History of the Radiological Health Program of the Pan American Health Organization1

Antecedentes históricos / Historical background

The radiological health program of the Pan Ameri- History of the can Health Organization (PAHO) was established in 1960. Although the program has undergone vari- radiological health ous organizational changes, it continues to oper- program of the ate to this date. It has been operational through the administrations of five of the Directors of the Pan American Health Pan American Sanitary Bureau (PASB), which is PAHO’s Secretariat, and has been located in various Organization1 PAHO divisions or areas of work. Its program emphasis has evolved with the requirements of the Member States of PAHO. However, the program has essentially remained a unit with activities in 2 3 Gerald P. Hanson, Cari Borrás, research, training, radiation protection, and services and Pablo Jiménez 4 in the areas of public health and clinical medicine.

1959–1975, PASB DIRECTOR ABRAHAM HORWITZ

In the 1950s the world superpowers were actively engaged in a nuclear arms race and were test- ing weapons in the atmosphere. Governments and people throughout the world were deeply concerned about the effects of worldwide radioactive fallout. Civil defense shelters were being con- structed to protect against such fallout and against nuclear blasts, and schoolchildren were being taught to deal with a nuclear attack. Also, the peaceful uses of atomic energy were being promoted, and radioisotopes were being developed for diagnosis, research, and therapy. In 1960, PAHO established the Radiological Health Unit, with two professionals and a secretary, to promote the role of public health authorities in the field of applied nuclear energy. The head of the Unit was Regional Radiological Health Advisor Irvin Lourie, a physician who was supported by Specialized Technical Advisor Thomas Shea, a health physicist. Key words: delivery of health care, radiologic health, The 1960 Annual report of the Director of the radiology, radiation protection, radiotherapy, Pan PASB (1) stated that the program of the Radiologi- American Health Organization, Americas. cal Health Unit would be directed along four main lines: (1) stimulating national health services to develop procedures for regulations governing the use 1 A more extensive version of this article will be available on the PAHO of X-rays and radioisotopes and the disposal of website (www.paho.org). 2 Former Regional Advisor in Radiological Health for the Pan American radioactive wastes, based on the recommendations Health Organization, Washington, D.C., United States of America. of the International Commission on Radiological Send correspondence to: Dr. Gerald P. Hanson, 2 Winterberry Court, Bethesda, Maryland 20817, United States of America. Protection; (2) promoting the teaching of basic 3 Former Regional Advisor in Radiological Health for the Pan American health physics and radiological protection in Health Organization, Washington, D.C., United States of America. 4 Current Regional Advisor in Radiological Health for the Pan Ameri- schools of medicine, dentistry, public health, veteri- can Health Organization, Washington, D.C., United States of America. nary medicine, etc.; (3) fostering the use of radioiso-

Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 87 Historical background Hanson et al. • PAHO’s radiological health program topes for medical diagnosis, therapy, and research, Over the 1960–1964 period, the Radiological and (4) encouraging research on applications of ra- Health Unit also directed efforts toward such other diation that might be of importance to medicine, areas as: (1) providing fellowships for training PAHO public health, or veterinary medicine. staff and national professionals, (2) preparing In 1962 the XVI Pan American Sanitary Con- Spanish-language translations of training materials ference approved a research policy for PAHO and (manuals, pamphlets, slides, movies) and dissemi- requested that the Director of the PASB “take all nating these materials, (3) promoting radiation con- possible steps to expand the research activities of trol legislation and regulations and establishing the Organization, including specific projects and national programs, (4) providing advice to govern- their financing, for the mutual benefit of the coun- ments concerning radiation exposure and control, tries of the Region [of the Americas]” (2). In 1962, (5) assisting governments in obtaining international PAHO established the Advisory Committee on support and arranging scientific collaboration, and Medical Research (ACMR). This had a stimulating (6) representing PAHO at international conferences effect on the research aspects of PAHO’s technical and meetings. programs, including radiological health. A program for the radiological surveillance of In collaboration with physicist Merrill Eisen- air and milk in Latin America and the Caribbean bud of New York University (NYU), preliminary was in operation from 1962 to 1981. At the end of studies were performed of food, water, and human 1976 this program was reevaluated. Subsequently, teeth from the areas of Brazil with a high natural ra- in collaboration with the School of Public Health diation background. Later, a conference was held to of the University of Texas, a program to measure elucidate the public health significance of back- environmental radiation exposure using thermo- ground radiation, and financial support for the Bio- luminescent dosimeters was organized. By 1981, in- physics Institute of the University of Brazil and the terest in environmental surveillance had waned. A Catholic University of Rio de Janeiro to conduct bio- final report was prepared, and all activities were logical and physical studies was obtained from the terminated. Atomic Energy Commission of the United States of By 1963, PAHO Regional Radiological Health America. During the course of the project, numerous Advisor Lourie was disappointed that it had not Brazilian scientists received training in Brazil and at been possible to establish a single national radiation New York University, and valuable information con- protection program within the health ministries. He cerning chronic exposure in areas of high natural ra- felt it was imperative to assign a staff member to the diation background was obtained. PAHO continued field. Specialized Technical Advisor Shea did not to support this project until the end of 1975. By then, wish to leave the Washington, D.C., area and re- development, such as paved roads and building con- signed from PAHO. struction, had changed the character of the area. In December 1964, PAHO recruited Gerald In Chile a coordinated research project on Hanson, a 28-year-old engineer, to be Regional Ad- manganese poisoning in miners was initiated, with visor in Radiation Protection. Hanson had master’s collaboration between the Brookhaven National degrees in sanitary engineering and in radiological Laboratory, for biochemical analysis, and the health from the University of Michigan, as well as School of Medicine of the Catholic University of practical experience as a radiation control program Chile, for clinical evaluation. Initiated in 1962, the director for the state of Kansas and as a radiation project continued through 1974. It resulted in an safety officer for a federal government laboratory in understanding of the biochemical basis of action of the United States. various amino acids in chronic manganese poison- Stationed in Lima, Peru, Hanson was re- ing and in Parkinson’s disease. sponsible for providing advice and establishing In 1962 and 1963, plans were made to study radiation protection programs within the health the effects of irradiation at high altitudes on large ministries of the countries of Latin America and the animals (burros and llamas). In November 1964, a Caribbean. During the 1965–1968 period, Hanson meeting was held in Lima, Peru, to develop a re- made numerous visits to countries that had research project. The altiplano (highland plateau) of quested technical advice. The topics covered in- Peru was selected as a natural laboratory environ- cluded identification of sources of radiation; ra- ment to determine if hypoxia exerts a protective in- diation protection surveys in hospitals, medical fluence by reducing the number of cases of aplastic centers, and industries; drafting of legislation and anemia following high doses of gamma radiation, regulations; organizing radiation protection ser- as well as to study the central nervous system syn- vices, including film dosimetry laboratories; train- drome. It was envisaged that this information ing of national staff, including the identification of might contribute to a better understanding of the potential leaders for fellowship support; setting up development of leukemia in humans. and operating fallout monitoring programs; pro-

