1. INTRODUCTION

Figure 1: Map of West Asia Region

It is known that the Gross Domestic Product (GDP) per capita is high in most of the region, but health prioritization is low in a number of states. It has been noted that Nuclear Medicine facilities and manpower as well as radiopharmaceuticals are available but remain underutilized because of traditional beliefs, fear of radiation, and lack of awareness and education as well as promotion and marketing in the field of Nuclear Medicine. (Table 3)

The advantages of Nuclear Medicine are well established. Nuclear Medicine techniques are non-invasive and provide an added feature of physiologic, metabolic and molecular information. They are likewise cost- effective and hence should be integrated into the present health care system of West Asia.

The presence of several Nuclear Medicine facilities equipped with modern planar gamma camera and SPECT systems, and most importantly the capability to produce radiopharmaceutical kits (like Iran and Syria) are added features which will contribute in the promotion of Nuclear Medicine to the fullest.

However, problems in infrastructure with respect to high quality state of the art equipment, radiopharmaceuticals, trained manpower and quality assurance programs have been identified in several countries of the region. In a few member states, there is lack of basic nuclear facilities. In the field of education, training and research in Nuclear Medicine, there has been also lack of training centers and accreditation programs in some member states as well as standardization of procedural techniques. Overall, there is a lack of general awareness among the user groups about the usefulness of nuclear medicine applications. It was also noted in general that there is a lack of expertise in networking, electronic archiving and storage of patients' data and images. It would be very cost effective to use PC-based Networking and Internet for Tele-Nuclear Medicine among member states and international groups. These are causes of some areas of concern and may need special attention.

The assistance provided by the IAEA under RAW/6/010 aims to address the major health problems, as well as support for infrastructures, of West Asia where Nuclear Medicine could play a major role. The project has been designed in the hope that there will be active participation and utmost cooperation among the Member States and according to the Agency's Technical Cooperation Strategy.

STRATEGIC CONTEXT:

1. Corporate Mandate and Function:

The objective of the IAEA as stipulated in the Statute (Article-II) is:

…To accelerate and enlarge the contribution of atomic energy for peace, health and prosperity throughout the world…….

In other words, the objective of the Agency, apart from promoting peace, is also to contribute to the socio-economic development of the world. This objective is to be met through the following function captured in Article IIIA of the Statute:

"To encourage and assist research on, and the development and practical

application of atomic energy for peaceful uses and if requested to do so, to act as an intermediary for the purposes of securing the performance of services or the supplying of equipment, or facilities by one member of the Agency for another; and perform any operation or service useful in Research on or development or practical application of; atomic energy for peaceful purposes…."

2. Mandate of the proposed thematic project:

In line with the above, the mandate of the proposed thematic project on

health care is defined as follows:

To accelerate and enlarge the contribution of nuclear medicine for health

and prosperity in W. Asia .

3. Major program challenges:
1. To facilitate disease management through effective diagnosis and treatment using nuclear medicine techniques
2. To develop human resources in the field of Nuclear Medicine
3. To integrate nuclear medicine into the routine educational curriculum of undergraduate and postgraduate training programs.
4. To make available and maintain appropriate nuclear medicine equipment and supplies
5. To market nuclear medicine to reach its full potential to benefit the people of W.Asia
6. To standardize various diagnostic and therapeutic nuclear medicine procedures and protocols in accordance with International norms and standards.
4. Major program Mission:

1. To promote, enlarge and enhance the contribution of Nuclear Medicine to meet the needs of Member States in addressing health problems in diabetes, coronary artery disease, thyroid cancer, general bacterial Infection, Helicobacter Pylori infection, breast cancer, general aspects of nuclear oncology, palliation of bone pain and management of joint diseases.
2. To integrate nuclear medicine into the health care system

1. Major program Vision:

1. Elements of Vision:

• General advantages of nuclear medicine: functional studies , Non-invasive ,cost effective when appropriately chosen
• Islands of expertise in the region
• Regional capability in radiopharmacy (Iran and Syria having excellent radiopharmacy facilities to meet regional demands)
• Catalytic presence of the IAEA
• Reasonable availability of information and communication tools for regional promotion of nuclear medicine

• Lack of awareness among the public and the user groups (Cardiologists, nephrologists etc.)
• Lack of resources , including manpower; equipment , and radiopharmaceutical supplies in some countries
• Lack of quality assurance and technical backup facilities.
• Lack of training programs and proper accreditation
• Absence of standardized procedural techniques and protocols

• Optimally utilizing resource centers to the benefit of region.
• Facilitating regular supply of cost effective radionuclides (Indigenous regional supply and new sources of supply) by promoting regional cooperation in the development of radiopharmaceuticals.
• Introducing new and emerging cost effective diagnostic and therapeutic nuclear medicine techniques.
• Promoting and improving nuclear medicine through information and communication technology.
• Developing and utilizing quality assurance and technical support facilities.
• To undertake upstream work in nuclear medicine addressing some of the pressing clinical problems of the region

• Low socio-economic status in several countries of the region.
• Competing demands from other technologies
• Low accessibility and poor communication in some countries
• Misplaced nuclear phobia. Anything nuclear is wrong and get destructive, hence untouchable.
• High initial capital cost and running cost
• Rapid development of technology.

