MEDICAL PHYSICS IN NIGERIA – A ROAD MAP

Abstract

Nigeria is situated on the West Coast of the African Continent with a population of about 150 Million  and  Abuja  at  the  centre  which  also  serves  as  its  Federal  Capital.  The  historica levolution of medical physics as a profession and the current state of affairs together with the daunting challenges  staring the professionals  are discussed in  this  paper.

 The role of  theVienna-based  International  Atomic  Energy  Agency  (IAEA)  in  the  establishment  of  clinical training programmes and in tackling the obstacles militating against the recognition of the profession in the continent of Africa and elsewhere in the world is appreciated as well as the recent interest shown by the American Association of Physicists in Medicine (AAPM) to partnerwith the Nigerian Association of Medical Physicists (NAMP) to give it a lift. The German Medical Physics Association (DGMP) is hereby requested to also partner with NAMP to take it to the next level of its developmental strides.
1. Introduction
In recent years, various reports have cited the increase of cancer incidence in Africa. This increase  could  be  attributed  to  factors  such  as  lack  of  resources,  infrastructures,socioeconomic status,  cultural  and political  situations.  According to  GLOBOCAN 2008,  the cancer incidence with exclusion of non-melanoma skin cancer for Nigerian males and femaleswas 95.1/100,000 and 128.4/100,000 respectively, with 75.4/100,000 as the death rate from cancer for both sexes. The number of new cases was estimated to be 40.1/1 00,000 for males and 61.7/100,000 for females, with prostate, liver, non-Hodgkin lymphoma, colorectum and leukemia cancers cataloged as the five most frequent cancers for Nigerian males and for their Nigerian females counterparts are the breast, cervix uteri, liver, colorectum and non-Hodgkin lymphoma cancers. It  is anticipated that by 2020, the cancer incidence in the country could rise to 54.8/100.000 for males and 83.5/100.000 for females.
The emergence of medical physics in Nigeria has a symbiotic relationship with the advent of Radiotherapy service in the country perhaps because of the greater risks and consequence that can result from the unwholesome application of this treatment modality and this dates back to the mid seventies (1974-75) when the first cobalt-60 machine was commissioned for patient treatment at the Lagos University Teaching Hospital in Lagos, South-West Nigeria.
Some  few  professionals  initiated  the  formation  of  the  Nigerian  Association  of  MedicalPhysicists (NAMP) in the early eighties and with great enthusiasm conducted a number of sensitization  activities  towards  bringing  the  importance  of  this  field  of  study  to  national consciousness. However this effort came to a decline in the late nineties. The activation of the Nigeria  Nuclear  Regulatory  Authority  (NNRA)  in  2001  appeared  to  bring  to  forefront  the importance of medical physics in the country especially in the health establishment as well as the  radiation  protection  regime  in  the  industrial  sector  with  particular  emphasis  on  the petroleum industry where a substantial amount of radioactive materials are in use.
The preponderance of physicists are stationed in the hospital radiotherapy departments and universities. In Nigeria, radiotherapy seems to fare better than nuclear medicine in terms of facilities/equipments  and  personnel,  however  there  are  hundreds  of  diagnostic  radiology establishments  with  thousands of  x-ray facilities  with  minimal  or  no  radiation  safety  and protection officers so designated.
There are presently over  fifty universities, more than twenty inadequate running teaching hospitals and nine radiotherapy centres in the country, one is owned by a private entity while the  remaining  eight  are  established  by  the  Federal  Government  of  Nigeria.  The facilities amongst these nine centres include: five linear accelerators, three Co-60 treatment machines, two high dose rate (Co-60 and Ir-l92) and three low-doserate (Cs-137) brachytherapy machines, four CT -SIMS and two conventional simulators as well as six treatment planning systems out of which two are now obsolete and not fùnctional.
