M. La Follette School of Public Affairs is a teaching and research department
of the University of Wisconsin–Madison. The school takes no stand on policy issues;
opinions expressed in these pages reflect the views of the authors.
The University of Wisconsin–Madison is an equal opportunity and affirmative-action educator and employer.
We promote excellence through diversity in all programs.
Table of Contents
List of Tables ...................................................................................................................................v
List of Figures ..................................................................................................................................v
Foreword ........................................................................................................................................ vi
Acknowledgments......................................................................................................................... vii
Executive Summary ..................................................................................................................... viii
1
Introduction ..............................................................................................................................9
1.1 Radiotherapy and Cancer ..................................................................................................9
1.2 LINAC vs. Cobalt-60 Teletherapy Unit ............................................................................9
2
Stakeholders ...........................................................................................................................10
2.1 Recipient Country Identification .....................................................................................11
2.2 LINAC Identification and Donation ...............................................................................11
2.3 Site Preparation ...............................................................................................................12
2.4 Cobalt-60 Unit Disposal ..................................................................................................13
2.5 Special Role of the Private Sector ...................................................................................13
3
Criteria ...................................................................................................................................14
3.1 Framework ......................................................................................................................14
3.2 Medical Need and Cancer in Developing Countries .......................................................15
3.2.1
Cancer Incidence, Mortality, Projections.................................................................16
3.2.2
Role of Radiotherapy in Cancer Control .................................................................16
3.3 Technical Feasibility .......................................................................................................18
3.3.1
LINAC Costs ...........................................................................................................18
3.3.1.1
LINAC Unit and Operating Costs ................................................................... 19
3.3.1.2
Country Variation in LINAC Cost per Fraction .............................................. 21
3.3.1.3
LINAC Health Care Facility Costs .................................................................. 21
3.3.2
Infrastructure ............................................................................................................22
3.3.2.1
Needs Assessment and Communication .......................................................... 22
3.3.2.2
LINAC Site Infrastructure ............................................................................... 22
3.3.2.3
Human Capital ................................................................................................. 24
3.3.2.4
Disposal ........................................................................................................... 26
3.3.2.5
Country Wealth and LINAC Density as Measures of Infrastructure .............. 27
3.3.3
Policy and Regulatory Environment ........................................................................30
3.3.3.1
National Cancer Plan ....................................................................................... 30
3.3.3.2
National Regulatory Authority for Radiotherapy Machines ........................... 31
3.3.3.3
National Procurement Authority for Radiotherapy Machines ......................... 32
3.3.3.4
Donation Guidelines for Radiotherapy Machines ........................................... 32
3.4 Security............................................................................................................................33
3.4.1
Theft and Loss of Control of Radiological Material ................................................33
3.4.2
Benefits of Securing Source Material ......................................................................34
3.4.3
Protecting Cobalt-60 Radioactive Source Material .................................................35
3.4.4
Risk Environment Score ..........................................................................................36
4
Recommendations ..................................................................................................................37
Appendices .....................................................................................................................................38
Appendix A: Summary of Key Considerations .........................................................................38
Appendix B: Stakeholders .........................................................................................................40
Appendix C: Meets Medical Need Ranking ..............................................................................42
Appendix D: Technical Feasibility Ranking .............................................................................50
Appendix E: World Bank Income Region and WHO Regions .................................................57
Appendix F: Regulatory Factors ................................................................................................58
Appendix G: Security Threat Ranking ......................................................................................61
References ......................................................................................................................................66
List of Tables
Table 1: Therapy Unit and Operating Costs ..................................................................................21
Table 2: LINAC Building Plans ....................................................................................................24
Table 3: World Bank Income Classes ............................................................................................28
Table 4: Radiotherapy Densities by Income ..................................................................................29
Table 5: Radiotherapy Densities by Region ..................................................................................29
Table 6: National Cancer Plans......................................................................................................31
Table 7: Risk Environment Score Components .............................................................................36
Table B1: Relevant Stakeholders by Stage of the Exchange .........................................................40
Table C1: LMIC Ranking based on Medical Need Variable .........................................................43
Table C2: Ranking of LMICs with Incomplete Medical Need Data .............................................46
Table D1: LMIC Ranking based on Technical Feasibility ............................................................50
Table D2: Area 4 LMIC Ranking based on Technical Feasibility ................................................54
Table F1: Regulatory Factors.........................................................................................................58
Table G1: LMIC Ranking based on Risk Environment Score ......................................................61
List of Figures
Figure 1: Framework......................................................................................................................15
Figure 2: Cancer Deaths by Income Status ....................................................................................17
Figure 3: LMIC Cancer Deaths by Region ....................................................................................17
Figure 4: LMIC Radiotherapy Demand .........................................................................................17
Figure 5: LMIC Cancer Deaths by Type .......................................................................................17
Figure 6: LINAC Density vs. GNI per Capita (LMICs) ................................................................28
Figure 7: Incidence by Material Origin .........................................................................................34
Figure E1: World Bank Income Classification ..............................................................................57
Figure E2: World Health Organization Regions ............................................................................57
Figure G1: Risk Environment Map of LMICs with Cobalt-60 Units ............................................61
v
Foreword
The La Follette School of Public Affairs at the University of WisconsinMadison offers a twoyear graduate program leading to a Master of Public Affairs or a Master of International Public
Affairs degree. In both programs, students develop analytical tools with which to assess policy
responses to issues, evaluate implications of policies for efficiency and equity, and interpret and
present data relevant to policy considerations.
Students in the Master of International Public Affairs program produced this report for the
National Nuclear Security Administration. The students are enrolled in the Workshop in
International Public Affairs, the capstone course in their graduate program. The workshop
challenges the students to improve their analytical skills by applying them to an issue with a
substantial international component and to contribute useful knowledge and recommendations to
their client. It provides them with practical experience applying the tools of analysis acquired
during three semesters of prior coursework to actual problems clients face in the public, nongovernmental, and private sectors. Students work in teams to produce carefully crafted policy
reports that meet high professional standards. The reports are research-based, analytical,
evaluative, and (where relevant) prescriptive responses for real-world clients. This culminating
experience is the ideal equivalent of the thesis for the La Follette School degrees in public
affairs. While the acquisition of a set of analytical skills is important, it is no substitute for
learning by doing.
The opinions and judgments presented in the report do not represent the views, official or
unofficial, of the La Follette School or of the client for which the report was prepared.
Melanie Frances Manion
Vilas-Jordan Professor of Public Affairs and Political Science
May 2015
Madison, Wisconsin
vi
Acknowledgments
We would like to thank the entire La Follette School faculty and administrative staff for their
assistance and feedback throughout this policy report. Their dedication and support were critical
to the development and publication of our policy report. Specifically, we thank Professor
Melanie Manion for her invaluable counsel, support, and direction throughout this project. Her
dedication was critical to the development and publication of our policy analysis. We also thank
Ms. Malika Taalbi and Ms. Kristina Hatcher for the opportunity to apply our policy analysis
skills to a complex and engaging real-world scenario. We would not have been able to produce
this report without the support of Ms. Taalbi and the U.S. Government Office of Radiological
Security.
vii
Executive Summary
At the request of the National Nuclear Security Administration’s Office of Radiological Security,
we analyze a proposal to facilitate the exchange of cobalt-60 teletherapy units in low-andmiddle-income countries for more advanced linear accelerator radiotherapy machines from
United States and other high-income countries. The purpose of the exchange is to prevent theft or
diversion of cobalt-60 for use in dirty bombs. Outside resources are needed to push countries
towards adopting the more technologically complex and resource intensive linear accelerator
unit. Our analysis delineates requirements for a viable exchange.
We identify stakeholders and criteria salient to the proposed initiative and its long-term success.
Stakeholders include international governmental organizations, national governments, private
sector corporations, actors within the medical community, and non-governmental organizations.
Stakeholders are relevant at different stages, including budgeting and planning, installation, and
disposal.
Our criteria to evaluate prospective recipient countries is formulated under a three-pronged
framework. The overall long-term integrity of the initiative requires success in each respective
prong. Weakness in one component of the framework may lead to the initiative’s reversal or
collapse.
The first prong considers the recipient country’s medical needs to combat cancer. Low- and
middle-income countries face a cancer epidemic, but radiotherapy access and needs differ
geographically. We analyze the composition of available radiotherapy services by country,
which provides insights into country-level cancer control priority and need for radiotherapy
treatment. If the proposed initiative does not meet the country’s medical and cancer treatment
needs, it will be very difficult to find low- and middle-income countries participate in the
exchange.
The second prong considers technical feasibility in prospective recipient countries. Components
for a viable exchange include the capacity to absorb the greater marginal costs associated with
linear accelerators and country-level infrastructure requirements. Essential infrastructure include
adequate human capital resources, an accommodative regulatory regime, progressive medical
device procurement plans, and a regulated radioactive source disposal procedure. Without
adequate technical feasibility the country may revert to cobalt-60 units.
The third prong promotes prioritization of countries with a high risk of radiological material
theft. The frequency and magnitude of regional radiological theft is a priority in determining
prospective recipient countries; however, we defer to the NNSA’s expertise on security risks.
The proposed initiative in a country with a high security risk provides a greater marginal benefit
than it does in a country with a low security risk.
We recommend the National Nuclear Security Administration involve a network of stakeholders
to ensure the initiative’s success. The initiative must take into account the criteria in the threepronged framework. Countries will require various levels of technical support to ensure the
exchange is viable. Based on our findings, we provide a list of questions to inform actual
decision-making.
viii
1
Introduction
This report examines a National Nuclear Security Administration (NNSA) proposal to exchange
cobalt-60 teletherapy units in low- and-middle-income countries (LMICs) for linear accelerators
(LINACs) as part of a global campaign to prevent the theft and diversion of nuclear and
radiological material. Cobalt-60 and other radiological isotopes used in medical and industrial
fields can be transformed into dirty bombs that can cause widespread social and economic
disruption. The NNSA proposal is based on a transfer it facilitated to replace two cobalt-60 units
at the Kharkiv Institute of Physics and Technology in Ukraine in 2014 with a LINAC machine
donated by the University of Minnesota Masonic Children’s Hospital. In this transfer, the NNSA
also partnered with Argonne National Laboratories and Radiating Hope, which facilitated the
legal and logistical aspects of transferring the donated LINACs.
1.1
Radiotherapy and Cancer
Although early detection can lead to a decline in deaths from cancer, many people in developing
and middle-income countries lack the financial means to seek medical consultation, and many of
the countries have neither staff nor infrastructure to support treatment. Cancer places a
disproportionate burden on developing countries: LMICs accounted for 57 percent of the 14
million people diagnosed with cancer worldwide in 2012, but 65 percent of deaths. Cancer is the
lead killer in poor countries, where it reaches levels higher than AIDS, malaria, and tuberculosis
combined (The Economist 2014).
Improvements in research and increases in human capital resources in the medical field have led
to advanced technology that is more effective in cancer treatment. Surgery is the biggest
contributor to cancer cure rates, but the second biggest source is radiotherapy (Dodwell and
Crellin 2006). While demand for radiotherapy has increased due to increased cancer incidence
rates, treatment supply remains in deficit. Medical communities in developing countries seek
further radiotherapy devices to address increasing cancer incidence rates (Grover et al. 2014).
Radiotherapy mitigates organ destruction and is a more sustainable method to control localized
cancerous tissue (Dodwell and Crellin 2006). Even though the technology exists, LMICs face
numerous obstacles in treatment supply. One significant obstacle is the lack of adequate staff:
many developing countries lack treatment centers and trained oncologists (Grover et al. 2014).
Addressing the lack of staff requires more than simply improving technology, it requires
increased education and training.
Because radiotherapy is a favored option, high demand for it is not met due to the lack or
shortages of radiographers, physicists, and dosimetrists (Dodwell and Crellin 2006). Even if the
more effective technology is provided to LMICs, these countries still face a shortfall in who will
administer the treatments and who has the training to know how to properly and effectively use
the technology.
1.2
LINAC vs. Cobalt-60 Teletherapy Unit
In 1951, the first cobalt-60 unit was installed for clinical use in London, Canada, and led to the
rise of cobalt-60 machines being constructed and utilized all over the globe. Cobalt-60 units
serve as a major cancer treatment to millions of people for many decades; they were the best
9
option available to fight cancer. The use of cobalt-60 units significantly decreased near the end
of the 20th century. In the late 1950s LINAC were first installed for clinical use and overtime
became the predominant cancer treatment technology in high-income countries (HINCs).
LINACs’ ability to provide a superior dosimetry, the most precise calculation of the amount,
rate, and distribution of radiation emitted from a source of ionizing radiation is cited as the
primary reason for this transition. LINACs are also preferred to cobalt-60 units because it is
believed that cobalt-60 units provide “substandard treatment” (Page et al. 2014). The inferior
precision makes cobalt-60 a less attractive cancer treatment option for treatment facilities in the
United States, but many developing countries cannot afford the initial capital investment and
subsequent infrastructure needed to support a LINAC. Many LMICs even lack the resources to
obtain a new cobalt-60 unit. As a result, many countries use cobalt-60 units well past the
recommended lifespan. It was reported in 2010 that about half of the cobalt-60 units in Africa
were 20 years or older and require replacement (Page et al. 2014).
Cobalt-60 units are relatively more reliable, simpler to repair, easier to operate safely, lower in
unit and operating costs, and easier to use to administer treatment. On the other hand, LINACs
provide higher-quality dosimetry, reduced radiological security risks, and greater radiation
safety. The paramount weakness of LINACs is that they require adequate infrastructure, a stable
and reliable power supply, maintenance, and detailed training (Page et al. 2014).