88 Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 Hanson et al. • PAHO’s radiological health program Historical background moting and coordinating research; and coordinat- ual on dosimetry. When finished, the manuscript, ing activities with national and international radia- including its Spanish translation, was handed over tion protection agencies. to the IAEA, and the world-renowned Manual of A training team was formed by appointing dosimetry in radiotherapy (the “Massey Manual”) two consultants: Jorge Roman, an occupational was published in 1970, bearing the logos of the health engineer from Peru, and Robert Bostrom, a IAEA, PAHO, and WHO (3). training specialist from the U.S. Public Health Ser- In 1970 a Regional course for physicists spe- vice (USPHS). Using excellent training materials cializing in radiotherapy was presented at the (the Basic science review and the Basic manual on radi- Puerto Rico Nuclear Center, jointly sponsored by ation protection) that had been prepared in collabo- PAHO and the IAEA. Similar courses were held in ration with the USPHS, short courses were pre- 1973 in Mexico and in 1975 in Brazil and Chile. sented in various countries. Following PAHO’s recommendation, in 1969 In mid-1967, PAHO Regional Radiological WHO established the first Regional Reference Cen- Health Advisor Lourie felt he had no alternative but ter for Secondary Standard Dosimetry (SSD) within to resign. He had made the strongest case possible the laboratories of the Atomic Energy Commission for increasing the resources available to the PAHO of Argentina. For many years this laboratory, and radiological health program, but was informed by others throughout the world (including ones es- the Director that no additional funds or staff would tablished within the Nuclear Energy Commission be assigned. From that point onward, until Jorge of Brazil and the Health Ministry of Mexico), re- Litvak, a Chilean endocrinologist with training ceived funding from WHO. The periodic newsletter in nuclear medicine, joined PAHO in 1969, the of the Secondary Standard Dosimetry Laboratories program was implemented by the unit’s secretary, (SSDLs) was published by WHO from 1970 until (Rida Luellsdorf), in Washington, D.C., and Re- 1986, at which time the IAEA took over the respon- gional Advisor Hanson, now stationed in Santiago, sibility. By the end of 2005 there were 81 SSDLs in Chile. 64 countries, and 13 of these laboratories were lo- By the end of 1968, 10 countries had signed cated in 13 different countries of the Americas. formal agreements with PAHO for assistance in es- Also arising out of the 1968 meeting in Cara- tablishing a radiation protection program within cas was the postal IAEA/WHO program for the in- their health ministries. These countries were Argen- tercomparison of radiation therapy doses, using tina, Bolivia, Brazil, Chile, Colombia, Costa Rica, thermoluminescent dosimeters (TLDs). Two physi- Guyana, Jamaica, Uruguay, and Venezuela. In the cists serving with the IAEA, Paul Pfalzner of radiological fallout surveillance program, 12 sta- Canada and Robert Loevinger of the United States, tions in 10 countries were in operation, with all 12 had devised a simple method for measuring the ra- forwarding daily air samples and 6 sending weekly diation dose from cobalt-60 teletherapy units by to monthly composite milk samples. Also, with co- using capsules containing thermoluminescent operation from the U.S. Atomic Energy Commis- powder that could easily be transported through sion, six radiological health scientific libraries, with the mail. PAHO and WHO immediately grasped several hundred volumes each, were established. the impact that such a system could have on im- They were located in Argentina, Bolivia, Brazil, proving the practice of radiation therapy, and they Chile, Colombia, and Venezuela. joined with IAEA to organize this service on a In 1968 a seminal meeting on dosimetric re- worldwide basis. From its inception in 1969 quirements in radiotherapy centers, took place in through the end of 2005, approximately 2 200 mea- Caracas, Venezuela, with participation from the In- surements (radiation-beam checks) in 330 hospitals ternational Atomic Energy Agency (IAEA), PAHO, or radiation therapy centers in 24 countries in the and the World Health Organization (WHO). The Americas were made. Since 1991, this has included recommendations of the meeting included three measurements on linear accelerators. The results key items: (1) preparation of a basic manual on of the TLD program—now known as postal dose dosimetry adapted to Latin American needs, (2) or- audits—are described in an article by Izewska ˙ et al. ganization of Regional training courses in radio- in the current issue of this journal (4). therapy physics, and (3) creation of Regional Participation in the 1968 Caracas meeting ce- dosimetry laboratories. On several occasions in mented Hanson’s resolve to obtain training in med- 1969 and 1970, PAHO invited a physicist, John ical physics. While conducting radiation protection Massey of the Christie Hospital in Manchester, surveys in hospitals and training national staff for United Kingdom, and a radiation oncologist, Mayer this purpose, he was shocked by the lack of support Zaharia of the National Cancer Institute in Lima, for radiological physics. The hospital physicist was Peru, to PAHO Headquarters in Washington, D.C. practically nonexistent, with probably no more Those two experts worked with Litvak on the man- than a dozen medical radiation physicists working

Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 89 Historical background Hanson et al. • PAHO’s radiological health program in hospitals in all of Latin America and the Ca- in deciding whether to accept the offers. During ribbean (2 in Argentina, 5 in Brazil, 1 in Colombia, this period PAHO also learned about a revolution- 1 in Jamaica, and 3 in Mexico). In contrast, in 2006 ary new diagnostic X-ray machine. Richard Cham- the International Organization for Medical Physics berlain, a diagnostic radiologist at the University of had around 600 members from 11 countries of Latin Pennsylvania, who had developed the machine, America and the Caribbean. named it the “Technamatic.” The PASB Director allowed Hanson a two- In the latter part of 1973 the vacant post of Re- year leave of absence to obtain his doctoral degree gional Advisor in Radiological Health was filled. at the University of California in Los Angeles The Radiological Health Unit had a new chief, Go- (UCLA). Subsequently, Jorge Litvak was invited to dofredo Gomez Crespo, a physician from Spain, take the vacant post of Regional Advisor in Radio- who had been the regional advisor in the WHO Re- logical Health in Washington, D.C. Jorge Roman gional Office for the Eastern Mediterranean. From was appointed to the post of Regional Advisor in 1974 to 1979, both the regional advisor in radiolog- Radiation Protection in Santiago, Chile. During ical health and the regional advisor in radiation 1969 and 1970, Litvak and Roman worked as a physics were stationed in Washington, D.C. Gomez team, PAHO’s program continued, and a general Crespo devoted his efforts mainly to diagnostic ra- model for radiation protection legislation was pre- diology, nuclear medicine, and radiation therapy. pared. In these two years a record number of 18 fel- Hanson worked in radiation protection, envi- lowships was awarded for radiological health stud- ronmental surveillance, and support for radiation ies to officials from Argentina, Barbados, Bolivia, therapy, including the Postal TLD Intercomparison Brazil, British Honduras, Chile, Colombia, Costa Program. Rica, Ecuador, Jamaica, Peru, Trinidad and Tobago, Soon after becoming the chief of the PAHO and Venezuela. Radiological Health Unit, Gomez Crespo was intro- The team of Litvak and Roman did not con- duced to Chamberlain and immediately recognized tinue beyond the first months of 1971. Roman’s con- the utility of the Technamatic X-ray machine that tract was not renewed, and soon afterward Litvak Chamberlain had developed. The Unit’s two re- returned to Chile. By April 1971, Hanson had com- gional advisors organized a pivotal working group pleted his doctoral studies at UCLA and was as- meeting, held in March 1975 at PAHO Headquar- signed to PAHO Headquarters. ters in Washington, D.C., on planning and develop- The Radiological Health Unit entered into an ing radiological facilities. Chamberlain, who was era of close cooperation with the PAHO Cancer Unit terminally ill, participated vigorously, along with and, in collaboration with the national cancer au- experts from Europe, Latin America, and the thorities of Brazil, a study group meeting on the United States, including Thure Holm, a diagnostic training of personnel in Physics Applied to Radio- radiologist from Sweden who was an expert on therapy was held in Rio de Janeiro in 1972. Radiation X-ray equipment. The working group developed a oncologists, physicists, and cancer specialists from diagnostic radiology system for primary care cen- the Region met with PAHO staff and consultants to ters, including the specifications for a simple X-ray develop a plan to satisfy the need for radiotherapy machine that could operate under adverse condi- physics services. PAHO invited Carlos Eduardo de tions. The working group also developed designs Almeida, a young Brazilian student who was pursu- for appropriate X-ray rooms and plans for the training a degree in medical physics at the University of ing of radiology personnel. A year later, Philip Texas’ M. D. Anderson Hospital in Houston, Texas, Palmer, a diagnostic radiologist from the Univer- to attend the meeting as a consultant. Subsequently, sity of California in Davis who had also attended de Almeida made a significant contribution to the the March 1975 meeting, wrote a manual that pro- development of medical physics and radiation provided the information needed to establish an X-ray tection in the Region of the Americas. department in a small hospital. PAHO published In 1973, PAHO provided to the Government the text (5) in both English- and Spanish-language of Haiti a special type of cobalt-60 teletherapy unit editions in 1978. called JANUS that had been designed by Ulrich Henschke, a radiation oncologist. With PAHO’s support, Henschke and his colleagues provided opera- 1975–1983, PASB DIRECTOR tional assistance and training in radiation therapy. HECTOR ACUÑA The PAHO Radiological Health Unit also began working closely with the Pan American De- Hector Acuña became the Director of the velopment Foundation (PADF), and donations of PASB in 1975. One of his first priorities was reorga- used equipment were offered to countries in the nizing the institution. The Radiological Health Unit Americas. PADF relied on PAHO’s technical advice became part of the Environmental Health Division,

90 Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 Hanson et al. • PAHO’s radiological health program Historical background where it remained until 1979. Within the Environ- therapy, and nuclear medicine) as well as protec- mental Health Division, the country-level projects tion from radiation hazards from any source. dealing with air pollution, industrial hygiene, and In the area of diagnostic radiology, efforts fo- radiation protection were consolidated within the cused on developing the simplified X-ray system. Division’s core program of water supply and waste In 1980 a commitment was obtained from the Gen- water disposal. Within a few years, in most coun- eral Electric Company to provide four prototypes tries the country-level budget assigned for the entire of their new “Technamatic” machine for a field trial environmental engineering program was less than in Latin America. This was an updated version of the previous budgets for either industrial hygiene or Chamberlain’s invention. The new machines incor- radiation protection activities alone. During the porated an improved tube stand and an advanced 1970s, PAHO had made bilateral agreements with inverter type of “multipulse” X-ray generator. Since several Latin American and Caribbean governments Chamberlain had purposely left the name “Techna- to establish radiological protection programs. When matic” in the public domain (without trademark the agreements reached the end of their timeframe, protection), General Electric used the name because they were not renewed, and by 1977, none of the it sounded innovative. PAHO selected Colombia to country radiation protection projects remained. receive the four machines since that country had an During his years in the Environmental Health active primary care program. The machines were Division, the Regional Advisor in Radiological delivered in 1983, and the successful field trial was Health continued to promote the primary care radi- concluded in 1984. ology system (PCRS) and the training of technolo- In 1980, in collaboration with the Inter- gists. A prototype machine loaned by the Univer- American Social Security Research Center (Centro sity of Pennsylvania was tested for three months in Interamericano de Estudios de Seguridad Social, CIESS), El Salvador in 1975, and a report on that was pre- a seminar was held in Mexico City to assess the sta- sented at the Second International Symposium on tus of diagnostic radiology in the Region of the the Planning of Radiological Departments, held in Americas. Also in 1980 the results of a survey of Philadelphia, Pennsylvania, United States, in 1976. Spanish-language teaching materials for X-ray tech- Information concerning curricula in technologist nologists that had been initiated the year before training programs was obtained through visits to were published by PAHO. In 1981, in collabora- various countries, and in 1976 a meeting of direc- tion with Member States and the Inter-American tors of schools and programs in X-ray technology College of Radiology, a rapid assessment of the ra- training was held in Caracas, Venezuela. diological health situation was conducted by the In the radiation protection area, continuing Radiological Health Unit, using questionnaires support was provided to the national programs covering diagnostic radiology, radiotherapy, nu- through visits by the Regional Advisor in Radiation clear medicine, and radiation protection. The pro- Physics and the Regional project’s resources, be- duction of training materials for technologists was cause country projects had declined. The concept promoted by the Radiological Health Unit through of incorporating the emerging activity of quality cooperation with other PAHO technical units in an assurance into national programs was promoted, international workshop on the training of middle- as were the radiation protection aspects of facility level technicians held at PAHO Headquarters in planning; quality assurance in diagnostic radiol- Washington, D.C., in 1981. ogy, nuclear medicine, and radiation therapy; and In the radiotherapy area, the IAEA/WHO the maintenance of radiological equipment. Contact Postal Dose Intercomparison Program for cobalt-60 was maintained with international organizations, teletherapy machines was gradually expanded, such as the International Commission on Radiolog- with an average of 60 radiotherapy centers per year ical Protection (ICRP) and the International Com- being included over the 1979–1986 period. In 1980, mission on Radiation Units and Measurements PAHO provided follow-up technical cooperation, (ICRU), to assure uniformity in PAHO’s efforts to through visits by a radiation physicist to identify promote international standards. and correct errors in those radiotherapy centers The Radiological Health Unit was transferred where a deviation of greater that 5% between their from the Environmental Health Division to the Dis- reported measurements and the actual values mea- ease Prevention and Control Division in mid-1979, sured in the IAEA laboratory had been found. This and soon after, Gomez Crespo left PAHO. The re- was the first time that such on-site follow-up was sponsibilities of both the Regional Advisor in Ra- provided, a practice that both PAHO and the IAEA diological Health and the Regional Advisor in Ra- have continued to this date. diation Physics were entrusted to Hanson. The In the area of nuclear medicine, in collabora- Radiological Health Unit was now dealing with ration with the USPHS Bureau of Radiological Health diation medicine (diagnostic radiology, radiation and the Federated Council of Nuclear Medicine

Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 91 Historical background Hanson et al. • PAHO’s radiological health program

Organizations, the Radiological Health Unit orga- From 1983 until 1987, the PAHO radiological nized an international symposium on quality as- health program continued on its main course, with surance, which was held in April 1981 at PAHO radiation medicine (diagnostic radiology, radiation Headquarters, with 200 participants. The purpose therapy, and nuclear medicine) and radiation pro- was to review the status of nuclear medicine and to tection being its major components. develop minimum standards for quality assurance A survey conducted by the Radiological programs. PAHO also collaborated in organizing a Health Unit in 1983–1984 in cooperation with the workshop on quality assurance for in vivo proce- health authorities of Argentina, Brazil, Colombia, dures in Santa Fe de Bogotá, Colombia (May 1981), Costa Rica, the Dominican Republic, Ecuador, Mex- and helped the IAEA and the Brazilian Association ico, and Nicaragua showed that the use of X-ray of Medical Physicists (Associação Brasileira de Física equipment for diagnosis was low in small hospitals Médica, ABFM) organize a workshop on quality as- (ranging from 1% to 5% of patients) as compared to surance in São Paulo, Brazil (September 1981). referral hospitals, where 20% to 30% of patients un- Again in collaboration with the USPHS Bureau of derwent an X-ray examination. This reinforced the Radiological Health and the Federated Council of priority given by PAHO and WHO to basic radiol- Nuclear Medicine Organizations, in 1982 PAHO ogy at the Regional and global levels. hosted the International Symposium on the Devel- Four basic X-ray machines manufactured by oping Role of Short-Lived Radionuclides in Nuclear the Siemens Corporation were delivered to Nica- Medical Practice. With the same partners, PAHO ragua in 1984 and, with the collaboration of WHO also hosted the following symposia: Single Photon Headquarters staff (radiologist Eero Lehtinen), a Ultrashort-Lived Radionuclides in Medical Prac- field trial was conducted. In 1985, two machines tice (1983), Clinical Applications of Radionuclide manufactured by the Phillips Corporation were Studies of the Brain (1984), and The Role of Non- installed for a field trial in Chile. Results again Invasive Imaging Modalities in Clinical Decision- demonstrated that with a short training period and Making: Coronary Artery Disease (1985). proper supervision, excellent radiographs could be In radiation protection, the collaborative ef- produced by local hospital staff. forts of PAHO and the national radiation protection In the radiotherapy area, efforts were made services of Argentina, Colombia, and Mexico re- by the Radiological Health Unit to extend and im- sulted in the publication of Volume I of the revised prove the IAEA/WHO Postal Dose Intercompari- Manual básico de protección radiológica [Basic Manual son Program, following the recommendations of a on Radiation Protection] by the Ministry of Health working group meeting of the SSDL directors of Colombia. In collaboration with the Brazilian hosted by the M. D. Anderson Hospital in Houston Institute of Radiation Protection and Dosimetry in 1982. However, the results remained essentially (Instituto de Radioproteção e Dosimetria, IRD) and the same, with only 60% of participating centers with support from the U.S. Department of Energy, meeting the standard criteria of a deviation of 5% or PAHO organized the Regional Seminar on Ra- less. In 1983 a key meeting, the First International diation Accidents and Procedures for Managing Symposium on Quality Assurance in Radiation Irradiated Persons, which was held in Itaipava, Therapy: Clinical and Physical Aspects, was held at Brazil, in December 1981. Seven years later, when PAHO Headquarters in Washington, D.C., with the a cesium-137 contamination accident occurred in collaboration of radiological societies from Europe, Goiânia, Brazil, the Brazilian authorities were Latin America, and the United States and govern- firmly in control of the situation and, using both ment institutions. The participants reviewed expe- national and local experts, skillfully handled the riences in radiation therapy from around the world, aftermath. and a consensus was reached concerning minimal as well as optimal standards for both clinical and physical aspects of quality assurance. The proceed- 1983–1994, PASB DIRECTOR ings were published by Pergamon Press in 1984 on CARLYLE GUERRA DE MACEDO behalf of the co-organizers of the meeting (6). During 1984 and 1985, assistance was pro- Soon after Carlyle Guerra de Macedo became vided to Argentina in a successful effort that re- the Director of the PASB in 1983, PAHO Headquar- sulted in the production of a cobalt-60 teletherapy ters staff members were assembled into groups for machine within the country. With PAHO’s collabo- an introspective analysis that covered a period of ration, Neutron Products, a United States company several months. Shortly after, the function of pro- that refurbished used cobalt-60 units, provided gram coordinator was created in the various PAHO valuable technical assistance to Argentine institu- technical divisions and continued until 2003. tions. These included the Ministry of Health, the

92 Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 Hanson et al. • PAHO’s radiological health program Historical background