The centres are located at: The Ahmadu Bello University Teaching Hospital (ABUTH) Zaria,Federal Medical Centre (FMC) Gombe, Usman Danfodio University Teaching Hospital (UDUTH)Sokoto, The National Hospital, Abuja (NHA), The University of Benin Teaching Hospital (UBTH)Benin-City, The University of Nigeria Teaching Hospital (UNTH) Enugu, The University CollegeHospital  (UCH)  Ibadan,  The  Lagos  University  Teaching  Hospital  (LUTH)  Lagos  and  EKOHospitals Lagos (a private outfit) in the South-Western part of Nigeria.
The Departments of Nuclear Medicine exist at the National Hospital, Abuja and the University College Hospital in Ibadan. Some nuclear medicine facilities are also available at the Radiation Biology  and  Radiotherapy  department  of  LUTH-Lagos,  and  at  the  department  of  Internal Medicine of UNTH-Enugu. Two of these centres have a gamma camera each; one single-head(Siemens E-Cam) in Ibadan and a dual-head Hungarian-made Mediso (Nucline Spirit  DH-V:Dual-Head Spect and Whole Body Digital Gamma Camera) camera in Abuja. The other two centres only have in their possession some few Geiger counters for Radioimmunoassay (RIA) studies.
2. Personnel
There are about forty  Medical Physicists in Nigeria and less than half of this number can be said to be properly qualified. Also, less than half of these numbers are practicing in a health establishment. Most of the physicists who are in the hospitals could only be found in the Radiotherapy and Oncology departments  with  only  two in  the diagnostic  radiology and a similar number in the nuclear medicine departments.
About  twenty  trainees  are  currently  at  different  stages  towards  the  completion  of  their postgraduate degrees (M.Sc.) in Medical Physics at the six University departments of Phhysics,where the academie curriculum of  medical  physics  are  run without  clinical  or  on  the job training components.
With the activation of the Nigerian Nuclear Regulatory Authority (NNRA), a critical mass of between fifty and one hundred medical physicists shall be needed in our hospitals especially as  radiation  protection  officers  and  quality  control/assurance  enforcers  in  the  diagnostic radiology departments which are very numerous in the country. Of immediate and particular importance are the University Teaching Hospitals (17 Federal and 6 State), the Federal MedicalCentres (22 ofthem), the Specialist Hospitals (3 and 3 Orthopedie and 8 Neuro-Psychiatrie -making a total of 14) and the few thousands private health establishments, which all have diagnostic facilities as part of the armamentarium of equipments in their possession.
In terms of future needs with respect to the Federal Government of Nigeria development plans in the health  sector,  more medical   physicists  shall  be  required for  effective  and efficient quality control assurance in the radiotherapy, nuclear medicine and radiology programmes in the country.
Presently, there is no formal/official recognition for the profession in Nigeria and hence there is no registration or accreditation process in place. Although there is the Nigerian Association of  Medical  Physicists  (NAMP),  it  is  more  of  an  amorphous  body  of  professionals  with qualifications  very  close  or  related  disciplines  to  medical  physics.  The  relevance  and achievement of this association however is its dogged and consistent fight on the need for the Nigerian  government  to  give  legitimacy  to  its  promulgation  of  the  Nuclear  Safety  and Radiation Protection Decree 19 of 1995 which provides for the establishment of the Nigerian Nuclear Regulatory Authority. However, a bill for an act to establish the Nigerian College of Medical Physics in the Federal Republic of Nigeria to provide for the conduct of examination of candidates in specialized fields of Physics in Medicine, to regulate the practice of the Medical Physics profession in Nigeria and for other related matters is already in the parliament and is receiving the necessary attention albeit very slowly.