Before pairing a LINAC device with a recipient country and medical facility, the appropriate
physical infrastructure to operate a LINAC needs to available. Budgeting of additional financial
resources are required due to the significantly higher initial LINAC capital investment and
operational costs. LINACs require infrastructure support and stable electricity supply. One
requirement of LINAC technology is reliable electricity during treatment. These requirements
pose a challenge for some countries. For example, after South Africa updated to a new LINAC,
the unit frequently shut down due to power shortages and incompetent technical support. Even if
the NNSA initiative eliminates prohibitive initial capital costs thorough the donation of a LINAC
unit, the proposal does not reduce the high operational costs are include upgrades to electrical
systems. LMICs face greater obstacles in operating and running LINACs than cobalt-60 units.
Cobalt-60 units do not require an unwavering power supplies to generate stable and reliable
radiation beams. The proposed initiative has careful consider how best to allocate resources to
support LMICs throughout the transition to a LINAC-based cancer treatment regime (Page et al.
2014).
2
Stakeholders
In planning this initiative, the NNSA can coordinate with expert stakeholders to ensure the
initiative’s long-term success. Stakeholders include international, national, and sub-national
actors with significant interest in the long-term outcome of the initiative. In addition to providing
crucial buy-in to the initiative’s operation, a number of the actors outlined below can provide
critical and expert advice on program implementation. This section outlines governmental, nongovernmental, and private-sector actors who can be involved in implementation including initial
planning, LINAC identification, site preparation, and cobalt-60 unit disposal. An extensive list of
potential stakeholders organized around the phase of the exchange is provided in Appendix B.
10
2.1
Recipient Country Identification
Identifying capable and willing partners to receive the donated LINAC is an essential first step in
implementation of this program. While leveraging pre-existing bilateral relationships may be
sufficient for securing an initial set of partners, the expertise and connections of a variety of
outside organizations can help secure the long-term viability of the project.
The World Health Organization (WHO) and the International Atomic Energy Agency (IAEA)
are bolstering radiotherapy capabilities in developing nations. In addition to various independent
initiatives, these two inter-governmental organizations cooperate on the Programme of Action
for Cancer Therapy (PACT). This initiative works with national governments to create and
improve plans to respond to the emerging cancer epidemic in LMICs. Of particular interest is the
PACT advisory group, which works extensively with developing nations to coordinate the
smooth and sustainable transfer of radiotherapy equipment to them.
A wide array of non-governmental organizations are responding to the emerging threat of cancer
in the developing world. These organizations include the Global Task Force on Expanding
Access to Cancer Care and Control, the Africa Oxford Cancer Foundation, and RadiatingHope.
While contacts with other non-governmental organizations can be an important part of the
NNSA initiative, these three organizations were created as multi-disciplinary efforts to
coordinate a wide variety of organizations. As a result, the relationships these organizations can
call on and leverage during this phase of the project are of particular importance.
Finally, national government organizations and health professionals in a recipient country play
indispensable roles in determining whether the proposed exchange of a cobalt-60 unit for a
LINAC is appropriate under particular circumstances. Of particular note are ministry of health
officials, who will be able to provide the most up-to-date information on the state of the
country’s health infrastructure as well as valuable personal contacts within the health system
itself. This information is invaluable in determining which institutions are most suitable
recipients and what sorts of accommodations will be needed to ensure long-term sustainability of
an exchange.
2.2
LINAC Identification and Donation
Identifying institutions willing to donate used but serviceable LINACs is a second essential part
of program implementation. For this stage, the NNSA can leverage its connections with nonprofit organizations such as RadiatingHope and Argonne National Laboratories. The NNSA can
build connections with other organizations that may be able to broaden the search for donated
LINACs.
Since 2005, an American non-governmental organization, the East Meets West Foundation, has
assisted the government of Vietnam to fund two LINACs and one cobalt-60 unit (FNCA 2015).
The NNSA can consider working with organizations to receive assistance in the financial aspects
of LINAC identification and donation.
11
2.3
Site Preparation
Readying the donated LINAC for transport to the receiving institution and preparing that
institution to receive the LINAC is the largest and most complex stage of this project. Successful
completion would involve extensive communication with each of the stakeholders noted above,
while requiring coordination with government agencies to approve the physical transfer of the
device and specialist actors to ensure the long-term sustainability of the LINAC’s operation.
The LINAC is a complex and expensive piece of equipment. Transferring it would involve
health officials in the receiving country and require coordination with customs, transportation,
and foreign affairs officials to secure needed permits to move the device. LINAC transfers may
fall under some U.S. export controls, complicating NNSA coordination with some countries. As
a result, coordination with the U.S. Department of State is an essential step before any transfer
takes place.
Before LINAC transfer can take place, however, the device itself may require substantial repairs
and upgrades to ensure it is fully operational when it arrives at the receiving institution. Through
its involvement in the Ukraine project, RadiatingHope gained experience coordinating this
process, which involves contracting with private companies to inspect and refurbish the donated
machine, and ensuring complete records of that process are transmitted to the receiving
institution in a form usable to the personnel who will operate the LINAC.
The physical construction needed at the receiving site to accommodate the newly donated
LINAC must be planned in coordination with local and international medical experts. The IAEA
provides guidelines on proper shielding of teletherapy units. Additionally, consulting companies
and local contractors are required to design or update the facility to accept the donated LINAC
device, and moving companies are needed to move the unit into the facility.
Education of the receiving staff to ensure they can properly operate and maintain the donated
equipment is an essential part of ensuring the long-term sustainability of this project. A variety of
regional intergovernmental organizations already support the education of oncology personnel,
such as the African Regional Co-Operative Agreement for Research, Development, and Training
Related to Nuclear Science and Technology. This organization can be useful to the NNSA in
identifying a recipient country because its personnel know the region, and also, are able to assist
in education and training of radiation oncologists and medical physicists (International Atomic
Energy Agency 2010; International Atomic Energy Agency 2003). Other regional and multinational organizations that can be of assistance to the proposed initiative include the Regional
Co-operative Arrangements for the Promotion of Nuclear Science and Technology in Latin
America, the Arab Atomic Energy Agency, and the Forum of Nuclear Cooperation in Asia.
RadiatingHope provides operational and peer support to radiation clinics in developing countries
and shares expert knowledge on cancer cases using cloud-based collaboration platform Quentry
(Brainlab 2014). The Tropical Health and Education Trust, an affiliate of UK Aid, works with
structured health partnerships between the UK and LMICs to educate, train, and provide access
to donated medical devices (Mullally 2013).
12
Additionally, securing buy-in and support from oncologists and technicians who have experience
operating LINAC machines already in the receiving country can be an excellent source of
operational knowledge to the receiving personnel.
2.4
Cobalt-60 Unit Disposal
Disposal or storage of the decommissioned cobalt-60 gamma-ray source is a final major stage of
the project. Disposal involves dismantling and decommissioning the cobalt-60 unit itself and
transferring its radiation source to an acceptable long-term storage or disposal facility.
Decommissioning the source can be a logistically and legally difficult process, given the
sensitivity of the material involved. Therefore, if at all possible, partner countries should have
the capacity to store or dispose of the decommissioned source.
In the event that the receiving national government lacks the capacity to properly store or dispose
of the cobalt-60, international organizations such as the IAEA Technical Cooperation Program
may be able and willing to augment the government’s storage capacity. The Technical
Cooperation Program operates a mobile hot cell program that has been used to store radioactive
sources such as cobalt-60 for long periods of time in a variety of countries, and it assists member
states by providing international experts to develop and implement policy and strategy for
radioactive source management (International Atomic Energy Agency 2013b). The U.S.
Department of Energy, under its International Radiological Threat Reduction Program and OffSite Source Recovery Project, works in identifying, recovering, securing, and storing vulnerable,
high-risk radiological sources (Medalia 2011). The Arab Atomic Energy Agency, a suborganization of the Arab League, assists in setting up regulations for radiation protection,
security, and safe handling of radioactive materials for its 13 member states (AAEA 2015).
In the event that the partner government cannot properly dispose of this source, governments of
the countries where cobalt-60 was originally produced are often legally obligated to receive the
spent fuel. The technical, logistical, and legal hurdles involved in moving these materials across
national borders and oceans may render such an operation difficult and costly. Almost one-third
of incidents of theft and loss recorded in 2013, for example, occurred when the radioactive
material was in transit (James Martin Center for Nonproliferation Studies 2015). Using the
services of private companies such as CargoNet and FreightWatch International, the NNSA can
help determine safe routes of cargo travel to the disposal or storage facility.
2.5
Special Role of the Private Sector
In addition to providing services, private-sector corporations could play a vital role in increasing
access to LINACs in the developing world. Varian Medical Systems, Elektra, Siemens, and other
companies have extensive knowledge in LINAC research and development. Thus far, however,
this product development has been targeted primarily at high-end health care markets in the
developed world. With the increasing prevalence of cancer in LMICs, coupled with rising
personal income, a market may be developing for lower-cost, lower-maintenance versions of the
LINACs available in HINCs. While these machines may not be as powerful or as versatile as
those in more affluent societies, the inherently greater precision and energy density of the
LINAC may allow relatively simple LINACs to compete in a less affluent society. Development
of a simpler product for sale specifically in developing countries is not without precedent:
13
General Electric has had success redesigning cardiograph machines for these markets.
Facilitating this development may be another way to decrease the prevalence of cobalt-60 units.
3
Criteria
To devise criteria for successful LINAC transfers, we develop a three-prong framework and
provide recommendations to promote the likelihood of a long-term, successful LINAC donation.
Section 3.1 outlines our framework. Section 3.2 focuses on the medical need in LMICs, based on
cancer prevalence. Section 3.3 discusses technical feasibility, which we identify as the linchpin
of a successful LINAC transfer and, for that reason, discuss in greater detail. Section 3.4
discusses the cobalt-60 security concern; here, we provide analysis, yet largely defer to the
NNSA’s judgment and expertise. In the appendices, we rank LMICs according to each criterion.
3.1
Framework
The Global Threat Reduction Initiative works to convert, remove, and protect radiological
material in civilian sites in the United States and abroad (NNSA 2014). This proposal seeks to
exchange cobalt-60 units for LINACs and is part of the initiative’s long-term goals. We argue the
proposed initiative’s success is contingent the framework’s three prongs:
 First, the exchange must reduce the radiological security threat within the LMIC, and the
regional and global communities. A recipient country with a high security threat, such as
theft, provides a marginally higher security benefit if the LINAC-cobalt-60 initiative
leads to a successful exchange.
 Second, the recipient country must have the technical capacity to support a LINAC. High
technical feasibility includes adequate financial resources, supportive physical and human
capital, and an accommodative regulatory environment.
 Third, the exchange must contribute to the LMIC’s medical needs to mitigate the cancer
epidemic. The proposed initiative must assist the recipient country with combating the
cancer epidemic and lack of cancer treatment services. High medical need may
incentivize stakeholder engagement and the initiative’s adoption by domestic
governments.
Figure 1 illustrates our criteria framework. Area 1 represents ideal recipient countries, which
require little additional NNSA support besides facilitation of the exchange. Area 2 countries can
support LINACs and face a high security threat, yet lack a cancer epidemic. LINACs can be
installed and require little additional support. However, the public health payoff is less for
countries with greater medical need. Area 3 countries have a high security threat and growing
cancer epidemic, yet lack the technical ability to support a LINAC machine. These countries
need to develop additional capacities and receive external support for a successful exchange.
Area 4 countries have high technical feasibility and a growing cancer concern; however, they
lack a prevalent security threat. These countries are not a priority in the short term.
14
Figure 1: Framework
Source: (Authors)
All three prongs should be considered when selecting recipient countries. We rank LMICs in
each of the three prongs using a proxy, which we discuss in more detail throughout the
remainder of the report. Proxies are supported by research and developed using third-party
indices or specific data relevant to each prong. These proxies assist and inform the NNSA in its
recipient country selection. Areas 1, 2, 3, and 4 represent overlap which can be found using these
proxies. We do not find a scenario where countries perfectly overlap in Area 1.
The initiative’s purpose is not solely to identify criteria indicating greatest successful exchange
likelihood, but also to identify stakeholders and consider how to leverage their strengths to
improve a LMIC’s candidacy. For example, a country may lack full technical feasibility, yet
through assistance facilitated via the proposed initiative, become a relatively ideal country in
time.
3.2
Medical Need and Cancer in Developing Countries
Cancer is an emerging public health crisis in the developing word and has an estimated annual
cost to LMICs of $800 billion1 in 2010 (Knaul et al. 2014). As LMICs industrialize, changes in
environment, lifestyle, and behavior increase cancer incidence. The changes in risk factors
coupled with a relatively growing and aging population results in the prevalence of cancer in the
population to increase. These societal changes in LMIC have led the WHO to predict cancer
incidence and mortality rates to continually rise (World Health Organization 2014b). Cancer
burden is shifting to LMICs. Based on 2012 GLOBOCAN projections, cancer accounted for 8
million cancer diagnoses and 5.3 million deaths in 2012 (Ferlay et al. 2010). These figures
account for 57 percent of cancer incidence and 66 percent of cancer mortality worldwide (Torre
et al. 2015) . For individuals living in less developed countries, cancer diagnosis usually occurs
1
This annual cost estimate uses a value of statistical life approach which includes, for example, the value the
individuals themselves place on lost income, out-of-pocket spending on health, and a monetization of pain, and
suffering.
