With the country’s estimated cancer rate standing at about 100,000 new cases yearly, all hands should be on deck. But this has not been the case. Now, the Central Bank of Nigeria’s (CBN’s) policy on foreign exchange has worsened the situation. The Centre for Nuclear Medicine, University College Hospital (UCH), in Ibadan and its sister in Abuja are hard-hit by the CBN’s decision mandating forex users to deposit fund 48 hours ahead. OLUKOREDE YISHAU examines how this policy has worsened an already bad situation.
On normal days, the nuclear medicine centres at the University College Hospital (UCH), Ibadan and the National Hospital, Abuja are overwhelmed. The bulk of their patients have one form of cancer or the other. Some are there for one diagnosis or the other. With the country recording about 100,000 new cases of cancer annually and some 2 million existing cases, it is not surprising that these centres are like mad houses. It actually used to be crazier at the UCH centre when it was the only one in the country and patients have to travel from all over the country to see the experts.
The Ibadan, Oyo State centre was established in 2006 by the International Atomic Energy Agency based in Vienna, Austria. Its medical equipment are financed and supplied by the International Atomic Energy Agency. Its premises are paid for by the agency. Its main purpose: offer radio-active treatment at next-to-nothing rates to patients suffering from various forms of cancer. In 2008, an Abuja centre was opened to ease the pressure on the Ibadan centre.
When working at optimal levels, the two centres are unable to meet the medical needs of the people. Now, their activities are hampered by the Central Bank of Nigeria (CBN). And for the patients, it is to your tent o Israel!
The CBN last week directed commercial banks to pay for their dollar purchases at the official forex window 48 hours ahead of the bid date. The policy requires banks and other forex dealers to deposit the naira equivalent of the forex bids to the apex bank 48 hours in advance.
This policy is bad news to importers of radiopharmaceuticals used in treatment of cancer patients and others with serious ailments. The two centres in Ibadan and Abuja, which are funded by the International Atomic Energy Agency (IAEA), are now in dilemma.
The Ibadan, which banks with Guaranty Trust Bank Plc, has been unable to meet the new demand because its access to cash is limited since it is a charity. The policy shift means more pains for its cancer patients. Since it is unable to meet this demand, less patients have access to the cancer drugs. An already difficult situation has thus been aggravated.
The centres have had to put importation of drugs for the patients on hold. Yet, CBN Director of Corporate Communications Ibrahim Mu’azu said the apex bank could not give exemptions because it would not know where to draw the line. He added that the centres should plan ahead.
For centres, which do not have loads of cash, planning ahead can be difficult, said a source. “Both the CBN and the banks do not understand the harm they are doing to the health of cancer patients who need these drugs to stay alive. Why can’t they give a waiver to providers of medical services. For us, the drugs used in UCH are not produced in Nigeria or even West Africa. They are imported from France and Hungary,” the source said.
GTBank CEO Segun Agbaje said: “I think the policy will help the CBN a lot to determine what the real demand for forex is or what spurious demand is. It is going to ensure that what we operate is effective demand backed by cash. So, that way, it is easy for the Central Bank to actually determine what the demand is and ensure it is a proper demand.”
The centres are looking up to President Muhammadu Buhari to save them. When this is done, it will be the umpteenth time, the Presidency and other stakeholders have had to come to its rescue.
The NNRA debacle
In December of 2013, the Nigeria Nuclear Regulatory Authority (NNRA), an agency under the Ministry of Petroleum saddled with the responsibility of managing radioactivity in the country, decided to hike the licence fees for the importation of radioactive materials. From N250,000, the renewal cash was jerked up to N2 million, representing a 700 per cent increment. Without the licence, the centres would not be given clearance by the International Atomic Energy Agency (IAEA) to import radioactive nuclear materials used for diagnoses and treatment of cancer patients .
The National Coordinator of National Nuclear Medicine Project, Prof Bola Osifo, who oversees the two centres, was alarmed. The centres could not afford the money and between December 2013 and March of last year or thereabout, they could not practise.
The National Coordinator of Nuclear Medicine project in a letter dated December 13, 2013 to the NNRA, expressed bewilderment over the arbitrary increase of license fees , declaring that the centres been a non-profit making body could not afford to pay N2million every year for licence.