3. Availability of Training Programmes
There are six university departments that offer sorne traininng programmes at the M. Sc. level covering the lecture modules but the practical/on-the-job training component has been fraught with problems over the years
The National Hospital, Abuja is one centre of excellence that can fill this void of practical/on-the-job training debacle particularly with respect to the radiotherapy, nuclear medicine and diagnostic radiology programmes.  It  has two Magnetic Resonance Imaging (MRI) machines(0.2T Simens and 1.5T Philips), 16 Slice Brilliance Computed Tomography (CT) with Easy-Visionworkstation  from Philips,  Mammography (with  a  cytoguide for  biopsy),  several  ultrasoundmachines (some with cardiac option and Doppler facility) and many bulky facilities (diagnost94  with  DSI,  diagnost  94,  trauma  diagnost,  several  C-arm,  etc)  for  conventional  x-raydiagnosis in its Radiology department.  The Radiotherapy department has an Elekta Linear Accelerator  (with  6  &  15  MY  photons  and  4,  6,8,10  &  18  MeV  electron  energies),  aConventional  Simulator,  a  150  KV  Pantak  superficial  machine,  two  AMRA  LDR  remoteafterloader brachytherapy facilities, a 3-D treatment planning system which is not functionaland a mould room facility. AlI the above mentioned equipment and facilities are available to deliver high quality services and also geared towards meaningful and productive research activities. The National Hospital also has the only Medical Physics department in any of the  tertiary health establishments in Nigeria.
Some serious collaborative arrangements are currently being worked out among professionals in these establishments towards alleviating the enormous training need that is required to build up the medical physics resource base in the country both in the short and long-term.
4. Regulatory Requirements
The regulatory requirements on performance of  QA/QC  by medical physicists in the country have been developed by the Nigerian Nuclear Regulatory Authority (NNRA) using some lAEA technical documents as a reference and template and these publications have been gazetted.The departments of Radiological Safety, Nuclear Safety as well Authorization and Enforcementof the Authority are now fully functional.
The Nuclear Safety and Radiation Protection Act of 1995 calls for the establishment of the Nigerian  Nuclear  Regulatory  Authority  (NNRA)  and has  spelt  out  its  functions,  power  and structure. The body was eventually established in 2001 with the appointment of the Director-General.
The authority is charged with the responsibility for nuclear safety and radiological protection in Nigeria. As part of its functions, the authority has the mandate to regulate the possession and application of radioactive substances and deviees emitting radiation; regulate the safe promotion of nuclear research and development and the application of nuclear energy forpeaceful purposes; ensure protection of life, health, property and the environment from the harmful effects of ionizing radiation while allowing beneficial practices involving exposure to ionizing radiation and also to perform all necessary functions to enable Nigeria to meet its national and international safeguards and safety obligations in the application of nuclear energy and ionizing radiation.
The NNRA is the custodian of the Nuclear Safety and Radiation Protection Act 19 of 1995. The Authority ensures compliance with the provision of the law otherwise radiation protection and safety  might  be  compromised,  thereby  jeopardising  the  health  of  the  populace.  It  also endorses any effort that promotes safe use of radiation while minimizing the unnecessary dose to the patients, staff and the public.
5. The Role of IAEA and other Professional/Development Partners
As can be gleaned from this short treatise, the training needed to build-up a strong and sustainable resource base for Medical Physicists in Nigeria is overwhelming and scary.However a systematic approach towards ameliorating this scenario in the short and long-termwill no doubt go a long way in helping the development and sustainability of medical physics in the continent in general and Nigeria in particular.
The  country  is  considering  the  implementation  of  the  medical  physics  residency  (clinicaltraining) programme that was recently piloted in Thailand and Philippines (Clinical Training of Medical Physicists Specializing in Radiation Oncology – published as an lAEA Training CourseSeries No. 37 of 2009) to complement the established academie programmes in some of the universities. The IAEA states that “It is emphasized that the holder of a university degree inmedical  physics  without  the  required  hospital  training  cannot  be  considered  clinically qualified”.
The objective of the clinical training programme for medical physicists specialising in radiationoncology is to produce an independent practitioner who is a lifelong learner and who can work unsupervised at a safe and highly professional standard. The clinical training programme is seeking to assist this objective through provision of a detailed guide to clinical training, provision of an implementation strategy to allow effective clinical training by forming a basis for a national or regional qualification (education and clinical training) standard, providing assistance to national bodies and departments to deliver the training programme through a pilot programme, promoting quality improvement of the programme and strengthening of the national capacity to sustain such a clinical training programme after initial introduction.