15
at advanced stages, and access to effective treatment is limited or unavailable. Effective
treatment is in stark contrast in HINCs with broad application of effective prevention measures,
early detection, and access to treatment.
We provide a LMIC Meets Medical Need ranking using a proxy based on cancer incidence rates
from Globocan data and convert this population into an estimate of country level demand for
radiotherapy machines. (See Appendix C for a discussion of calculations and complete ranking
of LMICs). The top five countries based on this proxy are: Ethiopia, Uganda, Madagascar,
Tanzania, and Cambodia.
3.2.1 Cancer Incidence, Mortality, Projections
Cancer incidence and mortality are increasing globally. The probability of surviving cancer is 51
percent in developed countries and 16 percent in less-developed countries (Ferlay et al. 2010).
Understanding which types of cancers affect which regions is crucial to determine which LMICs
are most amenable to LINAC donations.
The WHO collects a myriad of data on mortality. These country-level data also contain region
and income identifiers. Figure 2 plots percentage of total cancer deaths over time separated by
income status (World Health Organization 2015). These data illustrate the growth of the cancer
epidemic in LMICs relative to HINCs. Therefore any action taken by the NNSA cannot
undermine any cancer reduction effort or disrupt the cancer treatment status quo.
Regional data are useful to see which LMIC areas have the greatest cancer incidence. Figure 3
plots all cancer deaths in LMICs: actual cancer deaths for 2000 and 2012, and cancer death
projections for 2015 and 2030. As shown, cancer deaths are more prominent in the Western
Pacific and South-East Asia.
Different cancers require different treatments. Figure 4 shows LMIC cancer related deaths by
type. Trachea, bronchus, lung, stomach, and liver cancer have the highest mortality rates. Highly
preventable cancer deaths, including bronchus and lung, demonstrate how cancer prevention
education can reduce reliance on teletherapy machines. Reducing demand increases the ability of
LMIC medical professionals to switch to LINAC devices once the cobalt-60 units are demanded
less.
3.2.2 Role of Radiotherapy in Cancer Control
Until LMICs implement more expansive preventative cancer plans, a higher number of patients
will receive late-stage cancer diagnoses. Diagnoses at advanced stage cancer means radiotherapy
becomes the last resort to cure or prolong a patient’s life and an absolutely vital component of
cancer treatment. In 2012, of the 8 million new cases of cancer in developing countries, 60 to 68
percent needing radiotherapy services for palliative and curative cancer treatment (Grover, Dixit,
and Metz 2015; Ravichandran 2009). Health care systems in these countries are already stressed
from health shocks and lack the resources and technical knowledge to obtain a radiotherapy
device without international support.
16
Figure 2: Cancer Deaths by Income Status
Figure 2: LMIC Cancer Deaths by Region
Source: Authors using data from WHO 2015
Source: Authors using data from WHO 2015
Figure 4: LMIC Cancer Deaths by Type
Figure 3: LMIC Radiotherapy Demand
Source: Authors using data from WHO 2015
Source: Authors using data from:
GLOBALCOM 2012
17
We conduct an analysis to determine the medical demand met for cancer patients needing
radiotherapy in LMICs differentiated by region (Error! Reference source not found.). (See
Appendix C for a country-level calculation and ranking.) Results show that no regions meet
demand for radiotherapy units. We determine that Africa and South-East Asia have the most
unmet supply for radiotherapy devices, meeting only 18 percent and 19 percent of medical need
respectively. The Americas meet the most medical need, with 70 percent of supply of
radiotherapy units available for treatment.
3.3
Technical Feasibility
The NNSA initiative’s success is conditional on the long-term capability of the recipient country
to effectively operate the donated LINAC. We discuss LINAC costs, infrastructure, and the
policy and regulatory environment required to transfer, maintain, and operate a LINAC in the
prospective recipient country. We offer key technical considerations for each technical feasibility
criterion that the NNSA should evaluate before an exchange is initiated. (See Appendix A for
these key considerations.)
We define a successful recipient country as one able to support the LINAC throughout its useful
life. The WHO discusses specific obstacles. We draw on WHO findings and our own to provide
a technical feasibility overview. The items listed below are criteria to evaluate the technical
capacity of a recipient country (World Health Organization, Department of Essential Health
Technologies 2011b):








high-level communication between the donor and recipient country
sufficient appreciation of the challenges of the recipient’s context
sufficient linkages across activities by organizations working on donations
sufficient financial resources to support new medical equipment
sufficient support for the long-term integration of new equipment
sufficient personnel and human capital necessities
accommodative regulatory environment
accountability of tracking and monitoring donations and existing quantification
framework for donation impact
We rank LMIC infrastructure, which is one component of technical feasibility, using a country’s
density of LINAC machines and gross national income (GNI) per capita. LMICs with no cobalt60 units are ranked separately to LMICs with cobalt-60 units because there is no relevant
security threat. We discuss these data in Appendix D.
3.3.1 LINAC Costs
LINAC costs can be prohibitively high for prospective recipient countries and vary dramatically
based on geographic location. A country’s ability to absorb these additional costs indicates
greater technical feasibility. We recommend the NNSA donate to countries with the adequate
financial resources and requisite infrastructure to support the fixed and variable LINAC costs. In
this section, we deploy a micro-level approach, focusing on the costs of a single LINAC to
18
illustrate why adequate financing is necessary. We do not incorporate the shadow costs of cobalt60 units.2
The IAEA outlines costs that countries should consider when creating a radiotherapy facility or
expanding a facility. Our findings expand this list to include the following: unit costs, operating
costs, long-term maintenance and servicing costs, source replacement and disposal costs (when
applicable), health care facility costs, and average cost per fraction, the average cost for a single
treatment dose during a LINAC’s lifespan.
We recommend the NNSA ensure countries create a resource allocation plan that incorporates
these cost considerations to ensure they have the financial capacity to support a LINAC. These
costs vary significantly with geographic location, machine age, and supply of physical and
human capital required to replace and install the LINAC (Van Der Giessen et al. 2004). We
discuss costs, their variation, and their implications below.
3.3.1.1 LINAC Unit and Operating Costs
The unit and operating cost of a single new LINAC are prohibitive for many LMICs. A LINAC’s
unit and operating costs can be three to five times more than a cobalt-60 unit, with operating
costs three to six times the cost of cobalt-60 unit (National Research Council 2008). However,
low-energy LINACs, which use substantially less electricity than high-energy LINACs, are
suitable for many LMICs, meaning some LMICs will have the capacity to purchase and maintain
LINACs, although many countries will need financing from domestic and foreign sources.
A new LINAC’s $2 million unit cost is outside the financial capacity of many LMICs (National
Research Council 2008). However, a discount or donation may significantly help a country in
search of a LINAC. Unit cost variation depends on age and technical specifications of the unit,
including the machine’s required megavoltage. Insurance, import duties, agent fees, and
supplementary services and equipment purchased add cost variation that is largely countryspecific (International Atomic Energy Agency 2010). Supplementary services and equipment
include personnel training and contract servicing. Dr. Norman Coleman of the Center for Cancer
Research noted in an interview that refurbished or used LINACs may come at a fraction of the
cost of a new unit. However, a refurbished device comes with a trade-off of a shorter lifespan
and more repairs. We recommend the NNSA require a recipient country to devise a replacement
plan for the donated LINAC at the end of its lifespan to meet retirement costs.
LINAC operating costs relative to the cobalt-60 unit operating costs are significantly higher.
These operating costs include equipment-related costs, long-term maintenance and servicing
2
For example, a formal cost-benefit analysis would quantify additional costs of a cobalt-60 unit not considered in
our analysis. A cost-benefit analysis would consider the direct cost of an actual deployment of a radiological
dispersal device on human health (physical injury, psychological harm, loss of life), damage to property,
contamination of buildings and property, and indirect costs of economic loss of activity (Stewart 2010; Kelly 2006;
Rosoff and Winterfeldt 2007). Other indirect costs needed to prevent an attack include administrative costs and
procurement of technology employed to strengthen security (Kelly 2006). Cost is involved in the training of first
responders to guarantee effective disaster response to radiological contamination (Ferguson, Kazi, and Perera 2003)
and insurance costs for the government and private industry (Michel-Kerjan, Raschky, and Kunreuther 2014). Costs
associated with the radiological storage facility include building site construction, operation, and maintenance
(Boeing Company 2007).
19
costs, and radioactive material replacement costs (applicable to cobalt-60 units only). An
advantage of a LINAC is it does not require radioactive source replacement or disposal every
seven years, which on average a cobalt-60 unit requires (Reddy 2013). Thus, a LINAC
represents a cost saving to the recipient country in the event of an exchange. In many countries,
the required cobalt-60 source replacement results in greater long-term costs. For example, in
India when the cost of radioactive source replacement is included as an operating cost for 10
years, cobalt-60 units are more expensive than LINACs by 175 percent (Reddy 2013).
However, a disadvantage of a LINAC is the relatively more complex and extensive long-term
maintenance and servicing, excluding radioactive source replacement, which requires
professionally trained staff. Health care facilities may contract with corporations such as
Radiology Oncology Systems to service LINAC machines. Long-term maintenance costs are
equivalent to 6.7 to 7.5 percent of the overall unit cost, depending on machine voltage. Longterm maintenance costs do not include personnel to administer treatment, such as radiotherapy
technicians (National Research Council 2008). A LMIC may commit to the proposed initiative if
its government understands the cost trade-offs.
Additional LINAC operating burdens include a relatively greater time for corrective maintenance
and calibration. LINAC’s reported down time for repairs are approximately 8 percent of
operating time. This downtime is seven percentage points greater than breakdown time for
cobalt-60 units (when the LINAC is in an LMIC). LINAC down time in LMICs is largely
attributed to lack of financial resources, which leads to repair delay (Van Der Giessen et al.
2004). Calibrating output is crucial for effective cancer treatment and prevention of secondary
cancers. Output calibration also varies by radiotherapy machine. A LINAC requires output
calibrations 52 times more frequently than a cobalt-60 unit (National Research Council 2008).
Machine calibrations imposes additional servicing and personnel costs on already limited health
care infrastructure in LMICs.
The recipient countries should plan long term for the LINAC cost premium and provide adequate
financial resources to accommodate the new, high operating costs. Table 1 displays cost
differentials across radiotherapy machines LINACs primarily fall into three energy categories:
low, medium, and high. Low-energy LINACs, 4 to 6 megavolts, are relatively more suitable for
LMICs and are comparable to cobalt-60 unit costs (Reddy 2013). The 6-megavolt LINAC, which
provides superior treatment to a cobalt-60 unit, is relatively inexpensive and may prove most
viable for health care systems with limited financial resources to support recurring operating
expenses. The 18- megavolt LINAC is a feasible option in a country with adequate financial
resources to fund ongoing maintenance and adequate power supply.
20
Table 1: Therapy Unit and Operating Costs
Radiotherapy Machine
Unit Cost
(per unit)
Operating Costs
(per year)
Decommission Costs
(per source)
Co–60 Unit
750,000
50,000
LINAC 6 megavolts
2,250,000
150,000
Not Applicable
LINAC 18 megavolts
4,000,000
300,000
Not Applicable
20,000
80,000
Source: (National Research Council 2008) (Authors)
Notes: Costs in U.S. dollars. Operating cost(s) include: equipment-related costs, maintenance costs,
servicing costs, and source replacement; costs do not include required additional personnel costs, such as
radiotherapists and operators.
Modified cobalt-60 units pose a concern for the proposed NNSA initiative because they offer
superior radiotherapy services relative to traditional cobalt-60 units, yet at a low cost relative to a
LINAC. For example, multi-leaf collimators, dynamic wedges, and dynamic operation—
traditionally LINAC-specific technology—are now available cobalt-60 unit upgrades (National
Research Council 2008). These features enhance the precision and accuracy of the treatment; the
cobalt-60 security risk remains, however.
3.3.1.2 Country Variation in LINAC Cost per Fraction
We recommend the NSSA remain cognizant of LINAC cost per fraction variation. Cost per
fraction—the average cost for a single treatment dose over the LINAC’s life span—varies by
country and can be substantially more (or less) than the cost per fraction of a cobalt-60 unit.
LINAC cost per fraction averages 85 percentage points more than cobalt-60 units (Van Der
Giessen et al. 2004) . Cost per fraction also varies geographically and is contingent on countryspecific factors, which include the country’s cobalt-60 supplies, per-capita income, regulatory
requirements, and taxes. Accounting for these different factors in the recipient country is
important because they may increase or decrease the cost of treatment, relative to a cobalt-60
unit. A high cost per fraction of a cobalt-60 unit relative to a LINAC is a stronger incentive for a
country to participate in the proposed initiative.
LINAC median cost per fraction is $11.02 with a lower and upper bound of $3.27 and $39.59,
respectively. Van Der Giessen et al. (2004) found a LINAC cost per fraction of less than $5 in
Cuba, approximately $10 in Indonesia, and more than $30 in South Africa, which illustrates the
cost variation among LMICs using the same technology.
The variation in cost per fraction is substantially greater in countries that supply their own
cobalt-60 versus countries that import. In countries that supply their own cobalt-60, LINAC cost
per fraction may exceed cobalt-60 unit cost per fraction by more than 530 percentage points
(Van Der Giessen et al. 2004). In LMICs that produce their own cobalt-60, political and
economic vested interests make participation in the proposed initiative unlikely.