The letter reads:” It is difficult for me to understand your review of fees after I had applied for licence for 2014 since November 8, 2013. The fact is that no department of Nuclear Medicine in this country can afford to pay your fees. Your Commission is already ruining our 2014 practice as our suppliers have written to us to submit our licences latest December 23, 2013. Please remember that we are practicing in a hospital which is not a profitable business venture , rather it is to help millions of Nigerians who are very sick and cannot afford to go anywhere else for their medical care unlike the elites of this country . We would like to remind you that we are running an IAEA project where all the equipment are given free of charge by the agency.”
The then Deputy Leader of the Senate, Abdul Ningi, last year, raised a Point of Order on a matter of urgent public importance, calling on the Senate to investigate the licence fee increase.
He said: “Bureaucratic bottleneck has stopped the treatment of cancer patients in the country, resulting in the death of many people, which is avoidable. Since last December, no single cancer patient has been treated by the Nuclear Department of UCH and the National Hospital, Abuja, because they were not licensed.
“With this ugly development, most cancer patients in Nigeria will die because of lack of treatment, except those who can afford to travel abroad. It’s very wrong for them to review upward the licence fee because it is critical to the treatment of cancer patients.”
The Senate invited the then NNRA chief Dr Martin Ogharandukun, who was not convincing about the reason for the hike. The matter was eventually resolved in the interest of the centres and Ogharandukun was relieved of his job by the Presidency.
At other times, Customs have also seized the centres’ drugs over duties. These are drugs that are time-bound and should not be kept at the ports for long.
Other woes
The centres also face other avoidable challenges. Unlike other types of medicine, nuclear medicine depends on radioactive materials. The radio-pharmaceutical materials it uses in the treatment of cancer patients are not available in Nigeria and have to be imported. This means bureaucratic hitches with the Customs have to be surmounted each time importation is done.
For every consignment imported every month, it pays anti-bomb personnel to escort them because the contents have radioactive agents. Importation, clearance and local transportation costs are passed to the patients thereby increasing their woes.
In a paper titled ‘Avoidable challenges of a nuclear medicine facility in a developing nation’ in the Indian journal of Nuclear Medicine by Kayode Solomon Adedapo,Yetunde Ajoke Onimode, John Enyi Ejeh, and Adewale Oluwaseun Adepoju, these nuclear experts identified other challenges to include poor electricity supply, short life span of radioactivity materials and so on. They also identified the shortage of a vital tool known as the 99Mo/99mTc generators.
They said: “It is desirable that imported radioisotopes should have relatively long half-lives. Thus, cyclotron products such as fluorine-18 (18F), carbon-11 (11C) and iodine-123 (123I) (with half-lives of 110 min, 20 min and 13 h, respectively) will not be available in these countries except at enormous cost to patients by ordering additional quantities of radioactivity (higher activity) to compensate for the short half-lives. This precludes the option of positron emission tomography (PET) imaging, as PET radiotracers are notoriously short-lived. A shortage of 99Mo/99mTc generators has been experienced in recent times. Understandably, countries which produce these generators would then reduce their exports in order to satisfy local demands. This shortfall in exports in turn adversely affects their foreign clients.
“These challenges might be overcome if radiopharmaceutical production facilities were made available in these developing countries as obtains in the advanced world. This will also lead to saving of the foreign exchange for the importation of radiopharmaceuticals. Amendments of unnecessary aspects of government bureaucracy would also help.
“In Nigeria, the Nigeria Atomic Energy Commission (NAEC) has begun plans for a new nuclear reactor. Although it is meant to help boost electric power generation, it is hoped that radioisotopes will also be produced from the reactor for use in nuclear medicine. Provision of small cyclotrons to provide nuclear medicine centers with desired radioisotopes is another way that this challenge might be overcome.”
On electricity supply, they said: “The national power supply is not dependable, erratic and prone to surges. There are frequent interruptions in power supply, necessitating the need for uninterruptible power supplies and fuel generator back-up. As such, establishments rely on alternate sources of power. These activities once again increase the cost of service delivery. Power cuts also have an adverse effect on equipment, leading to a shortened lifespan of these machines. Their maintenance and replacement subsequently become more frequent than obtains in environments with constant, reliable and adequate power supplies. Power cuts also interrupt air-conditioning, which is essential in order to maintain the optimal temperature of equipment and components of the gamma camera such as the sodium iodide crystal; this affects the performance of these equipments. In a ripple effect, camera down-time also delays and suspends availability of services to patients and the necessary changes in patient management that these procedures might have provoked. Such delays, especially in cancer patients, have grave consequences. Improvement in public power supply in countries such as ours would go a long way in overcoming these challenges.”