Atomic Energy Commission, and the Institute of and/or Regional training events that were orga- Applied Research in Bariloche, which subsequently nized and/or cosponsored by PAHO. The most sig- collaborated in designing and manufacturing the nificant one was a hands-on course on physical Argentine machine. dosimetry in radiation therapy held in San Antonio, In the area of nuclear medicine, PAHO, in Texas, in August 1988, which was attended by 45 collaboration with the WHO Collaborating Center Latin American medical physicists. The event was in Nuclear Medicine in Danbury, Connecticut, cosponsored by the International Organization for United States, launched a new program for evalu- Medical Physics (IOMP) and the medical physics ating the quality of nuclear imaging procedures societies of the United States (AAPM), Latin Amer- in 1983, using specially designed “phantoms” that ica (ALFIM), and Spain (SEFM), in collaboration could be mailed. Designed by the American Col- with PAHO and the IAEA. lege of Pathologists, the phantoms simulated vari- A different training approach was taken in de- ous human organs as required for the relevant nu- veloping and establishing the radiological physics clear imaging procedure. centers, which were institutions that could provide In radiation protection, assistance was pro- in situ practical training in radiological physics to vided to 20 countries from 1983 to 1986, through physicians, medical physicists, engineers, and tech- visits by the PAHO regional advisor and consul- nologists involved in diagnostic and therapeutic ra- tants, on legislation, organization of services, radia- diology services. The first center was established in tion measurements, radiation accidents, shielding Caracas, Venezuela, in 1993, and the second one was calculations, and training. set up in Tegucigalpa, Honduras, in 1995. In April 1987, Hanson was invited to become Through the IAEA/WHO postal dose audits, the Chief of Radiation Medicine at WHO Head- which verified the accuracy of the calibration of quarters in Geneva, Switzerland, and resigned from high-energy radiotherapy units with TLDs, and PAHO. In March 1988, Cari Borrás took over the through the quality assurance workshops on radia- position of Regional Advisor in Radiological Health tion therapy held during that period (7, 8), it was at PAHO Headquarters in Washington, D.C. A ascertained that the source strength of most cobalt- native of Spain, Borrás had a doctor of science de- 60 units in Latin American and Caribbean countries gree from the University of Barcelona. She had pre- was too low for effective radiotherapy treatments. pared her thesis at Thomas Jefferson University in In 1993, PAHO, in collaboration with WHO, the Philadelphia, Pennsylvania, as a Fulbright scholar. IAEA, and the United Nations Industrial Develop- By the time she joined PAHO she had considerable ment Organization, convened an advisory group international experience. meeting in Washington, D.C., to assess the situation From 1988 to 1994, under Director Macedo’s and make recommendations concerning the prob- administration, Borrás continued PAHO’s technical lems of existing teletherapy units, including both cooperation. She worked at both the Regional and cobalt-60 units and current linear accelerators. The country levels. Her tasks included data collection proceedings of the meeting, which were published and situation analysis; revision and development of by Los Alamos National Laboratory in Decem- standards and guidelines; preparation and distribu- ber 1995 (11), also presented new alternative de- tion of publications; consultations in radiation med- signs for teletherapy units. icine and in radiation protection; assessment of Consultations with the countries of the policies and resources for radiology services cov- Americas concerned radiation medicine and also erage and for radiation protection programs; train- radiation safety, including prevention, prepared- ing activities, such as courses, seminars, and con- ness, and response in case of a nuclear accident gresses; organization of and participation in or a radiological emergency. The most significant scientific meetings; promotion and development of radiological accident during that period involved quality assurance programs; support to and collab- three workers in San Salvador, El Salvador, in oration with WHO and IAEA programs; initiation February 1989, with a cobalt-60 industrial irra- of a network of radiological physics centers, equip- diator used for sterilizing medical products. Due ment donations, and loans; the removal of spent ra- to the high radiation doses that the workers re- dioactive sources, and assistance in case of radio- ceived, one of them died and another had his legs logical emergencies (7, 8). The radiological health amputated (12). information collected from the countries was Other minor accidents or incidents involved mainly published in PAHO’s quadrennial Health in discarded brachytherapy sources in several Carib- the Americas report (9, 10). bean countries in the early 1990s. Concerned about Efforts centered mainly on education. The potential exposures, PAHO contracted a United PAHO Regional Advisor lectured in 40 country States company, NSSI/Sources and Services, to de-

Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 93 Historical background Hanson et al. • PAHO’s radiological health program contaminate the premises where needed, to condi- the IAEA (17); joined the Inter-Agency Committee tion the sources, and to transport the sources to the on Response to Nuclear Accidents (IACRNA); and United States for safe storage. became part of the Joint Radiation Emergency Man- To prevent radiological accidents and to im- agement Plan of the International Organizations prove the radiation safety infrastructure in its (18). PAHO also increased its radiation protection Member States, PAHO joined the Inter-Agency technical cooperation in the area of nonionizing ra- Committee on Radiation Safety (IACRS) in 1991 diation, providing advice on the health effects of and strengthened its cooperation with WHO and electromagnetic fields (especially those of cellular the IAEA. In 1993, it cosponsored a workshop on telephones), lasers, microwaves, ultrasound, mag- radiation safety for Central America and the Ca- netic resonance, and ultraviolet light. ribbean. In 1994 the XXIV Sanitary Conference The educational activities continued. During endorsed the International Basic Safety Standards that period the Regional Advisor lectured in 98 for Protection against Ionizing Radiation and for country and/or Regional training events that were the Safety of Radiation Sources (BSS) (13), which organized and/or cosponsored by PAHO (19–21). had been jointly prepared through the IACRS. Most of the courses were aimed at Member States of PAHO or WHO and dealt with the implementation of the BSS in medical practice. A training manual, 1995–2003, PASB DIRECTOR consisting of 1 200 slides, was developed by PAHO SIR GEORGE A.O. ALLEYNE for the IAEA. The radiological physics center in Teguci- In the year 2000, PAHO’s radiological health galpa, Honduras, was coordinated by the Au- activities became part of the Essential Drugs and tonomous University of Honduras (Universidad Technology Program within the Division of Health Autónoma de Honduras), which signed an agreement Systems and Services. Borrás became the program’s with the Ministry of Health to carry out activities of coordinator, while also continuing to be responsi- joint interest, including a special degree program ble for radiological health activities. PAHO pre- for radiation technologists. In 1997–1999, this center sented guidelines on radiology services in a 1997 was partially subsidized, through PAHO, by the publication, Organization, Development, Quality As- Ministry of Health of Spain. surance and Radiation Protection in Radiology Services: PAHO continued to provide support during Imaging and Radiation Therapy (14). The text, which this period to the World Health Imaging System described the organizational and technical aspects for Radiography (WHIS-RAD). In the mid-1990s, of radiology services, was aimed at political lead- it purchased 11 of these units and installed them ers, administrators, planners, and health profes- in Haiti. In spite of the inherent reliability of the sionals, as well as ministries of health, and was equipment, the services had serious problems be- intended to help them allocate resources and deter- cause of lack of maintenance, poor X-ray technician mine technological configurations for the provision training, and inadequate radiation protection mea- of decentralized radiology services under health sures. Other efforts to upgrade radiology services sector reform. involved Belize, Chile, Dominica, Haiti, St. Kitts Guidelines for patient radiation protection and Nevis, and Trinidad and Tobago. were given at the International Conference on the Efforts to upgrade radiotherapy services were Radiological Protection of Patients in Diagnostic carried out in various countries of the Americas. and Interventional Radiology, Nuclear Medicine In Colombia, a countrywide evaluation was con- and Radiotherapy, which was held in Málaga, ducted; in Honduras, remote-control low-dose rate Spain, in 2001 and cosponsored by the IAEA, the brachytherapy was introduced; in Trinidad and To- European Commission (EC), PAHO, and WHO bago, a completely new cancer treatment facility (15). It was attended by 800 people, 17 of them par- was planned; and in Panama, cobalt therapy was tially subsidized by PAHO. In 2002 the IAEA Board replaced by linear accelerators. Quality assurance of Governors approved an International Action programs in radiation therapy services continued Plan on the Radiological Protection of Patients, to to be promoted, mainly through the TLD IAEA/ be carried out in cosponsorship with the EC, WHO Regional postal dose audit. A meeting on this PAHO, and WHO. PAHO, along with several other program for TLD program coordinators from the international organizations, also cosponsored the Region of the Americas was held in Santo Do- IAEA’s new requirements on preparedness and re- mingo, Dominican Republic, in July 1999. sponse for a nuclear or radiological emergency (16). If one of the participating Costa Rican fa- PAHO also participated in an international confer- cilities had acknowledged a significant deviation ence on the management of radioactive waste from that had appeared for several years, it could have non-power applications, which was organized by prevented the overexposure of 114 patients—many

94 Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 Hanson et al. • PAHO’s radiological health program Historical background of them children—that occurred as a consequence 2003 TO THE PRESENT, PASB DIRECTOR of a miscalibration of a cobalt-60 unit. PAHO was MIRTA ROSAS PERIAGO asked to provide technical assistance, and a year later the IAEA carried out its own investigation. In January 2003, Mirta Roses Periago, who PAHO was also asked to investigate a radiother- had previously served for eight years as the As- apy overexposure incident that occurred in Panama, sistant Director of the PASB, was the first woman to caused by the improper use of treatment planning become the Director of the PASB. Organizational software. The details of the Panama exposure are changes were made, and the radiological health published in this issue of this journal, in a report by program was located in the Area of Technology and Borrás (22). Health Services Delivery (THS), first within the In November 2001 and April 2002, Costa Rica Health Services Organization Unit and finally again asked PAHO to assess potential radiation within the Unit of Essential Medicines, Vaccines, overexposures, this time caused by one or two med- and Health Technologies. Regardless of its location, ical linear accelerators. No evidence of overexpo- the radiological health program carries out its ac- sures was found. tivities by interacting with numerous areas within Recognizing the need for standards in medical PAHO, following the new management model im- radiation dosimetry, PAHO cosponsored an inter- plemented by Director Roses. national symposium in 2002 on standards and codes Pablo Jiménez joined PAHO in July 2002 as an of practice in medical radiation dosimetry (23). associate professional expert and became the regional PAHO also promoted an accreditation program for advisor of the radiological health program in Janu- radiotherapy services to be implemented in the ary 2004. A physicist, Jiménez received the Spanish countries of Latin America and the Caribbean. equivalent of a master of science degree in physics In 1999 the radiological health program won from the University of Madrid (Universidad Com- the research competition convened by PAHO’s Di- plutense de Madrid) in 1988, and a degree (equivalent rector, with the theme of “quality assessment of ra- to a medical specialty) in medical physics and radia- diology services,” and prepared the terms of refer- tion protection from Spain’s Ministry of Health and ence for the submission of projects. Seven countries Ministry of Education in 1996. The other professional applied, and five of them (Argentina, Bolivia, who was working in the radiological health program Colombia, Cuba, and Mexico) were awarded a re- at PAHO Headquarters during this period, as an search contract, which involved medical physicists associate professional officer, was Ileana Fleitas. A and radiologists in these countries. The results of nuclear engineer from Cuba, she joined PAHO in this health services delivery research project are February 2003 and returned to Cuba in February presented in this issue of this journal, in an article 2006, where she is now working as a PAHO staff by Fleitas et al. (24). member in the radiological health program. In 2001 a Regional diagnostic radiology re- The main activities since 2003 have included search program to evaluate the image quality and strengthening diagnostic imaging and radiotherapy the average glandular dose in mammography units services, promoting regulations to protect against in countries of the Americas was undertaken by both ionizing and non–ionizing radiation, and im- PAHO and the Inter-American College of Radiol- proving the countries’ capacity to respond to radio- ogy, in collaboration with the IRD in Brazil, and logical or nuclear emergencies. Emphasis has been the Center for Devices and Radiological Health placed on advising on technology management. (CDRH) in the United States. Data from 61 units in Concerning diagnostic imaging and radiation 11 Latin American and Caribbean countries were oncology services, currently around 150 high-energy collected and analyzed. Eighty-eight percent of radiotherapy units are checked annually in Latin the units evaluated complied with the image qual- America and the Caribbean through the IAEA/ ity requirement, and only 8.5% of all the units ex- WHO TLD postal dose audit. The evaluation of radi- ceeded the dose limit for the average glandular ation therapy and diagnostic imaging services has dose.5 been continued in the Bahamas, Costa Rica, Guyana, Nicaragua, and Panama. Technical advice and assessment in technology management were provided for the incorpora- tion of new technology in Argentina, Costa Rica, 5 Borrás C, Mota H, Skvarca JJ. Measurements of image quality and Cuba, El Salvador, Guatemala, Trinidad and To- dose in 61 mammography units in 11 countries [conference presen- tation]. 89th Radiological Society of North America Scientific As- bago, Uruguay, and Venezuela. sembly and Annual Meeting, 28 November–3 December 2004, Chi- The radiological health program has also cago, Illinois, United States. Abstract available at: http://rsna2003. rsna.org/rsna2003/VBK/conference/event_display.cfm?id=66601& been very active in organizing, cosponsoring, and em_id=3107772. Accessed on 19 February 2006. supporting educational activities at the national,

Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 95 Historical background Hanson et al. • PAHO’s radiological health program

Regional, and global levels. The program orga- ticipated in the 2004 version of the Joint Radiation nized a workshop on clinical quality in radiation Emergency Management Plan of the International therapy in Montevideo, Uruguay, and two subre- Organizations (18). It also attended the I and II Steer- gional training workshops on quality assurance in ing Panel Committee Meetings of the International radiology services for radiographers and radiolog- Action Plan for the Radiological Protection of Pa- ical technologists, one in San Salvador, El Salvador tients, in Madrid, contributing to drafting the actions for radiological technologists from Central Amer- for 2006 and 2007 geared to promoting education and ica, and the other in Guyana for radiographers and training, providing assistance, rendering services, radiological technologists from the Caribbean. fostering information exchange, and coordinating re- Within a project called Teaching the Teachers Ini- search in the areas of diagnostic and interventional tiative for Ultrasound Training in Latin America radiology, nuclear medicine, and radiation therapy and the Caribbean, a total of 12 radiologists from 12 (25). PAHO also organized and hosted the XI Meet- countries was selected to attend an intensive 12- ing of the IACRS, a distinction it had not held since week training program during 2005 and 2006 at the 1992. It also continued participating in the IAEA Ra- Jefferson Ultrasound Research and Education Insti- diation Safety Standards Committee (RASSC) meet- tute, which is located in Philadelphia and is one of ings and the WHO Radiation Emergency Medical the PAHO/WHO Collaborating Centers. A total of Preparedness and Assistance Network (REMPAN). six educational centers in ultrasound will be estab- The PAHO radiological health program has now be- lished in the Region by the end of 2007. gun the process of revising the BSS. The most important international meetings, congresses, and conferences where the radiological health program was represented and where sup- CONCLUSIONS port was provided during this period were the XI Congress of the International Radiation Protection PAHO’s radiological health program has been Association, in Madrid, Spain; the III Iberian Latin in existence for nearly half a century. The program American and Caribbean Congress of Medical has focused on specific issues in keeping with the Physics, in Rio de Janeiro; the Regional CRILA Con- times, as well as on the priorities of PAHO’s Mem- gress, in Lima; National Infrastructures for Radi- ber States. The latter have had at their disposal the ation Safety: Towards Effective and Sustainable most current scientific and professional knowledge Systems, in Rabat, Morocco; and the VI and VII and advice available, as well as a steady partner for Regional Congresses of the International Radiation continuously improving their national institutions. Protection Association, in Lima. As new discoveries and new challenges ap- Concerning other activities, national regula- pear, the most important needs envisaged for the tions were evaluated and comments on them were immediate future are: education and training in sent to the Bahamas, Bolivia, Honduras, Panama, evaluating, incorporating, and utilizing new tech- and Paraguay. A Regional compilation of the na- nologies; support for strengthening radiological tional regulations on non–ionizing radiation was diagnostic and therapeutic services; support for completed; a radiation emergency exercise was ex- research on analyzing and evaluating outcomes; im- ecuted jointly with the Organization of American plementing ways to safeguard patients and staff, in- States, in Barbados; a self-evaluation guideline to cluding strengthening regulations; and improving respond to radiological emergencies was prepared the capacity to respond to radiological and nuclear and sent to Peru; and a workshop for Andean coun- emergencies. tries on dangerous radioactive materials was held With the continuing confidence and support in Quito, Ecuador. of PAHO’s Member States, the PAHO radiological In addition, the PAHO radiological health pro- health program is expected to continue to respond gram actively participates in two IAEA Regional to their needs. cooperation agreements for Latin America and the Caribbean (Acuerdos Regionales de Cooperación para América Latina y el Caribe, ARCAL) dealing with ra- SINOPSIS diology and the education of medical physicists. One of the strategic lines consists of the establish- Historia del programa de radiología ment of a formal agreement with the IAEA’s Tech- y radioprotección de la Organización nical Cooperation Department, which will include Panamericana de la Salud a joint Regional project for 2007/2008 to improve the quality of radiation therapy. El programa de radiología y radioprotección de la Organi- At the global level, the practice of co-sponsoring zación Panamericana de la Salud (OPS) se estableció en relevant IAEA publications continued. PAHO par- 1960. En ese entonces, las superpotencias mundiales se en-

96 Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 Hanson et al. • PAHO’s radiological health program Historical background frascaban en la carrera armamentista; hacían pruebas con tarias de las radiaciones, y a las instituciones clínicas acerca armas nuc1eares en la atmósfera y los pueblos y gobiernos de las modalidades radiológicas diagnósticas y terapéuticas del mundo les temían a los efectos de la lluvia radiactiva. más recientes. Como en sus inicios, el programa continúa Además, se comenzaba a fomentar el uso pacífico de las ra- prestando atención a las siguientes necesidades de la Región: diaciones en la medicina, la investigación y la industria, por la educación y capacitación del personal de radiología para lo cual se necesitaba una protección adecuada contra estas que aprenda a evaluar, incorporar y utilizar con eficacia y se- nuevas formas de energía. Como se señaló en el Informe guridad las nuevas tecnologías; el apoyo gerencial y técnico anual del Director de la OPS, los objetivos de ese nuevo para fortalecer los servicios radiológicos; el asesoramiento in- programa de la Organización eran: 1) incentivar la adopción tegral orientado a establecer o mejorar los programas guber- de reglamentos aplicables al uso de las radiaciones en conso- namentales de radioprotección, incluida la adopción de legis- nancia con las recomendaciones de la Comisión Internacio- lación y reglamentación para el control de las radiaciones nal de Protección Radiológica; 2) promover la enseñanza de ionizantes y no ionizantes; el fomento de la investigación la física médica y de la protección radiológica; 3) ayudar a para analizar y definir prioridades; y el fortalecimiento de la desarrollar las aplicaciones de los radioisótopos en el diag- capacidad institucional con miras a responder a las emergen- nóstico, el tratamiento y la investigación médica; y 4) im- cias radiológicas y nucleares. A pesar de que surgen nuevos pulsar las investigaciones relacionadas con el uso de las ra- retos a medida que se producen nuevos descubrimientos, el diaciones en la medicina, la salud pública y la veterinaria. Programa de radiología y radioprotección de la OPS seguirá Durante casi medio siglo, el programa de radiología y ra- respondiendo a las necesidades de los Estados Miembros. dioprotección de la OPS ha centrado su atención en diversos temas, según las necesidades y prioridades de los Estados Palabras clave: prestación de atención de salud, ra- Miembros. Para ello siempre ha contado con personal alta- diología, protección radiológica, radioterapia, Or- mente calificado capaz de asesorar a los ministerios de salud ganización Panamericana de la Salud, Américas. acerca de las políticas relacionadas con las aplicaciones sani-