3.3.1.3 LINAC Health Care Facility Costs
A LINAC requires additional physical infrastructure at the health care facility, imposing high
costs and requirements on LMICs. A LINAC will not be viable in the absence of such support
21
and facility infrastructure. LMICs may need additional financial support or expertise in preparing
an LINAC adequate facility.
Additional physical infrastructure includes a ceiling and floor supports reinforced above and
beyond what cobalt-60 unit infrastructure requires. A LINAC requires an adequate,
uninterruptable power supply. The quantity of power is conditional on the megavoltage of the
LINAC device, which can range from 4 to 22 megavolts. An emergency power generator is
required in the event of power failure to reduce risk of lost or damaged data and injury to the
patient.
If a LMIC lacks radiotherapy services, it will need to construct a facility built specifically to
handle radiological medical devices. New facilities can cost upward of $5 million (International
Atomic Energy Agency 2010). Countries that require and cannot afford a new facility are not
ideal candidates for an exchange.
3.3.2 Infrastructure
Adequate country-level medical infrastructure and conditions indicate the capacity for the
recipient country to participate in the exchange. While the NNSA would facilitate the initial
LINAC donation, the long-term success of the program is conditional on the capacity of the
recipient country to support a LINAC cancer treatment facility.
In this section we discuss required and recommended country-level medical infrastructure.
Presence of specific country-level infrastructure can indicate a greater likelihood of successful
and sustainable exchange. Needs assessment, communication, site facilities, human capital, and
cobalt-60 disposal processes are all infrastructure factors that the NNSA must consider.
3.3.2.1 Needs Assessment and Communication
A high level of communication between the donor country, recipient country, and external
stakeholders is vital to ensure a successful and sustainable exchange. In particular, a formal
country-level needs assessment, which addresses concerns regarding adequate funding,
personnel, and other support, may increase likelihood of success and enhance communication
among stakeholders. A needs assessment is a starting point to ensure the country and health care
facility need a machine and are aware of the obstacles and challenges (Datta, Samiei, and Bodis
2014). Additionally, a needs assessment may indicate the recipient's understanding of national
capacity to support a LINAC and provide insight to the NNSA on a specific country’s or
facility’s limitations (World Health Organization, Department of Essential Health Technologies
2011a).
Due to the relative complexity of a LINAC versus a cobalt-60 unit, we advise the recipient
country conduct a needs assessment and devise an action plan that addresses technical concerns.
We speculate many LMICs do not have the capacity to fully create a thorough needs assessment.
The NNSA should form partnerships with stakeholders to assess the country’s readiness and
capacity to participate in the exchange.
3.3.2.2 LINAC Site Infrastructure
The cancer facility receiving the donated LINAC may need structural adjustments to prepare for
the permanent installation of the unit. The extent of pre-installation construction depends on
22
whether the LINAC replaces a cobalt-60 unit or is located in a new facility. To minimize liability
risk exposure and maintain the integrity of the transfer, the NNSA should ensure benefits the
country adheres to general construction safety procedures and manufacturer specification.
Regulatory building standards ensure the structural integrity of the health care facility. The
quality of construction should meet international standards. The donated LINAC device should
be installed in a treatment center subject to building ordinances and safety procedures to
maintain adequate amount of shielding, weight-bearing floor, support, ceiling height and floor
space for a control room, treatment suite, and equipment room. Manufacturers can be consulted
and site planners can evaluate the site for compliance. These standards will protect patients and
staff from harmful doses of non-isotopic radiation and improve the lifetime of the facility and
LINAC unit.
Besides structural changes to the receiving facility, LINACs require a stable electrical
infrastructure and other utilities such as information technology connections and plumbing.
These technical aspects are necessary for the operation and adequate cooling of the LINAC. All
LINAC models have manufacturer recommendations that outline optimal system requirements
for electrical needs. These include specifications about input voltage, line voltage regulation
(voltage stabilization), and electrical loads, including a mandatory ground conductor that
improves the safety and useful life of the unit. Contractors must follow these electrical
recommendations to protect the safety of patients, staff, and the public.
Because the unit emits a substantial amount of heat, external coolant requirements are also
necessary. Additional electrical requirements are needed to operate a heating, ventilating, and air
conditioning system to maintain 24-hour-a-day room temperature and humidity controls.
Additional plumbing is needed to operate cooling units in the equipment room. Adhering to
electrical and coolant guidelines prevent operational damage, extends the life of the device, and
protects the facility from fires.
Table 2 lists site specifications for a CyberKnife Robotic Radiosurgery System. Radiotherapy
and radiosurgery both deliver collimated beams of radiation (Accuray 2012). While, the make
and the model of any donated LINAC are unknown, general specifications about the Cyberknife
can provide basic information about building or remodeling a site with some possibly of error.
This discrepancy is because the Cyberknife is not an exact replication of LINAC technology.
When designing a building site, please defer to the actual LINAC model’s specification
guidelines.
23
Table 2: LINAC Building Plans
Building
Permits and licensing requirements of local, state and national codes; and
Regulatory Needs ordinances affecting site planning, site preparation, construction, system
installation and system maintenance.
Pre-installation
Construction
·designate space for control room, treatment suite and equipment room.
· construct new or additional shielding
· modify ceiling height and floor space
· provide all electrical, plumbing, fire protection, heating, ventilating, and
air conditioning, lighting and power distribution
· provide all information technology requirements
· supply other accessories such as cabinetry, sinks and other millwork
Radiation
Shielding
LINACs are shielded to limit the leakage of the primary beam into public
areas. Primary barrier thickness is 48 to 60 inches of standard density
concrete (2.3 grams per cubic centimeter) but depends on local
regulations. Primary barriers adjacent to public areas use 60 inches.
Secondary barriers, including the ceiling, use 42 inches.
Electrical
Requirements
· supply 480 voltage alternating current (VAC), 3-phase, 100 amps, 55
kilovolt amps (kVA) power (200-480 VAC input power is accepted but
150 amps is required)
· power conditioner (voltage stabilizer) is required if input voltage cannot
be regulated to within +/- 5 percent phase to phase
· uninterruptable power supply such as an emergency power generator is
required in the event of power failure to reduce risk of lost or damage to
data
Environmental
Requirements
The area that houses the LINAC equipment, such as the treatment and
equipment rooms, should be kept between 50-85º F(10-30º C) at all times,
with 30 percent to 70 percent relative humidity.
Information
Technology
Considerations
· install device software
· provide necessary Internet protocol addresses
Source: (Accuray 2012)
3.3.2.3 Human Capital
LMICs with sufficient staff to operate and maintain the donated LINAC have a greater likelihood
of success. Technical and medical personnel with advanced training and education are required
to operate radiotherapy centers. These professionals include radiation oncologists, radiation
biologists, radiation therapists, radiation oncology nurses, medical physicists, and nuclear
engineers. These professions require 12 years of primary school, four years of college, and two
to eight years of post-graduate education. Some professions may require several additional years
of residency requirements. To walk these career paths, people must have access to primary
education sufficient for university attendance, and beyond. The cost of university attendance can
24
be prohibitive, even in HINCs with subsidized higher education. This expense is an additional
barrier to entry, even for HINCs.
A second complicating factor is the global shortage of these trained medical professionals (Hoyler
et al. 2014), which results in extremely high wages that often drive professionals to relocate to
HINCs where they can make more money (Hagopian et al. 2004).
A tertiary factor is the lack of an international accreditation standard for the licensing and
regulation of these medical professionals. Advanced training in one country may be deemed
insufficient to practice the same profession in another country (Forcier, Simoens, and Giuffrida
2014).
These three problems—access to education, demand for high pay, and incongruent international
licensure requirements—present a daunting task for LMICs. Access to education is still a problem
in the United States and other HINCs. Not all HINCs can afford to employ these medical
professionals in sufficient supply. Not all trained medical professionals can practice
internationally. If training, acquisition, and retention of such qualified staff still results in shortages
for the HINCs, the chances of LMICs competing with HINCs for these professionals may be
insurmountable. Additionally, the requirements for a national education system from primary to
post-graduate education within these countries is a necessary investment, but beyond the scope of
this report. LMICs must seek alternatives, if not a stop-gap.
Advanced medical professionals are a requirement for the safe, effective operation and
maintenance of LINACs. In contrast, the educational requirements and diversity of medical
professional training is significantly less for cobalt-60 units. Because these units are operated in
LMICs, we assume education systems provide for a supply of medical professionals sufficient to
operate them. Furthermore, without appropriate medical staff, LMICs are significantly less likely
to seek procurement of LINACs. This situation allows for two options: train existing staff or
leverage existing international staff. Both options may be met through contributing financial
resources to the IAEA.
Through sub-units, the IAEA provides a plethora of resources for LMICs. The Division of
Human Health seeks to “enhance the capabilities in Member States to address needs related to
the prevention, diagnosis and treatment of diseases through the application of nuclear
techniques” (International Atomic Energy Agency 2014b). The Department of Technical
Cooperation “supports human resource capacity building activities, networking, knowledge
sharing and partnership facilitation, as well as the procurement of equipment” (International
Atomic Energy Agency 2013b). “The IAEA, through PACT (Programme of Action for Cancer
Therapy), the WHO, the International Agency for Research on Cancer (IARC) and other cancerrelated organizations work together to make a coordinated global response in supporting low and
middle income IAEA Member States in the implementation of comprehensive national cancer
control programmes” (International Atomic Energy Agency 2013a).
The magnitude of research, planning, resources, implementation, and cross-collaboration is well
beyond the scope of this report. However, we recommend utilizing IAEA resources to assess
cancer treatment education, and training needs required for effective and sustained LINAC
implementation in LMCs. Such capacity building is in the best interest for the success of the
25
NNSA’s proposed initiative to secure cobalt-60 units in exchange for LINACs by ensuring target
countries are able and willing to exchange teletherapy units.
3.3.2.4 Disposal
Even at the end of its useful life, the cobalt-60 radiation source remains highly radioactive. As a
result, transport to a long-term storage or disposal facility requires significant logistical planning,
coordination with local authorities, and associated costs. As radioactive waste, transportation
requires a specialized radioactive package to protect against radiation leakage and potential
shipping accidents. Given the expense and highly specialized purpose of these packages,
equipment may not be available in countries without substantial nuclear infrastructure. While
these packages may be rented or borrowed from organizations such as the United States Off-site
Source Recovery Project (Whitworth 2015) or the IAEA through its Mobile Hot Cell
(International Atomic Energy Agency 2012), these devices are large and expensive and require
substantial planning and expense to move them on site. Shortages of type-B container, which are
shielded and accident-proof transportation containers, have prevented the repatriation of United
States source material from Latin America. One potential solution is to wait to repatriate material
until higher-level wastes are removed from nuclear reactors.
The NNSA will need to coordinate extensively with national governments to secure proper
permits to use transportation networks and to use national ports of entry and exit because of the
sensitivity of the radioactive source. Many countries have a centralized nuclear regulatory
authority that could provide expertise in coordinating such a transfer (see IAEA website for a list
of nuclear regulatory authorities). Other countries, particularly those without a developed nuclear
industry, may lack this central authority. Lack of a central authority would require the NNSA or
the target health organization to negotiate for permits directly, which would complicate transport.
Therefore, the presence of such a centralized authority should be one criterion for program
participation.
Long-term storage or disposal within the host country, assuming these options exist, will prove
easier than international transfer of the material. Such a solution may take the form of a permanent
disposal facility. However, few countries host such facilities and those that do tend to have higher
national income and developed nuclear power programs (Streeper et al. 2008). A more likely
possibility is a national long-term, rather than permanent, storage facility monitored and
maintained by the national nuclear regulatory authority. While these facilities vary widely in their
capacity to secure radiological materials, they are solely dedicated to the safe and secure storage of
these materials. Long-term storage is not the optimal solution, but it is an improvement over the
status quo. In the long run, the IAEA already supports programs for upgrading long-term storage
facilities (IAEA, n.d. The Use of Management Sealed Radioactive Sources).
Another option is the transfer of the cobalt-60 radiation source to another country for final
disposition. When the host country lacks secure long-term storage, exportation may be the sole
option for disposal. This process brings substantial legal and logistical complications. IAEA
policies generally discourage international transfer of radioactive wastes. However, in some
cases the IAEA has acknowledged such transfers are beneficial (International Atomic Energy
Agency 2000). Even so, countries without vested interest in the material are unlikely to accept it
for long-term storage or permanent disposition.
26
When considering possible countries to accept the material, the material source and original
contract outlining the sale must be considered. For recently purchased material, the contract may
contain a clause requiring the seller to accept the material once spent for recycling or disposition.
This clause will require payment of a fee to cover transportation costs, which may be substantial
for areas with limited health funding. For U.S.-sourced material, the Off-site Source Recovery
Project may facilitate a transfer. However, the logistics of moving teletherapy radiation sources
have rendered such movements cost-ineffective and never completed in some instances (Los
Alamos National Laboratory 2008).
Various U.S. agencies provide expertise, sharing opportunities, and resources for disposing
cobalt-60 units. The Nuclear Regulatory Commission controls the use and transportation of
radioactive sources. The Department of Energy’s International Radiological Threat Reduction
Program and Off-Site Source Recovery Project identifies, recovers, secures, and stores
radiological sources. The Department of Energy is also working on a proposal to prevent intranational source diversion and to control source imports and exports. The State Department works
on strengthening border security to prevent unauthorized movement of radiological material, and
the Department of Homeland Security develops and operates equipment to detect radioactive
materials. The Environmental Protection Agency is involved through the Orphan Sources
Initiative to retrieve, reuse, and dispose of abandoned radioactive sources from non-nuclear
facilities (Medalia 2011).
