Can India catch up on nuclear medicine?

Nuclear medicine is indispensable for public health, and some countries do it better than others.

Amidst the coronavirus pandemic, nuclear medicine is having its time to shine. The International Atomic Agency (IAEA) is providing diagnostic kits and training to countries interested in using nuclear-assisted tests to detect the virus and track its transmission paths.

It’s not surprising that nuclear medicine is set to play a key role in the fight against the novel coronavirus. Nuclear medicine, which relies on the use of radioactive drugs or radiopharmaceuticals (RPs) for either diagnostic or therapeutic purpose, has rapidly become a crucial medical field and a shining example of the peaceful application of atomic energy.

A typical nuclear medicine examination consists of injecting a radiolabeled molecule as a biomarker that allows the tracking and detection of specific disease processes, and their evolution over time. Doing so is crucial for diagnosing and treating a variety of diseases, including cancer, heart, lung and kidney conditions as well as infectious diseases – especially important in the current Covid-19 pandemic.

The widespread use of RPs in nuclear medicine makes it clear that their reliable supply is crucial to upholding high medical standards across the globe. While a group of around 20 RPs, such as technetium-99m (Tc-99m), the most widely used medical isotope, have become indispensable, research is ongoing on others which may prove to be highly innovative and a big evolutionary step in modern personalized medicine.

Developed countries have easy access to radioisotopes and equipment; as a result, many aspects of nuclear medical applications are standard in these parts of the world. However, the story is often different in emerging markets, where advancements in nuclear medicine are currently difficult to apply.

Take India, for example. Despite spectacular economic and technological expansion in recent years, nuclear medicine in the country is still not anywhere near as developed or prioritized as in Europe. At the same time, available nuclear medicine varies greatly across the country, as centers of excellence are interspersed with regions of exceptionally low socio-economic development. It’s not surprising that India has a lot to catch up in that regard.

But just how big is the challenge really? In 2018, the country’s radio-medicine infrastructure consisted of 293 departments of nuclear medicine, 233 gamma cameras, 70 of which are coupled with CT, 222 PET-CT, 3 PET-MRI and 19 cyclotrons, for a population of 1.3 billion. To put this into perspective, that same year France counted 215 nuclear medicine departments, 458 gamma cameras, 118 of which were CT and 49 solid-state, 160 PET-CT and 3 PET-MRI, for a population of 66 million.

Assuming that routine public health problems are similar in India and France, authorities would need to provide at least 9000 SPECT and 3150 PET-CT cameras to reach the same standard relative to the population as France. Considering that France’s equipment is nothing exceptional, being at best average for Europe and noticeably less sophisticated than Germany or Belgium’s equipment, the gap that India needs to fill is gigantic.

However, with the challenge India faces comes a colossal opportunity for the development of nuclear medicine, if only to be able to perform the most essential examinations on a large scale. A lot more equipment is needed, but the particular importance of RPs can’t be overemphasized: without them no far-reaching examinations are possible in the first place, so the radionuclides required to produce RPs need to be available in sufficient amounts.

First priority, then, should be given to acquiring Mo-99/Tc-99m generators as well as cyclotrons to produce positron-emitting fluorine. This also creates a positive knock-on effect on employment, given that enough imaging technicians and nuclear doctors need to be trained to carry out the examinations and interpret them, along with radio-pharmacists to manufacture RPs. The challenge is significant, from a human and logistical perspective as well as a financial point of view. While these techniques seem expensive at first glance, however, they eventually generate considerable savings thanks to the optimization of the care they allow, resulting in a very favorable cost-benefit ratio in many medical and economic analyses.

From a policy point of view, New Delhi has two main options to achieve rapid progress. Policymakers need to ascertain whether an indigenous industry for the medical sector, working for example under technical licenses from established global companies with know-how in the field, can be created; or if a targeted import policy could show results quicker and at lower costs.

The latter provides particular advantages while national industrial laboratories for the production of radionuclides are being established. A laundry list of high-tech equipment – ranging from the production of Tc-99m generators from molybdenum to the production of this same molybdenum by irradiation in nuclear reactors, as well as gamma cameras – could be sourced from a number of external suppliers with experience in the field, such as Russia’s Rosatom or Germany’s Siemens, among others. Similarly, the production of cyclotrons in India remains currently unviable and a significant hurdle, which should be overcome as soon as possible.

All of this means that for the time being, short of being able to produce them domestically, India needs to import precursors and RT-nuclides along with the technology needed for their production. But ultimately, India has little choice but to produce radiopharmaceuticals indigenously: as the Nuclear Energy Agency notes, “supply of Mo-99/Tc-99m to health care providers has often been unreliable over the past decade due to unexpected shutdowns and extended maintenance periods at some of the facilities that produce Mo-99, many of which are relatively old.”

Add to this the short half-lives of these isotopes (several hours), and it becomes clear that a country of India’s size cannot make itself exclusively depend on other countries for these vital resources and needs to have indigenous production sources to ensure security of supply.

Looking a few years ahead, India could well become a global leader in the field of nuclear medicine if the policies to develop this sector are rigorously pursued. The logistical, economic and human effort required will undoubtedly lead to a surge of investments in research in a country that already has world-class scientists conducting cutting-edge studies.

India will reap a lot of benefits from this, but the ultimate winner will be the global public. After all, nuclear medicine represents a relatively small scope of examinations, is expensive to develop, and cannot continue to evolve significantly unless it applied on a global scale. This is an area in which globalization shows its greatest promise.

Image credit: IAEA/Flickr