REFERENCES

1. Pan American Health Organization. An- 8. Pan American Health Organization. Re- ing and radiation therapy. Washington, nual report of the Director, 1960. Wash- port of the Director: Quadrennial 1990– D.C.: Pan American Health Organiza- ington, D.C.: PAHO; 1961. (Official Doc- 1993; annual 1993. Washington, D.C.: tion; 1997. ument No. 38). PAHO; 1993. (Official Document No. 262). 15. International Atomic Energy Agency. 2. Pan American Health Organization. An- 9. Pan American Health Organization. Radiological protection of patients in di- nual report of the Director, 1962. Wash- Health conditions in the Americas: 1990 agnostic and interventional radiology, ington, D.C.: PAHO; 1963. (Official Doc- edition. Washington, D.C.: PAHO; 1990. nuclear medicine and radiotherapy. Pro- ument No. 50). (PAHO Scientific Publication 524). ceedings of an international conference 3. International Atomic Energy Agency. 10. Pan American Health Organization. held in Málaga, Spain, 26–30 March Manual of dosimetry in radiotherapy. Health conditions in the Americas: 1994. 2001. Available from: http://www-pub. Vienna: IAEA; 1970. (Technical Report Washington, D.C.: PAHO; 1994. (Scien- iaea.org/MTCD/publications/PDF/ Series No. 110). tific Publication No. 549). Pub1113_scr/Pub1113_scr1.pdf [Web 4. Izewska ˙ J, Vatnitsky S, Shortt KR. Postal 11. Borrás C, Stovall J, eds. Design require- site]. Accessed 15 February 2006. dose audits for radiotherapy centers ments for megavoltage X-ray machines 16. International Atomic Energy Agency. in Latin America and the Caribbean: for cancer treatment in developing coun- Preparedness and response for a nuclear trends in 1969–2003. Rev Panam Salud tries: report of an Advisory Group Con- or radiological emergency. Vienna: Publica. 2006;20(2/3):161–72. sultation. Los Alamos: Los Alamos Na- IAEA; 2002. 5. Palmer PES. Radiology and primary tional Laboratory; 1995. (LA-UR-95-4528). 17. Borrás C, Rudder DDG, Porte J, Archi- care. Washington, D.C.: Pan American 12. International Atomic Energy Agency. bald A, Miller C, Lokerse AF, et al. Health Organization; 1978. (Scientific The radiological accident in San Sal- Radioactive waste management in Brit- Publication No. 357). vador. Vienna: IAEA; 1990. ish and Dutch Caribbean countries. In: 6. Hanks G, Svensson G, eds. Quality as- 13. Food and Agriculture Organization of Proceedings, International Conference surance in radiation therapy: clinical and the United Nations, International Atomic on Management of Radioactive Waste physical aspects. Proceedings of the First Energy Agency, International Labour from Non-Power Applications—Sharing International Symposium on Quality As- Organisation, Nuclear Agency of the Or- the Experience. Vienna: IAEA; 2002. sessment in Radiation Oncology, Wash- ganisation for Economic Co-operation Pp. 84–89. (IAEA-CN-87/91). ington, D.C., 8–10 June, 1983. New York: and Development, Pan American Health 18. International Atomic Energy Agency. Pergamon Press; 1984. (International Organization, World Health Organiza- Joint Radiation Emergency Manage- Journal of Radiation Oncology, Biology tion. International basic safety standards ment Plan of the International Organiza- Physics, Volume 10, Supplement 1). for protection against ionizing radiation tions. Vienna: IAEA; 2004. 7. Pan American Health Organization. Re- and for the safety of radiation sources. Vi- 19. Pan American Health Organization. port of the Director: quadrennial 1986– enna: IAEA; 1996. (Safety series 115). Leading Pan American health: quadren- 1990, annual 1989. Washington, D.C.: 14. Borrás C, ed. Organization, develop- nial report of the Director 1994–1997. PAHO; 1989 (Official Document No. ment, quality assurance and radiation Washington, D.C.: PAHO; 1998. (Offi- 234). protection in radiology services: imag- cial Document No. 287).

Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 97 Historical background Hanson et al. • PAHO’s radiological health program

20. Pan American Health Organization. tion and follow-up measures. Rev Panam La calidad de los servicios de radiolo- Charting a future for health in the Salud Publica. 2006;20(2/3); 173–87. gía en cinco países latinoamericanos. Americas. Quadrennial report of the Di- 23. Borrás C, Rudder D, Jiménez P. Use of Rev Panam Salud Publica. 2006;20(2/3): rector. Washington, D.C.: PAHO; 2002. imaging techniques in radiation oncol- 113–24. (Official Document No. 306). ogy. In: International Atomic Energy 25. International Atomic Energy Agency. In- 21. Pan American Health Organization. Agency. Standards and codes of practice ternational Action Plan for the Radiologi- Health in the Americas: 2002 edition. in medical radiation dosimetry. Pro- cal Protection of Patients. Available from: Washington, D.C.: PAHO; 2002. (PAHO ceedings of an international sympo- http://www-ns.iaea.org/downloads/ Scientific and Technical Publication No. sium, Vienna, 25-28 November 2002. Vi- rw/radiation-safety/PatientProtAction 587). enna: IAEA; 2003. Plangov2002-36gc46-12.pdf [Web site]. 22. Borrás C. Overexposure of radiation ther- 24. Fleitas I, Caspani CC, Borrás C, Plazas Accessed 15 February 2006. apy patients in Panama: problem recogni- MC, Miranda AA, Brandan ME, et al.

98 Rev Panam Salud Publica/Pan Am J Public Health 20(2/3), 2006 ARTÍCULOS E INFORMES ESPECIALES

ARTICLES AND SPECIAL REPORTS