3.3.2.5 Country Wealth and LINAC Density as Measures of Infrastructure
Country wealth and LINAC density are measures of the country’s LINAC infrastructure and
ability to absorb a LINAC. LMICs with greater wealth and LINAC density face lower marginal
costs when absorbing a LINAC because these measures suggest greater human capital resources,
greater public and private financial resources, adequate cobalt-60 disposal capabilities, and other
infrastructure factors. Also, the government and other stakeholders in such a country have a
greater capacity to adequately finance and support radiotherapy centers. Greater country wealth
results in more radiotherapy machines; more radiotherapy machines create economies of scale,
and absorbing an additional LINAC becomes less costly (Grau et al. 2014).
Greater wealth and LINAC density suggest a country has the technical feasibility required for a
successful exchange of a LINAC for a cobalt-60 unit. We measure country-wealth using GNI
per capita. LINAC density is the number of LINACs per million people. To add support to this
argument, we analyze the relationship between GNI per capita and LINAC density.
The World Bank’s income group classifications allow us to divide LMICs into three groups
according to GNI per capita. Table 3 displays the World Bank income stratification we use.
27
Table 3: World Bank Income Classes
World Bank Income Class
Income Range
Number of Countries
Low
$0 – $1,045
34
Lower-Middle
$1,046 – $4,125
48
Upper-Middle
$4,126 – $12,745
60
Source: (World Bank 2013)
Using density data from the WHO, we find a positive relationship between GNI per capita and
LINAC density. As shown in Error! Reference source not found.: For each $1,000 increase in
GNI per capita, LINAC density increases by 0.1419 machines per million people. Analyzing
LMICs by income group, a $1,000 increase in GNI per capita there is associated with a LINAC
density increase of 0.0536 in low-income countries, 0.1122 in LMICs, and 0.1890 in uppermiddle income countries (UMICs).
Figure 4: LINAC Density vs. GNI per Capita (LMICs)
Source: Authors using data from World Bank 2013, World
Health Organization 2013c
Twenty-five percent of low-income countries have a LINAC density greater than zero (of
available data), compared to more than 70 percent of LMICs and UMICs. We also find that
cobalt-60 units are more common in low-income countries than are LINACs. However, cobalt60 units are not specific to low-income countries. LMICs and UMICs have substantial cobalt-60
unit densities. These UMICs are relatively ideal for the proposed NNSA exchange because we
argue they are better-equipped and well-financed to absorb a LINAC and support it in the long
term. Table 4 displays the percentage of LMICs that have a density greater than zero.
Specifically, we examine the percentage of LMICs that have a cobalt-60 unit density greater than
zero, a LINAC density greater than zero, and a radiotherapy density greater than zero.
28
Radiotherapy density include LINAC density and cobalt-60 unit density. Our analysis suggests
that countries with higher GNI per capita in the upper- and lower-middle income countries with
LINAC infrastructure should be prioritized for the initiative (See Appendix E for a detailed
global map of income stratifications and regional groupings.)
Table 4: Radiotherapy Densities by Income
Cobalt-60 Unit
Density
(Percentage of
LMICs)
LINAC Density
(Percentage of
LMICs)
Radiotherapy
Density
(Percentage of
LMICs)
Low
46.15
25.00
53.85
Lower-Middle
73.68
71.79
78.57
Upper-Middle
72.55
72.55
81.13
Overall
66.96
62.28
74.38
Gross National
Income Per Capita
Source: (WHO Medical Device Database 2013)
Note: Density is a measure of the number of machines per million people.
We also suggest the NNSA focus on regions with relatively high gross national income per
capita and existing quality LINAC infrastructure. Such focus can create economies of scale and
lead to lower marginal costs. A regional focus allows pooling of financial and human capital
resources such as health care professionals. Table 5 displays a region’s percentage of countries
that have LINACs and shows that the NNSA should avoid prioritizing the Sub-Saharan Africa
and the Western Pacific. These regions lack significant LINAC infrastructure and have relatively
low GNI per capita. The numbers in parentheses are the number of countries within each region
with a density greater than zero.
Table 5: Radiotherapy Densities by Region
European
Mediterranean
European
African
Cobalt-60
unit
92.31
(12/13)
89.47
(17/19)
LINAC
92.31
(12/13)
Radiotherapy
92.31
(12/13)
Device
Americas
South-East
Asia
Western
Pacific
48.57
(17/35)
73.08
(7/26)
77.78
(7/9)
38.46
(5/13)
90.00
(20/20)
28.12
(9/32)
80.00
(20/25)
77.78
(7/9)
33.33
(5/15)
100.00
(20/20)
58.33
(21/36)
81.48
(22/27)
80.00
(8/10)
46.67
(7/15)
Source: (Authors) Data from: (World Health Organization 2013c)
LMICs with LINAC infrastructure and high GNI per capita should be prioritized due to a greater
likelihood of high technical feasibility. A regional focus may offer additional benefits. We rank
LMICs’ technical feasibility by LINAC density and stratify by income group for the proposed
29
initiative. The top five countries of technical feasibility are Latvia, Lithuania, Uruguay, Bosnia
and Herzegovina, and Venezuela. (We discuss the full ranking in detail in the Appendix D.)3
3.3.3 Policy and Regulatory Environment
In addition to LINAC costs and infrastructure, regulatory agencies and specific regulations may
enhance or reduce the technical feasibility of an exchange. In this section, we consider the
impact of national cancer plans, national regulatory agencies, national procurement authorities,
and donation guidelines for radiotherapy machines on the success of the proposed initiative.
3.3.3.1 National Cancer Plan
Countries with operational cancer policies that allocate adequate funding are good candidates to
receive a donated LINAC under the NNSA proposed initiative. The adoption of a cancer control
plan indicates the government has a strong commitment to reduce cancer incidence and mortality
rates, and is aware of challenges to supply treatment. Cancer programs that include mechanisms
to improve data collection; implement prevention campaigns; and establish plans for early
detection, diagnosis, and treatment demonstrate effective management of cancer epidemics. A
country with a robust cancer policy has a higher likelihood that it has budgeted and planned for
the technical requirements necessary to transfer and operate LINACs. Adequate preparation
accelerates the speed at which a LMIC can receive a LINAC and would improve the success of
the NNSA initiative.
The WHO Non-communicable Disease Country Capacity Survey proxies the robustness of a
country’s cancer policy. This survey assesses the capacity of countries to respond to noncommunicable diseases, such as cancer, through the collection of detailed information from
designated individuals within the ministry of health or national institute or agency in 193 WHO
member countries (World Health Organization 2012). According to a 2014 report, 85 percent of
countries have adopted cancer policies, strategies, or plans; 64 percent are operational with
adequate funding (Ullrich and Riley 2014).
Morocco is an example of a country that has made cancer control a national priority. The
Moroccan ministry of health developed a National Cancer Prevention and Control Plan for 2010
to 2019. Ratified in March 2010, the National Cancer Prevention and Control Plan focuses on
prevention, early detection, diagnosis and treatment, and palliative care with 78 operational
measures. From 2006 to 2012, the Lalla Salma Foundation for Cancer Prevention and Treatment
conducted an independent evaluation of the country’s activities relating to cancer. The evaluators
reported that 72 of the 78 measures had been initiated, with 51 in advanced stages of
development. One measure in the cancer control plan involves the building and equipping of
oncology centers. In the evaluation, Morocco improved from two oncology centers to nine and
from two accelerators to 22 in a six year period (Bakkali 2014). The NNSA may wish to partner
with countries similar to Morocco that demonstrate cancer policies that suggest institutional
capacity to manage resources effectively.
Europe and the Western Pacific have the highest rates of robust cancer plans with funding,
whereas Africa and the Eastern Mediterranean lack funds to support cancer policies (Ullrich and
3
These countries are ranked using LINAC density. However, one could also prioritize on the number of LINACs.
China, Brazil, India, Turkey, and Russian have the greatest number of LINACs. They also all have cobalt-60 units.
30
Riley 2014). Table 6 shows results from the WHO 2013 Non-communicable Disease Country
Capacity Survey by region.
Table 6: National Cancer Plans
Percentage of countries with cancer policies,
strategies, or plans
Number of
countries
Existing policy
Operational policy with
funding
Africa
37
73
38
Americas
31
90
65
Eastern Mediterranean
21
76
43
Europe
50
98
84
South-East Asia
10
70
70
Western Pacific
27
85
78
WHO region
Source: World Health Organization 2014a; Ullrich and Riley 2014
3.3.3.2 National Regulatory Authority for Radiotherapy Machines
The proposed NNSA initiative should prioritize an LMIC with a national regulatory authority
that governs medical devices. A national regulatory authority would aid in safe, secure, and
speedy transportation of the LINAC and streamlining of the regulatory process. A national
regulatory authority reduces the administrative burden on the NNSA and other relevant
government stakeholders. While most HINCs have national regulatory agencies with
enforcement power, there is greater variation among LMICs. If a country lacks a national
regulatory authority, the NNSA would need to communicate with subnational authorities. A
national regulatory authority should increase the LINAC’s long-term security; a regional or local
regulatory authority may be sufficient as long as the authority provides adequate oversight.
The WHO and the IAEA recommend that a national regulatory authority should be powerful and
independent from government agencies with conflicting interests. The IAEA advocates a
national regulatory authority governing radiological medical devices that is independent from
government departments with conflicting interests as well as any actors involved in the
construction and design of radiation sources (International Atomic Energy Agency 2010). A
national regulator of radiological medical devices dependent on other government departments
and outside interests may pose a significant obstacle in countries that produce their own cobalt60, such as India. The WHO further recommends a national regulatory authority should have
authority over pre-market approval, registration, and post-market surveillance (World Health
Organization, Department of Essential Health Technologies 2011b).
Appendix F lists LMICs that lack a national regulatory authority over medical devices. Most are
in Africa and island nations in the Caribbean and Pacific (World Health Organization 2013b).
31
3.3.3.3 National Procurement Authority for Radiotherapy Machines
The presence of a procurement authority at the national level may indicate a greater likelihood
for a successful exchange. A national procurement authority is an indicator of a LMIC’s
institutional capacity, which is usually accompanied by a nationally adopted procurement plan or
policy coordinating the procurement process. These national authorities may help streamline and
facilitate the exchange the procurement of medical devices at the country level.
In particular, most LMICs have explicit national authority over the procurement of medical
devices, which we argue indicate the NNSA should avoid LMICs that do not procure medical
devices at the national level (World Health Organization 2013d). This authority is likely due to
the necessity of a procurement plans or policy in state-run health care systems. However,
government supply agencies may have legal oversight over another government agency’s
medical procurement processes and could add complexity to the donation process.
If procurement authority rests with the national government, the NNSA must facilitate the
donation at the national level. While national medical procurement plans may help streamline
communication of the exchange, it is important to solicit input and comments from the receiving
health care facility. Recipient LMICs with policies mandating feedback from receiving health
care facilities helps to ensure the long-term sustainability of the LINAC donation (World Health
Organization, Department of Essential Health Technologies 2011b). Therefore, we advise
selecting LMICs with national procurement plans that solicit and consider the receiving health
care facility’s input.
Appendix F lists LMICs that do not procure medical devices at the national level. Among LMICs
there does not appear to be a geographic cluster. However, some of the poorest LMICs do not
procure medical devices at the national level. These include Cote d’Ivoire, Guinea-Bissau, and
the Democratic Republic of the Congo.
3.3.3.4 Donation Guidelines for Radiotherapy Machines
We argue that a LMIC that has already enacted WHO donation guidelines for radiotherapy
machines is a better candidate for the proposed initiative’s success. Inadequate national
guidelines may lead to poor preparation and needs assessments, which distorts the actual need
for a donation (World Health Organization, Department of Essential Health Technologies
2011b). However, exceptions may occur where the nationally approved guidelines are more
robust than are WHO guidelines. We suggest an evaluation of nationally approved guidelines on
a case-by-case basis, which may require significant time and research, another reason to facilitate
donations with LMICs that have enacted WHO guidelines.
LMICs use national or WHO donation guidelines more than HINCs do, which is attributed to
fewer medical device donations to HINCs. As the NNSA’s proposed initiative notes, medical
donations tend to flow from HINCs to LMICs, not the reverse. Thus, there is little need for
HINCs to enact donation guidelines. For example, the only HINC on the European continent that
has donation guidelines is the United Kingdom. The United States, Canada, and Japan all lack
active donation guidelines (World Health Organization 2013a).
32
Appendix F lists LMICs that lack donation guidelines or have “national guidelines” for medical
devices. Significant variation across LMICs exists; however, several regional trends are evident.
For example, Central and South America largely have national guidelines or an absence of
guidelines; Guatemala is the sole country with WHO guidelines.
3.4
Security
The NNSA assists international partners to better manage and monitor radiological material with
the intent to prevent a radiological attack or contamination. There are no easy solutions when
managing radiological source material and waste. Many LMICs need expert advice and
institutional support to reduce the risks these material pose to international security. In Ukraine,
the NNSA determined that the replacement of an existing cobalt-60 unit with a LINAC was more
cost effective than installing a hospital-level security system to protect source material from thief
or diversion. In this section, we examine the nature of the radiological source material and waste
management problems, assess the costs to society of a radiological attack or contamination, and
define a proxy that differentiates across countries by security risk. The proxy uses aspects of the
Nuclear Threat Initiative's Nuclear Security Index.