• Addressing health sector development needs and interests of Member States remains the main guiding principle. This connotes the necessity for Member States involvement in setting the priorities of the Thematic Project and in the formulation of its activities.
• The Thematic Project is problem rather than technique oriented. Thus, to ensure effectiveness and optimal use of resources it is essential to ensure integration of nuclear techniques in the package of techniques at the disposal of Member States. Furthermore, it is essential to, as much as is feasible, ensure cooperation / linkage with programs of other UN and international organizations, NGOs and the private sector.
• The Thematic Project will deliberately focus on application of nuclear techniques in order to preserve the unique nuclear role of the Agency. Thus; integration of the radiation and isotope techniques into packages involving non-nuclear techniques will be done in such a way that the nuclear "advantage" is maintained. This implies the need to carefully select nuclear techniques and problems on which the Thematic Project will place emphasis based on comparative advantage and safety.
• The Thematic Programme activities will focus on those areas where the Agency has proven track record or where there is critical market failure or the technology is not provided by the other sectors.
• To continue to remain relevant and useful to Member States, there will be a constant and dynamic review of the program from time to time, timely phasing out of redundant or obsolete techniques and introduction of new technology.

The Thematic Project will use the following criteria in setting priorities:

• Activities must address needs and interests of Member States as defined by Member States themselves
• Activities must show high probability of impact (nature and coverage of results) on the health and socio-economic condition of Member States
• Nuclear techniques/technologies must be involved. The nuclear technique(s) must have a comparative advantage to non-nuclear technique(s) in terms of cost-effectiveness or must be complementary or indispensable
• Activities must represent elements of a Long Term Strategy.
• Activities must have multiple Member State relevance where applicable particularly in the case of upstream research.
• Activities must complement efforts of other Agencies where applicable.

After an in-depth discussion of the most relevant health problems in the West Asia region, a list of diseases was prepared. The list included: coronary artery disease, Diabetes Mellitus, infection and infectious diseases, cancers and degenerative disorders. This was followed by preparation of an inventory of the nuclear medical facilities for West Asia. These facilities ranged from adequately staffed and equipped Nuclear Medicine departments to departments with bare minimum basic requirements. Subsequently an analysis of nuclear medical technology capability for the region was carried out. This was based on detailed consideration of availability of and accessibility to relevant radiopharmaceuticals, appropriate nuclear medicine equipment, level of accountability of technology among the user group (clinicians) and the cost-effectiveness of a given investigation to solve medical problems. A synthesis of all the above points resulted in a set of health issues that could be addressed effectively by the available nuclear medicine capabilities in the region (Pls. see Tables 2).

1. Overall Objective:

To contribute to the overall improvement of health care in West Asia using Nuclear Medicine techniques.

2. Specific Objectives:

To introduce/expand the application of various established diagnostic and therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals and reagents.

Outcome: Member States using new and adapted technology in the management of diabetes mellitus and prevention of its complications.

Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of diabetes mellitus. Number of new techniques introduced. Number of new radiopharmaceuticals and reagents used and number of patients investigated and treated.

To introduce/expand the application of various established diagnostic and therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals like Sistamibi, Rhenium-188 etc.

Outcome: Member States using new and adapted technology in the management of coronary artery disease.

Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of coronary artery disease. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated.

To introduce/expand the application of various established diagnostic and therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals and reagents.

Outcome: Member States using new and adapted technology in the management of thyroid cancer.

Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of thyroid cancer. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated.

To introduce/expand/promote the application of various established diagnostic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals like Tc-infecton, Tc-HIg, Ga-67, Indium-111 etc.

Outcome: Member States using new and adapted technology in the management of general bacterial infections.

Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of general bacterial infections. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated.

To introduce/expand the application of various established diagnostic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals.

Outcome: Member States using new and adapted technology in the management of H. pylori infection.

Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of H. pylori infection. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated.

To introduce/expand the application of various established diagnostic and interventional radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals.

Outcome: Member States using new and adapted technology in the management of breast cancer.

Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of breast cancer. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated.

To introduce/expand the application of various established diagnostic and therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective radiopharmaceuticals.