The AAPM is also considering the deployment of its remote training module by developing a pilot implementation of its web-based tools (TG 131 – Medical Physics Training in DevelopingCountries  in  the Region  –  Web  based  tools  for  Training  Medical  Physicists  Internationally)coupled with extensive local visits and emphasis on practical doing.
6. Future Prospects
With increasing complexity of cancer treatment using sophisticated technology, the growing number of cancer patients and the CUITent situation of medical physics in the country, the handful  of  medical  physicists  are  particularly  concerned  with  the  future  prospects  on  its reliability to offer the needed services such as quality assurance and other related issues.Such concern is also fuelled by the numerous radiology centres that do not meet up with the radiation protection as required by international standards. Addressing these needs would be an important challenge for  the future and would require a growing number of expertises.Common sense tells us that forging forward with long-term cooperation policies with established  institutions/associations  like  the  AAMP  and  DGMP  in  aspects  like  joined research  projects,  information  sharing,  partnership  and  exchange  programs  between hospitals/radiation institutions in Nigeria and abroad would not only benefit the current state of art  of  radiation  therapy  in  the  country  but  would  also  help  to  advance  the  science, education, the professional practice and structure of medical physics in Nigeria.  It  is hoped that these cooperation activities with foreign organizations, would draw some more attention of the Nigerian government to broaden its support to the NAMP, especially in aspects like adequate academie educational facilities and clinical training.
Furthermore, a strategic coordination is important to sustain connectivity of the future projects and programms ( such as greater cancer and radiation protection awareness, health insurance scheme, equipment donation) and a national repository of information would be perhaps the most useful tool for coordination. With such tools, one can predict a cautious but optimistic view of how the state of art of medical physics in Nigeria would develop in terms of technology, quality, accreditation, availability and accessibility of proper healthcare to cancer patients.
Finally, with the advent of companies like Varian Medical System, Elekta producing suitable radiotherapy machines that are affordable but up-to-date technology without sacrificing on quality and standards for developing countries, it is encouraged that other companies involve in radiation therapy, especially as concern QA/QC do the same.
7. Conclusion
ln conclusion, the DGMP is hereby called upon to assist with the daunting training needs and equipment donation similar to the recently inaugurated consultancy visit by the AAPM to the sustenance of the radiotherapy services in Nigeria in particular and the growth of the MedicalPhysics as a profession in general. This partnership will further complement the government intervention  which  informs the establishment of  more radiotherapy and nuclear  medicine centres as well  as refurbishment and replacement of most of the obsolete and dilapidated diagnostic radiology facilities in most of the teaching hospitals in the country.
References
(1) I.P. Farai, R.I. Obed, and N.N. Jibiri. (2006). Soil radioactivity and incidence of cancer in Nigeria. Journal of Environmental Radioactivity, Volume 90, Issue 1,2006, Pages 29-36.
(2) World Health Organization. (Brazzaville, 30 August 2007). Cancer Emerges as a Public Health Problem inAfrica. <http://www. afro. who. int/en/media-centre/pressreleases/191-cancer-emerges-as-a-public- health problem-in-africa. html>.
(3) GLOBOCAN 2008: Cancer Incidence and Mortality Worldwide. International Agency for Research on Cancer Press.
(4) IAEA 2009: Training Course Series No. 37 – Clinical Training of Medical Physicists Specializing inRadiation Oncology.
(5) Nuclear Safety and Radiation Protection Act, Lagos (1995)
(6) NNRA 2003 : Nigeria Basic Ionizing Radiation Regulations (NiBIRR)
(7) Pipman Yakov (2010) – On AAPM (personal Communication) Ortenau Klinikum Offenburg-Gengenbach, Ebertplatz 12, 77654 Offenburg, Germany Zeitschrift für medizinische Physik
Authors: Taofeeq Abdallah Ige , Ernest C. Nwabueze Okonkwo
National Hospital Abuja, P.M.B.425. Garki, Abuja, Nigeria
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