3.4.1 Theft and Loss of Control of Radiological Material
LMICs need support to manage their radiological sources to adhere to international safety
standards. Research shows three trends in LMIC radiological material: security breaches are
widespread across LMIC countries, the incidence of breaches is increasing, and some countries
pose more of a security threat than others. In recent years, the international media has reported a
number of high-profile incidents where radiation sources from cobalt-60 units were stolen or
lost, leading to death or illness for those exposed as a result. These incidents have taken place in
locations as diverse as India, Mexico, and Thailand. In addition to these cases, the IAEA’s
Incident and Trafficking Database reports roughly 40 cases of theft or loss of nuclear materials
each year among participating nations. Of these, a “significant proportion” are related to the loss
of sources used in medical diagnostic and radiotherapy applications (International Atomic
Energy Agency 2014a).
From 1993 to 2013, IAEA’s Incident and Trafficking Database reported 2,477 confirmed
incidents related to illegal possession, criminal activities, loss, theft, and other unauthorized
activities involving nuclear and radioactive materials. Almost 92 percent of the incidents were
related to radioactive materials. The Database on Nuclear Smuggling, Theft, and Orphan
Radiation Sources recorded 631 trafficking incidents in the Black Sea region from 1991 to 2012;
of these, almost 70 percent involved radioactive materials and unauthorized shipment of
radioactive and contaminated cargoes (Zaitseva and Steinhäusler 2014). Regional assessment of
incidents shows that trafficking incidents of radiological materials have increased over the years.
These findings indicates a substantial interest in acquiring radioactive materials for illegal usage.
The Database on Nuclear Smuggling, Theft and Orphan Sources indicates that the risk of theft
and loss of control is not uniform across countries. An analysis of all reported cases of nuclear
and radioactive diversion in former states of the Soviet Union from 2005 to 2012 reveals that
Russia, Ukraine, and Kazakhstan had the highest number of cases, as shown in Error!
Reference source not found.. The analysis of trafficking incidents in the Black Sea region from
33
1991 to 2012 corroborated that Russia, Ukraine, and Turkey had the highest number of
radioactive material incidents (James Martin Center for Nonproliferation Studies 2015).4
Figure 5: Incidence by Material Origin
Source: Authors, using data from James Martin Center for
Nonproliferation Studies 2013.
The increasing volume of cases that involve diversion of, theft of, and contamination from
radiological material suggests that many LMIC governments are failing their obligation to secure
radiological source material, putting the global community at risk. Ineffective monitoring
practices and other security problems increase the likelihood of radiological material getting into
the hands of groups or individuals planning a radiological attack. Eliminating the usage of
radiological source material has real benefits when weighed against the negative impacts from a
radiological attack or contamination of a public space.
3.4.2 Benefits of Securing Source Material
As one of the primary U.S. government agencies enforcing the country’s commitment to
eliminate the threat of nuclear and radiological terrorism, the NNSA has a significant interest in
working beyond U.S. borders with governments to enhance the secure handling of radiological
material. Cobalt-60 teletherapy units pose a significant risk to security due to their reliance on
relatively large quantities of a highly radioactive isotope for their operation. Benefits from
securing cobalt-60 source material and waste is twofold: (1) protecting communities from those
who intend to use radiological material for harm such as a radiological attack; and (2) protecting
the radiological source material from those who don’t know the harm and accidentally
4
For a wider analysis of global incidents of theft or loss of control, unrestricted access to protected databases such
as Incident and Trafficking Database and Database on Nuclear Smuggling, Theft, and Orphan Radiation Sources
could provide data on trends.
34
contaminate a public or private space. These possibilities are greater at hospitals in LMICs where
funding of adequate security is a challenge or where government controls on source material and
waste are underdeveloped.
In the event that an individual or organization gains access to a source of radiological material, it
would be used to create a radiological dispersal device. A 2009 study found that if such a device
were constructed, quantities as small as a few thousandths of a gram dispersed over one square
kilometer would require substantial remediation (Medalia 2011). Such a device could take many
forms, including dispersal from tanks mounted to a low-flying aircraft or packing the material
around a high-explosive to create a “dirty bomb.” If such a device were deployed successfully,
the cost in initial response, economic disruption, and remediation would be substantial. Costs
would depend on factors such as the size and design of the device, the location of the incident,
the weather at the time of the incident, and the required level of decontamination. Estimates of
the cost of a successful attack vary from less than $1 billion to near $100 billion, depending on
the parameters (Medalia 2011). A 2007 study found that the cost of a dual attack on the ports of
Long Beach and Los Angeles could run in excess of $30 billion, mostly as a result of economic
disruption (Rosoff and Winterfeldt 2007).5
Another possibility of harm to the public is improper disposal of radiological material. In 2010, a
medical device containing cobalt-60 appeared in a scrap yard in New Delhi, India. Eight people
were admitted to the hospital with acute radiation syndrome, and one died because of the
exposure (Stewart 2010). Mismanagement of orphaned radiological material has also occurred in
Thailand, Brazil, and Mexico. Each of these incidents indicates clear security and control
vulnerabilities at the affected facility that would be eliminated through the replacement of the
cobalt-60 unit with a LINAC.
3.4.3 Protecting Cobalt-60 Radioactive Source Material
Effective physical protection of the cobalt-60 unit at the hospital level is the first line of defense
in the effective control of the radiological source. The IAEA recommends graded security
measures depending on the IAEA categorization of radioactive sources. Cobalt-60 units fall
under IAEA Category 1, requiring security Level A, the highest degree of security, to prevent the
unauthorized removal of the cobalt-60 source from the medical facility (IAEA, 2009). The
NNSA should assess potential recipient facilities in terms of the level of on-site physical
protection measures.
Regardless of the site’s physical protection measures, hospitals are fundamentally for the public,
and are therefore not generally designed with security as a primary concern. Robert L. Johnson
(2015) from Argonne National Laboratory, who works as principle investigator for the NNSA’s
Global Treat Reduction Initiative RadTrax monitoring program, states:
Any facilities that use cobalt-60 teletherapy units are considered vulnerable. They are typically
open facilities for public use and security is very minimal. Even hospitals within high-income
countries like U.S. do not have programs to upgrade security. In fact physical security in most
5
Many technical factors limit the possibility of the deployment of a radiological dispersal device. An effective
device requires careful calculations to maximize harm and full understanding of cobalt-60 source material and
handling precautions (Medalia 2011).
35
hospitals in LMICs is not significant. Countries are comparable when assessed in terms of
vulnerability index for such open facilities.
Hospitals that lack proper security measures or have an orphaned cobalt-60 in high security risk
countries are a priority for this initiative as long as they meet criteria addressed in technical
feasibility.
3.4.4 Risk Environment Score
National-level factors can have a significant effect on the security of radiological material within
the country. Political instability, corruption, ineffective governance, and presence of groups
interested in illicitly acquiring radiological materials can all undermine the security of
radiological material at the national level, leading to potential thefts and loss while in use,
transport, and storage. As a country demonstrates more extreme forms of these destabilizing
factors, it should receive higher priority for the rapid replacement of cobalt-60 units.
To categorize LMICs according to the level of threat environment, we use the Risk Environment
Score of the Nuclear Threat Initiative’s 2014 Nuclear Materials Security Index. The initiative’s
index is a public assessment of nuclear material security conditions around the world, prepared
by the Nuclear Threat Initiative and The Economist’s Intelligence Unit (Nuclear Threat Initiative
2014). Although categories assessed in the index are related to nuclear material, the Risk
Environment Score's broader focus on political and security factors makes it applicable to
assessing radiological material security. Indicator and sub-indicators used to construct the Risk
Environment scores in Nuclear Threat Initiative index are shown in Table 7.
Table 7: Risk Environment Score Components
Political stability
-social unrest (large-scale demonstrations; political
strikes; and inter-ethnic, racial, or religious clashes)
orderly transfers of power
-international disputes and tensions (armed regional
conflicts, tensions with important trade or strategic
partners, resulting in economic sanctions or other
barriers to trade
-armed conflict
-violent demonstrations or violent civil or labor unrest
Effective governance
-effectiveness of the political system
-quality of bureaucracy
Pervasiveness of corruption
-pervasiveness of corruption
Groups interested in illicitly
acquiring nuclear materials
-terrorist or criminal groups interested in illicitly
acquiring materials
Source: Nuclear Threat Initiative 2014
The risk environmental score map and ranking of LMICs with cobalt-60 units is presented
in
36
Appendix G. The five lowest-scored LMICs (and therefore the top priority countries for
exchange) are Syria, Yemen, Sudan, Pakistan, and Nigeria. These low-scoring countries have the
least favorable nuclear security conditions, implying a security risk for radiological sources.
4
Recommendations
While the NNSA’s proposed initiative’s primary focus is to reduce the threat of theft or diversion
of radiological materials, we recommend the NNSA consider a broad array of factors when
matching donated LINACs with receiving countries. Our three specific recommendations follow.
1. Leverage proxies provided in this report to inform and prioritize potential candidate
countries. Technical feasibility is the most limiting factor and therefore should take
precedence over the medical need and security risk proxies. Once a country is chosen, the
key questions posed in Appendix A can assist in additional donor prioritization. Context,
time, place, and other factors will play a significant role.
2. Generate buy-in among diverse stakeholders within the global cancer control community.
We identify organizations that can play an important role in the long-term success of a
LINAC transfer. These organizations include private-sector corporations, actors within
the medical community, international governmental organizations, national governments,
and non-governmental organizations. Each has a stake in controlling cancer and can
provide valuable expertise and assistance throughout the transfer process.
3. Seek to transfer relatively low-cost, low-energy LINACs. Technical requirements for
individual LINACs can vary widely, so the NNSA should allocate more complicated or
delicate machines to countries and institutions with greater technical capacity.
Furthermore, as the market for cancer therapy in the developing world expands, the
NNSA should consider working with private-sector corporations to incentivize the
development of relatively simple and robust LINACs designed specifically for the
developing world. LINAC producers can look to the experience of General Electric's
deployment of specialized cardiograph machines as a model of successfully adapting
medical equipment for effective operation in this environment.
37
Appendices
Appendix A: Summary of Key Considerations
We present a set of considerations and questions that summarize our criteria in the report. These
considerations help to guide the selection of particular countries for the proposed initiatives.
Criteria Proxy for Country Selection
Throughout the report we cover numerous criteria within in our three-prong framework to
prioritize countries we use three proxies.
1. Medical Need – We advise using percentage of radiotherapy demand met as a proxy.
(See Appendix C for specific rankings).
2. Technical Feasibility – We advise using the presence of existing LINAC infrastructure
and GNI per capita as a proxy. (See Appendix D for specific rankings.)
3. Security Risk – We advise using the Risk Environment Score as a proxy. (See Error!
Reference source not found. for specific rankings.)
Additional Technical Feasibility Considerations
Technical feasibility is a substantial part of our report. If numerous criteria are met, we argue
they suggest a greater likelihood of the proposed initiative’s success. While we recommend the
NNSA rely on the proxy for prioritizing or selecting countries, the considerations below need to
be addressed alongside the technical feasibility ranking.
We understand this list is not fully comprehensive. However, we believe on the whole they
indicate if a country can support a LINAC in the long term.
LINAC Costs
1. Following the initial donation, does the receiving health care facility have adequate
financial resources to support the LINAC operating costs?
2. Following the end of the donated LINAC’s lifespan, does the recipient LMIC have the
necessary resources to replace the LINAC?
3. Is the recipient LMIC interested in upgrading its pre-existing Co - 60 units?
LINAC Cost Per Fraction Country Variation
1. Is the LINAC cost per fraction greater than the cobalt-60 cost per fraction in the
prospective recipient country?
2. Is the source of the variation because the country supplies its own cobalt-60?
LINAC Health Care Facility Costs
1. Does the recipient country have a radiotherapy facility?
2. Does the receiving health care facility have adequate LINAC physical infrastructure?
3. Does the receiving health care facility have adequate and consistent power supply?
38
Country Wealth and LINAC Supply Factors
1. Does the LMIC have a LINAC device, and if so, how many?
2. Does the World Bank classify the LMIC as an UMIC?
a. Prioritize the exchange with wealthier countries which have relatively higher
LINAC densities.
3. Does the World Bank classify the LMIC as a lower-middle income country?
a. Prioritize the exchange with wealthier countries which have relatively higher
LINAC densities.
4. Does the World Bank classify the LMIC as a low-income country?
a. A low-income country requires substantial infrastructure development and
support before an exchange.
National Cancer Plan
1. Does the country have a national cancer plan?
2. Is the plan adequately funded?
Human Capital
1. Does the LMIC have access to medical professionals to operate a LINAC?
2. Where are medical professionals trained and how much are they paid?
3. Does the target facility have high staff turnover?
Cobalt-60 Source Disposal
1. Does the host country have the capacity to store or dispose of the retired cobalt-60
radioactive source?
2. Will a neighboring country or the country of origination accept the cobalt-60 source?
3. Is the equipment required to move the radiation source available in the host country, or
can it be easily transported to the site?
4. What permissions must be obtained from the hosting government before the cobalt-60
source can be removed and transported?
National Regulatory Authority for Radiotherapy Devices
1. Does the LMIC have a national regulatory authority over medical devices?
2. Does the national regulatory authority have the power to regulate pre-market approval,
registration, and post-market surveillance of radiotherapy devices?
3. Is the national regulatory authority independent from government agencies with
conflicting interests?
National Procurement Authority for Radiotherapy Devices
1. Does the LMIC have a national procurement authority or plan?
2. Does the national procurement authority or plan cover radiotherapy machines?
3. Does the national procurement authority or plan solicit and consider comments from the
receiving health care facility?