Outcome: Member States using new and adapted technology in the management of cancer.

Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the management of cancer. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated.

To introduce/expand the application of various established therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective therapeutic radiopharmaceuticals.

Outcome: Member States using new and adapted technology in the palliation of metastatic bone pain.

Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the palliative treatment of metastatic bone pain. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated.

To introduce/expand the application of various established therapeutic radionuclide procedures, develop human resources, address critical areas through expert missions, provide equipment support where necessary and make available cost-effective therapeutic radiopharmaceuticals.

Outcome: Member States using new and adapted technology in the treatment of joint diseases.

Performance Indicators: Number of institutions in the Member States using nuclear medicine technology in the treatment of joint diseases. Number of new techniques introduced. Number of new radiopharmaceuticals used and number of patients investigated and treated.

To promote continuous professional development of nuclear medicine health professionals through group training, expert missions and improvement of information and communication technologies (ICT). Organize a number of regional and national training courses on topics enumerated in column b.1. Improve ICT in West Asia. Organize expert missions on specific areas for on-site training.

Outcome: Training of a large number of nuclear medicine physicians, technologists and physicists. Improvement in the quality of nuclear medicine practice in the region.

Performance indicators: Number of medical doctors, technologists and physicists trained. Number of new investigations/therapeutic procedures introduced. Number of regional/national training courses conducted. Number of expert missions fielded.

Carry out a thorough assessment of the status of existing nuclear equipment in the region, preparation of a database. Provide assistance to institutions in the Member States for maintenance and upgradation of nuclear medicine equipment by developing a link with the other new/on-going TC projects in the region on instrumentation.

Outcome: Training of nuclear medicine technologists, engineers and physicists on preventive maintenance, quality assurance and upgradation of nuclear equipment.

Performance indicators: Availability of a database. Number of technologists trained. Number of gamma cameras up-graded.

To create an awareness among the medical community about the importance of quality assurance in nuclear medicine and educating them on how to avail the technical expertise and support from the IAEA to further the growth of quality nuclear medicine practice in the region.

Outcome: Increasing awareness about quality assurance among the nuclear medicine community in West Asia. Enhanced standard of nuclear medicine practice.

Performance indicators: Number of nuclear medicine centers in the region incorporating quality assurance programmes in their routine day to day nuclear medicine practice.

To educate and advise the professionals in the Member States on preparation of specifications for the procurement of various nuclear medicine equipment including gamma cameras, SPECT systems, computers, gamma probes, radiation monitoring devices etc. To advise on how to carry out acceptance tests for equipment.

Outcome: Increasing awareness about current trends in nuclear equipment and various facilities and options offered by the manufacturers.

Performance indicators: Number of nuclear medicine professionals trained in the field.

Prepare a status report on the current practice of hospital radiopharmacy in the region through a task force with a specific mandate. Field expert missions to advise individual nuclear medicine departments to prepare their own radiopharmacy cold kits and Quality Assurance. To assist the West Asia Member States for the procurement of radiopharmaceutical kits like Sm-153, Ga-67, P-32, Sistamibi etc. at a reasonable price by identifying alternate sources and suppliers.

Outcome: Increasing number of nuclear medicine departments becoming self sufficient in routinely used radiopharmaceuticals like Tc-99m, DTPA, MDP, Pyrophosphotate, Phytate etc.

Performance indicators: Formation of a task force. Report of the task force. Number of nuclear medicine centers in the region doing their own hospital radiopharmacy.

In order to have an impact the activities must be intense, broad based, repetitive and encompass all fields of nuclear medicine practice. The following strategies and activities are recommended for programme delivery.

At the regional level

Regional group training programmes (training courses, workshops, seminars etc.)

Multi-centre studies

Task force meetings

Information and communication technology (ICT) based programmes

Equipment support

At the national levels

National group training programmes (training courses, workshops, seminars etc.)

National awareness meetings

Expert missions

Short term fellowships

Equipment support

Reagents supply

The Thematic Project will be coordinated by the IAEA from its headquarter at Vienna with the Project and Technical Officers responsible for the project.

Each Member State will nominate one National Project Co-ordinator, preferably a senior nuclear medicine physician with broad expertise and experience in both in-vivo and in-vitro nuclear medicine. The National Project Co-ordinator may induct sub-coordinators from other fields like radioimmunoassay, instrumentation, technologist training etc. as and when necessary. The National Project Co-ordinators will be responsible for coordinating the activities of the Thematic Project in their respective countries, interact with the project and technical officers of the IAEA and participate in the National Co-ordinators’meetings of the Thematic Project.

Iran, Jordan, Kuwait, Qatar, Syria, UAE, Uzbekistan and Yemen.