Donation Guidelines for Radiotherapy Machines
1. Does the LMIC have donation guidelines for radiotherapy machines?
2. Are the donation guidelines “national guidelines” or “WHO guidelines”?
39
Appendix B: Stakeholders
Table B1: Relevant Stakeholders by Stage of the Exchange
Overall planning
Planning












Africa Oxford Cancer Foundation
Delft
East Meets West Foundation
Elektra
Global Task Force on Expanding Access to Cancer Care and Control
International Agency for Research on Cancer
International Atomic Energy Agency
International Campaign for Establishment and Development of Oncology
Centers and Experts in Cancer without Borders
RadiatingHope
Siemens
Varian Medical Systems
World Health Organization
LINAC Identification and Donation
Donation























Advocates for World Health
American Medical Resource Foundation
Brother’s Brother Foundation Medical Program
Esperanca
European Society for Radiotherapy & Oncology
Global Hand
Global Links
Healing Hands International
Healthcare Equipment Recycling Organization
Healthcare4Africa
Humatem
International Aid - Medical Equipment Services
International Organization for Medical Physics
InterVol
Medical Bridges
MediSend International
MedShare
MedWish
Project C.U.R.E.
Recovered Medical Equipment for the Developing World
The Afya Foundation
The Partnership for Quality Medical Donations
The Tropical Health and Education Trust
40


RadiatingHope
The Tropical Health and Education Trust
Infrastructure
Requirements
and Security




East Meets West Foundation
CargoNet
FreightWatch International
Local/International Police
Educational
Programs and
Training


Africa Oxford Cancer Foundation
African Regional Co-Operative Agreement for Research, Development,
and Training Related to Nuclear Science and Technology
Health Emergencies in Large Populations Course (offered by the John
Hopkins Bloomberg School of Public Health in joint collaboration with
the International Committee of the Red Cross)
International Atomic Energy Agency
International Medical Corps
Merlin, part of Save the Children
Project HOPE
RedR
Regional Co-operative Arrangements for the Promotion of Nuclear
Science and Technology in Latin America
Varian Medical Systems
Refurbishing
Site preparation








Disposal
Disposal of
Cobalt-60 Unit










Arab Atomic Energy Agency
Canada in collaboration with the Global Threat Reduction Initiative
CargoNet
European Union (TC Program)
Forum of Nuclear Cooperation in Asia
FreightWatch International
International Atomic Energy Agency
Nordion Inc.
The Organization for Economic Co-Operation and Development (Nuclear
Energy Agency)
The United States Department of Energy (International Radiological
Threat Reduction Program and Off-Site Source Recovery Project)
41
Appendix C: Meets Medical Need Ranking
We use an estimate of country-level demand for radiotherapy machines to devise a LMIC
medical need proxy. Below we discuss how we measure this proxy as well as provide a ranking
of LMICs.
1. The Meets Medical Need proxy is created using data from the Globocan 2012 data set
(International Association for Research on Cancer 2015) and Directory of Radiotherapy
Centers (International Atomic Energy Agency 2015). It is a proxy for establishing the
existing radiotherapy infrastructure, as well as need for radiotherapy infrastructure with
levels of cancer incidence rates potentially treatable with radiotherapy. We assume that
treating cancer in one country is as valuable as treating cancer in another.
Radiotherapy units in operation = Country level estimate from Directory of Radiotherapy
Centers data
Radiotherapy units needed in 2012 = (Cancer incidence rate * .60) / 4506
First, we calculate the number of total radiotherapy devices needed to satisfy the
country’s radiotherapy demand based on incidence rates from the Globocan dataset.
Second, we divide the total number of LINAC machines in operation by the total
radiotherapy devices needed to treat cancer cases. Third, we translate this calculation into
a percentage.
LMIC Meets Medical Need proxy = (Radiotherapy units in operation / Radiotherapy
units needed) * 100
We use this percentage combined with an operational cancer plan to rank the medical need of a
country. Smaller percentage points indicate the level that radiotherapy need is not being met;
whereas percentages over 100 signify the medical needs of the cancer patients are being met.
Error! Reference source not found. is a ranking of countries that responded to the Noncommunicable Disease Country Capacity Survey that have an operational cancer policy. Error!
Reference source not found. is a ranking of those countries that responded in the survey that
they do not have an operational cancer policy (World Health Organization 2014b). Data from the
WHO 2014 country profiles regarding the number of radiotherapy clinics is also included in the
tables (World Health Organization 2014b). Countries that meet a lower percentage of their
radiotherapy treatment needs but have a relatively higher number of radiotherapy clinics may
pose a more ethical and technical feasible country in terms of medical need. Choosing a transfer
with a country such as Indonesia allows the NNSA to partner with a country that is meeting 11
percent of its radiotherapy treatment need. However, with 23 established clinics, the capability
for Indonesia to accept an additional radiotherapy unit successfully is greater than those
countries with only one clinic.
6
Calculation of the radiotherapy units needed in 2012 uses two assumptions. First, according to research, it is
estimated that 60-68 percent of new cancer patient will need radiotherapy treatment (Grover, Dixit, and Metz 2015;
Ravichandran 2009). In our calculation we opted for the more conservative estimate of 60 percent. Second, it
estimated that approximately 450 patients can be treated on one machine annually (Grover, Dixit, and Metz 2015).
42
We do not include countries that lack data or do not have any cobalt-60 units in the ranking.
Those countries that lack cobalt-60 units do not pose a security threat and should not be included
for in the initial phases of the exchange proposal. They are classified as Category 4 countries in
our framework as articulated in
Figure 1: Framework (pg. 15).
Table C1: LMIC Ranking based on Medical Need Variable
Rank
Country
Meets
Medical Need
Proxy
1
Ethiopia
2
1
No Data
2
Uganda
3
1
N
3
Madagascar
4
1
Y
4
Tanzania
4
2
No Data
5
Cambodia
5
1
Y
6
DPR of Korea
5
3
Y
7
Cameroon
5
2
Y
8
Myanmar
8
4
Y
9
Nigeria
10
9
N
10
Indonesia
11
23
Y
11
Kenya
11
4
Y
12
Senegal
11
1
N
13
Bangladesh
13
14
Y
14
Yemen
13
1
N
15
Tajikistan
14
1
Y
16
Zambia
14
1
Y
17
Pakistan
16
26
N
18
Ghana
19
3
Y
19
Uzbekistan
20
13
Y
43
Number of
Radiotherapy
Clinics
Operational
Cancer Policy
Meets
Medical Need
Proxy
Number of
Radiotherapy
Clinics
Operational
Cancer Policy
Rank
Country
20
Papua New Guinea
20
1
N
21
Viet Nam
22
19
Y
22
Nepal
24
5
N
23
Syrian Arab Republic
24
2
Y
24
Kyrgyzstan
26
1
Y
25
Iraq
26
8
Y
26
Cuba
27
9
Y
27
Armenia
28
3
Y
28
Nicaragua
29
1
N
29
Philippines
30
34
Y
30
Serbia
32
6
N
31
Bulgaria
35
13
Y
32
Romania
35
22
Y
33
Sudan
37
2
Y
34
Algeria
38
7
Y
35
Azerbaijan
38
2
Y
36
Jamaica
39
3
N
37
India
39
314
Y
38
China
40
1,105
Y
39
Sri Lanka
41
7
Y
40
Georgia
42
5
N
41
Egypt
45
34
N
42
Paraguay
46
3
Y
44
Rank
Country
Meets
Medical Need
Proxy
43
Bolivia
47
5
Y
44
El Salvador
50
4
Y
45
Thailand
50
29
Y
46
Albania
52
5
Y
47
Mongolia
56
1
Y
48
Ukraine
56
56
N
49
Iran
58
40
Y
50
Brazil
60
222
Y
51
Ecuador
61
10
Y
52
Peru
61
18
Y
53
Russian Federation
61
129
Y
54
Libya
62
4
N
55
Belarus
62
12
No Data
56
Dominican Republic
66
9
Y
57
Honduras
71
5
Y
58
Morocco
71
17
Y
59
Mexico
71
91
N
60
Kazakhstan
72
21
Y
61
Guatemala
73
8
Y
62
Costa Rica
75
3
Y
63
Argentina
76
82
Y
64
Latvia
80
4
Y
65
South Africa
82
39
No Data
45
Number of
Radiotherapy
Clinics
Operational
Cancer Policy
Meets
Medical Need
Proxy
Number of
Radiotherapy
Clinics
Operational
Cancer Policy
Rank
Country
66
Mauritius
86
1
No Data
67
Lithuania
88
6
Y
68
Malaysia
90
25
Y
69
Bosnia and Herzegovina
91
5
No Data
70
Colombia
94
55
Y
71
Chile
97
27
Y
72
Tunisia
105
10
N
73
Turkey
107
96
Y
74
Namibia
112
1
Don’t Know
75
Uruguay
129
10
Y
76
Jordan
129
5
Y
77
Venezuela
154
60
Y
78
Lebanon
174
9
Don’t Know
These countries either have no cobalt-60 units or lack data on cobalt-60 units and/or lack cancer
incidence rates. Therefore, we are unable to classify them.
Table 8: Ranking of LMICs with Incomplete Medical Need Data
Meets
Medical Need
Proxy
Number of
Radiotherapy
Clinics
Operational
Cancer Policy
Rank
Country
79
Afghanistan
0
No Data
N
80
Belize
0
No Data
N
81
Benin
0
No Data
N
82
Bhutan
0
No Data
N
83
Burkina Faso
0
No Data
N
46
Rank
Country
Meets
Medical Need
Proxy
84
Burundi
0
No Data
N
85
Cape Verde
0
No Data
No Data
86
Central African Republic
0
No Data
N
87
Chad
0
No Data
No Data
88
Comoros
0
No Data
N
89
Congo
0
No Data
Y
90
Côte d'Ivoire
0
No Data
Y
91
Democratic Republic of the Congo
0
No Data
No Data
92
Djibouti
0
No Data
N
93
Equatorial Guinea
0
No Data
N
94
Eritrea
0
No Data
Y
95
Fiji
0
No Data
Y
96
Gabon
0
No Data
N
97
Gambia
0
No Data
N
98
Guinea
0
No Data
Y
99
Guinea-Bissau
0
No Data
N
100
Haiti
0
No Data
No Data
101
Lao PDR
0
No Data
N
102
Lesotho
0
No Data
N
103
Liberia
0
No Data
N
104
Malawi
0
No Data
N
105
Maldives
0
No Data
N
106
Micronesia
0
No Data
Y
47
Number of
Radiotherapy
Clinics
Operational
Cancer Policy
Meets
Medical Need
Proxy
Number of
Radiotherapy
Clinics
Operational
Cancer Policy
Rank
Country
107
Mozambique
0
No Data
Y
108
Niger
0
No Data
N
109
Rwanda
0
No Data
Y
110
Samoa
0
No Data
Y
111
Sierra Leone
0
No Data
No Data
112
Solomon Islands
0
No Data
N
113
Somalia
0
No Data
N
114
South Sudan
0
No Data
No Data
115
Swaziland
0
No Data
N
116
Timor-Leste
0
No Data
No Data
117
Togo
0
No Data
Y
118
Turkmenistan
0
No Data
Y
119
Vanuatu
0
No Data
No Data
120
Mali
8
1
Don’t Know
121
Zimbabwe
19
122
Angola
22
2
No Data
123
Mauritania
41
1
Y
124
Botswana
46
1
N
125
The FYR of Macedonia
51
1
Y
126
Montenegro
71
1
Y
127
Guyana
74
1
No Data
128
Panama
111
2
N
129
Suriname
178
1
Y
48
2
N
Meets
Medical Need
Proxy
Number of
Radiotherapy
Clinics
Operational
Cancer Policy
Rank
Country
130
Antigua and Barbuda
No Data
No Data
N
131
Cook Islands
No Data
No Data
Y
132
Dominica
No Data
No Data
N
133
Grenada
No Data
No Data
N
134
Kiribati
No Data
No Data
Y
135
Marshall Islands
No Data
No Data
Y
136
Nauru
No Data
No Data
Y
137
Niue
No Data
No Data
Y
138
Palau
No Data
No Data
Y
139
Saint Lucia
No Data
No Data
N
140
Saint Vincent and the Grenadines
No Data
No Data
No Data
141
Sao Tome and Principe
No Data
No Data
Y
142
Seychelles
No Data
No Data
N
143
Tonga
No Data
No Data
Y
144
Tuvalu
No Data
No Data
N
49
Appendix D: Technical Feasibility Ranking
We use two factors to proxy LMIC technical feasibility. These two factors include LINAC
infrastructure and Gross National Income (GNI) per capita. Specifically, we use LINAC density
to measure LINAC infrastructure. Below we discuss how we measure each of these as well as
provide a ranking of LMICs.
1. LINAC infrastructure proxy is from the WHO. We assume LMICs with a greater LINAC
density have greater institutional support, medical knowledge, commitment to superior
medical services and face a lower marginal cost from adding an additional LINAC than a
LMIC with a lack of infrastructure.
LINAC infrastructure proxy = LINAC Density per million people
2. Gross National Income per capita data is from the World Bank (Atlas Method).
GNI per capita = GNI per Capita from World Bank
Note: LMI denotes Lower-middle income, not to be confused with LMIC
First, we rank countries using the LINAC density proxy within World Bank income
classification group (UMIC is ranked superior to lower-middle-income; lower-middle-income
ranked superior to low-income). Second, we sort countries on GNI per capita. For example, this
secondary ranking allows us to prioritize between two countries within the same income
classification with identical LINAC densities. We do not include countries that do not have any
cobalt-60 units. These are countries that do not pose a security threat due to the absence of
cobalt-60 and should not be included for in the initial phases of the exchange proposal. They are
classified as Area 4 countries as articulated in the framework discussion in report as articulated
in Figure 1: Framework (pg. 15).
Table 9: LMIC Ranking based on Technical Feasibility
Rank
Country
LINAC Density
Income
Classification
GNI per Capita
(USD)
1
Latvia
4.39
UMIC
15,280
2
Lithuania
3.65
UMIC
14,900
3
Uruguay
2.94
UMIC
15,180
4
Bosnia and Herzegovina
2.35
UMIC
4,780
5
Venezuela
1.61
UMIC
12,550
6
Azerbaijan
1.59
UMIC
7,350
7
Brazil
1.43
UMIC
11,690
50
Rank
Country
LINAC Density
Income
Classification
GNI per Capita
(USD)
8
Turkey
1.43
UMIC
10,970
9
Malaysia
1.41
UMIC
10,430
10
Serbia
1.37
UMIC
6,050
11
Lebanon
1.24
UMIC
9,870
12
Costa Rica
1.23
UMIC
9,550
13
Dominican Republic
0.96
UMIC
5,770
14
Ecuador
0.83
UMIC
5,760
15
Peru
0.82
UMIC
6,270
16
Mauritius
0.8
UMIC
9,260
17
Russian Federation
0.77
UMIC
13,850
18
Colombia
0.75
UMIC
7,590
19
China
0.73
UMIC
6,560
20
Bulgaria
0.69
UMIC
7,360
21
Chile
0.68
UMIC
15,230
22
Belarus
0.64
UMIC
6,730
23
Tunisia
0.64
UMIC
4,200
24
Thailand
0.63
UMIC
5,340
25
Jordan
0.55
UMIC
4,950
26
Iran
0.54
UMIC
5,780
27
Romania
0.51
UMIC
9,060
28
Kazakhstan
0.43
UMIC
11,550
29
South Africa
0.4
UMIC
7,190
30
Jamaica
0.37
UMIC
5,220
51
Rank
Country
LINAC Density
Income
Classification
GNI per Capita
(USD)
31
Cuba
0.36
UMIC
5,890
32
Algeria
0.18
UMIC
5,330
33
Mexico
0.17
UMIC
9,940
34
Iraq
0.12
UMIC
6,720
35
Georgia
0.69
LMI
3,570
36
Egypt
0.52
LMI
3,140
37
Guatemala
0.45
LMI
3,340
38
Ukraine
0.44
LMI
3,960
39
Mongolia
0.35
LMI
3,770
40
Armenia
0.34
LMI
3,800
41
Morocco
0.33
LMI
3,020
42
El Salvador
0.32
LMI
3,720
43
Republic of Moldova
0.29
LMI
2,470
44
Honduras
0.25
LMI
2,180
45
Viet Nam
0.2
LMI
1,740
46
Philippines
0.18
LMI
3,270
47
Kyrgyzstan
0.18
LMI
1,210
48
Nicaragua
0.16
LMI
1,790
49
Paraguay
0.15
LMI
4,010
50
India
0.15
LMI
1,570
51
Sri Lanka
0.09
LMI
3,170
52
Bolivia
0.09
LMI
2,550
53
Indonesia
0.08
LMI
3,580
52
Rank
Country
LINAC Density
Income
Classification
GNI per Capita
(USD)
54
Sudan
0.08
LMI
1,550
55
Zambia
0.07
LMI
1,810
56
Nigeria
0.05
LMI
2,710
57
Ghana
0.04
LMI
1,770
58
Pakistan
0.04
LMI
1,360
59
Yemen
0.04
LMI
1,330
60
Uzbekistan
0.03
LMI
1,880
61
Nepal
0.11
LIC
730
62
Kenya
0.09
LIC
1,160
63
Bangladesh
0.04
LIC
1,010
64
Namibia
0
UMIC
5,870
65
Albania
0
UMIC
4,710
66
Papua New Guinea
0
LMI
2,010
67
Cameroon
0
LMI
1,290
68
Senegal
0
LMI
1,050
69
Tajikistan
0
LIC
990
70
Cambodia
0
LIC
950
71
Tanzania
0
LIC
630
72
Uganda
0
LIC
550
73
Ethiopia
0
LIC
470
74
Madagascar
0
LIC
440
According to our data analysis, these countries do not have any cobalt-60. They are considered
Area 4 countries in our framework.
53
Table 10: Area 4 LMIC Ranking based on Technical Feasibility
Rank
Country
LINAC Density
Income
Classification
GNI per Capita
(USD)
1
Suriname
3.71
UMIC
9,370
2
Montenegro
3.22
UMIC
7,250
3
Macedonia
2.37
UMIC
4,870
4
Panama
1.55
UMIC
10,700
5
Guyana
1.25
LMI
3,750
6
Mauritania
0.26
LMI
1,060
7
Zimbabwe
0.21
LIC
860
8
Mali
0.07
LIC
670
9
Equatorial Guinea
0
UMIC
14,320
10
Gabon
0
UMIC
10,650
11
Botswana
0
UMIC
7,770
12
Turkmenistan
0
UMIC
6,880
13
Maldives
0
UMIC
5,600
14
Angola
0
UMIC
5,170
15
Belize
0
UMIC
4,510
16
Fiji
0
UMIC
4,370
17
Samoa
0
LMI
3,970
18
Timor-Leste
0
LMI
3,940
19
Cape Verde
0
LMI
3,620
20
Micronesia
0
LMI
3,280
21
Vanuatu
0
LMI
3,130
22
Swaziland
0
LMI
2,990
23
Congo
0
LMI
2,590
24
Bhutan
0
LMI
2,330
54
LINAC Density
Income
Classification
GNI per Capita
(USD)
Solomon Islands
0
LMI
1,600
26
Lesotho
0
LMI
1,500
27
Côte d'Ivoire
0
LMI
1,450
28
Laos
0
LMI
1,450
29
South Sudan
0
LMI
950
30
Chad
0
LIC
1,030
31
Comoros
0
LIC
840
32
Haiti
0
LIC
810
33
Benin
0
LIC
790
34
Afghanistan
0
LIC
690
35
Burkina Faso
0
LIC
670
36
Sierra Leone
0
LIC
660
37
Rwanda
0
LIC
630
38
Mozambique
0
LIC
610
39
Guinea-Bissau
0
LIC
590
40
Togo
0
LIC
530
41
Gambia
0
LIC
500
42
Eritrea
0
LIC
490
43
Guinea
0
LIC
460
44
D Republic of the Congo
0
LIC
430
45
Liberia
0
LIC
410
46
Niger
0
LIC
400
47
Central African Republic
0
LIC
320
48
Malawi
0
LIC
270
Rank
Country
25
55
Rank
Country
LINAC Density
Income
Classification
GNI per Capita
(USD)
49
Burundi
0
LIC
260
56
Appendix E: World Bank Income Region and WHO Regions
Figure E1: World Bank Income Classification
Source: World Bank 2013
Figure E1 displays the distribution of countries by income level within the seven regions defined
by the World Bank. These regions include North America, Latin America and the Caribbean,
Europe and Central Asia, the Middle East and North Africa, Sub-Saharan Africa, South Asia,
and East Asia and the Pacific. These regions and income level designations differ slightly from
those identified by the World Health Organization, which are illustrated in the Figure E2 below.
Figure E2: World Health Organization Regions
57
Source: World Health Organization 2013a
Appendix F: Regulatory Factors
*Denotes WHO policy or guidelines adopted
Table F1: Regulatory Factors
No National
No National
Regulatory Authority: Procurement:
Donation Policy or Guidelines in Place:
Afghanistan
Afghanistan
Albania
Philippines
Albania
Belize
Angola
Russia
Antigua and Barbuda
Bolivia
Argentina
Saudi Arabia
Azerbaijan
Brunei
Azerbaijan*
Sierra Leone
Bahamas
Colombia
Belarus*
Somalia*
Belize
Cote d’Ivoire
Bolivia
South Africa*
Botswana
Democratic Republic
of the Congo
Bosnia and
Herzegovina*
Sri Lanka*
Brunei
Dominica
Botswana*
Sudan*
Burkina Faso
El Salvador
Brunei*
Swaziland*
Burundi
Haiti
Cape Verde*
Tajikistan*
Cambodia
Gabon
Chad
Thailand
Chad
Gambia
China
Tonga
Dominica
Guinea-Bissau
Colombia
Turkey
Gabon
Jordan
Costa Rica
Uganda
Gambia
Lebanon
Cuba
Uruguay
Grenada
Liberia
Democratic Republic
of the Congo
Zambia*
Guinea-Bissau
Lithuania
Dominican Republic* Zimbabwe*
Guyana
Malaysia
Ecuador
Jamaica
Mauritius
Ethiopia
Kenya
Micronesia
Fiji
Kiribati
Namibia*
Gabon*
58
No National
No National
Regulatory Authority: Procurement:
Donation Policy or Guidelines in Place:
Liberia
Nauru
Ghana
Madagascar
Nigeria
Gambia*
Mauritius
Peru
Guatemala*
Micronesia
Philippines
Guinea*
Mongolia
Poland
Haiti*
Morocco
Russia
Honduras
Mozambique
Saint Lucia
Indonesia*
Nauru
Sao Tome and
Principe
Kenya
Niger
Senegal
Kiribati*
Papua New Guinea
Somalia
Kyrgyzstan
Paraguay
South Africa
Laos*
Poland
Timor-Leste
Liberia*
Saint Kitts and Nevis
Thailand
Lithuania
Saint Lucia
Togo
Madagascar
Saint Vincent
Tonga
Malawi
Sao Tome and
Principe
Turkey
Mexico
Seychelles
Moldova
Suriname
Montenegro*
Swaziland
Mozambique
Timor-Leste
Namibia
Togo
Nicaragua
Yemen
Oman
Zimbabwe
Panama
Papua New Guinea
Peru
59
60
Appendix G: Security Threat Ranking
Figure G1: Risk Environment Map of LMICs with Cobalt-60 Units
Source: Nuclear Threat Initiative 2014
The above map shows Nuclear Threat Initiative risk environment score of LMICs with cobalt-60
units. Given that the primary purpose of this initiative would be to reduce the number of cobalt60 machines in high-risk environments, efforts should be focused on those areas where security
is lowest and the number of cobalt-60 machines is highest.
Table G1: LMIC Ranking based on Risk Environment Score
Rank
Country
No of Cobalt-60
Teletherapy Units
Risk Environment
Score
1
Syrian Arab Republic
6
16
2
Yemen
2
16
3
Sudan
6
18
4
Pakistan
31
19
5
Nigeria
5
19
61
Rank
Country
No of Cobalt-60
Teletherapy Units
Risk Environment
Score
249
21
6
Russian Federation
7
Libya
4
21
8
Iraq
2
22
9
Tajikistan
1
22
10
Azerbaijan
2
23
11
Uzbekistan
5
24
12
Republic of Moldova
2
25
13
Bangladesh
12
26
14
Kenya
2
26
15
Kyrgyzstan
2
26
16
Albania
2
27
17
Philippines
10
29
18
Bosnia and Herzegovina
2
29
19
India
335
32
20
Egypt
23
32
21
Lebanon
3
32
22
Indonesia
20
33
23
Cambodia
1
33
24
Myanmar
6
34
25
Armenia
3
34
26
Iran
24
35
27
Algeria
10
35
28
Morocco
5
36
29
Uganda
1
36
62
Rank
Country
No of Cobalt-60
Teletherapy Units
Risk Environment
Score
30
Kazakhstan
32
37
31
Honduras
4
37
32
Nicaragua
2
37
33
Georgia
1
37
34
China
548
38
35
Tanzania
2
38
36
Turkey
51
39
37
Ukraine
86
40
38
Venezuela
31
40
39
Cameroon
1
40
40
Tunisia
10
41
41
Nepal
3
41
42
Papua New Guinea
2
41
43
Dem. People's Rep. of Korea
3
42
44
Ecuador
6
43
45
Guatemala
3
44
46
Colombia
35
46
47
Bolivia
6
46
48
Jordan
1
46
49
Serbia
1
47
50
Ethiopia
2
48
51
Thailand
29
49
52
Sri Lanka
11
50
53
Paraguay
1
50
63
Rank
Country
No of Cobalt-60
Teletherapy Units
Risk Environment
Score
54
Malaysia
6
51
55
Romania
15
53
56
Dominican Republic
3
53
57
Madagascar
1
53
58
Peru
10
54
59
Viet Nam
19
55
60
Mongolia
3
55
61
El Salvador
3
56
62
Zambia
1
56
63
Mexico
60
57
64
Belarus
16
58
65
South Africa
12
58
66
Bulgaria
9
58
67
Jamaica
2
58
68
Senegal
1
58
69
Brazil
62
59
70
Argentina
36
61
71
Ghana
3
63
72
Lithuania
4
66
73
Latvia
2
67
74
Namibia
2
69
75
Cuba
10
70
76
Mauritius
2
70
77
Uruguay
8
75
64
Rank
Country
No of Cobalt-60
Teletherapy Units
Risk Environment
Score
78
Costa Rica
3
77
79
Chile
13
81
65
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