The researchers also identified aged equipment as a major challenge contributing to patients woes.
“A recent survey published in 2011 by the International Atomic Energy Agency (IAEA) indicated that most gamma cameras in developing countries were over 6-year-old, with some even over 30-year-old. In the authors’ own country, the two available gamma cameras have been in use since 2006, with these centres performing between 600 and 700 studies per annum. Aged equipment functions sub-optimally and spare part production for these machines have often been discontinued. Coupled with the issues addressed in the section under electricity, this factor is another cause of poor service in nuclear medicine units in some developing countries. Regular replacement of equipment and their parts in these developing countries through government support or a revolving fund system is recommended,” the researchers said.
They also emphasized the need for local customer service for the equipment. Adedapo, Onimode, Ejeh, and Adepoju said the manufacturers of gamma cameras and other nuclear medicine equipment do not provide adequate local services.
This, they said, creates difficulty in maintenance of equipment and results in substantial dependence on external technical support which takes more time and money. They suggested that locally trained personnel must be available for preventive and first-line maintenance. That way, they argued that equipment downtime would be curtailed and patients’ suffering addressed. “We have experienced situations whereby the service engineer for the gamma camera in use had to be contacted to come in from overseas several times to repair the gamma camera when it breaks down. The fees for such consultations by the engineer are usually huge. The cost is borne by the host department and ultimately increases the cost of service delivery to patients,” they said.
What is nuclear medicine?
Adedapo, Onimode, Ejeh, and Adepoju said the benefits of nuclear medicine outweighs its perceived negative sides.
In their words: “Nuclear medicine is the branch of medicine that uses the tracer principle, most often with radiopharmaceuticals, to evaluate molecular, metabolic, physiologic and pathologic conditions of the body for the purposes of diagnosis, therapy and research. It involves the use of suitable pharmaceuticals labeled with radioisotopes to form radiopharmaceuticals. This enables imaging of the body using a special device known as a gamma camera. Depending on the type of examination required, the radiotracer may be administered by injection, ingestion or inhalation. The resulting gamma emissions from the patient are captured by the gamma camera detector and the image is displayed on the acquisition computer. This process enables the study of physiological processes and diagnosis of abnormal conditions. Radioisotopes are used because of the penetrating and ionizing characteristics of the radiations emitted from their decaying atoms. In comparison to conventional radiology, diagnostic nuclear medicine is essentially a functional imaging process reflecting physiological processes, whereas conventional radiology aims predominantly at obtaining anatomical images reflecting form and structure.
“Apprehensions about radiation exposure are common among the general public, but nuclear medicine procedures are relatively safe. Effective doses from 99mTc based procedures are said to be within range of the values for plain film X-ray procedures. They are generally less than the range for computed tomography and do not exceed twice the average dose to the general population from natural background radiation. Moreover, these procedures are relatively painless and free of side effects. Benefits derived definitely outweigh the risks.
“Penetrating radiation can produce physiological images of internal structures for the purpose of diagnosis. For therapeutic purposes on the other hand, radiation delivered to diseased cells disrupts normal cells moderately as the radiation delivered is mostly from â-particles which have quite a short range in tissue.
“The practice of nuclear medicine has clinical applications in virtually all systems of the body, for example, the skeletal, cardiac, endocrine, oncologic, gastrointestinal and renal systems. The commoner nuclear medicine procedures in developing countries are the bone scan, thyroid scan and the renal scan respectively. Some nuclear medicine techniques are also performed in vitro. Examples of these are glomerular filtration rate estimation, the C-14 urea breath test, detection of occult blood loss and the Schilling’s test.”
They continued: “Another clinical application of nuclear medicine is in the field of oncology. Cancer is a major public health concern in our country. From observations at our nuclear medicine center, breast cancer is the most common malignancy observed in oncology referrals among Nigerian women. It is often associated with a poor prognosis for a variety of reasons especially late presentation. Prostate cancer remains the most common malignancy among oncology referrals for men in the country. These observations are in agreement with those of other authors. The authors’ country has an estimated cancer incidence rate of about 100,000 new cases yearly, but presently has only two functional public nuclear medicine facilities. These centres are inadequate to match the rising demand for nuclear medicine services especially in the management of cancer, cardiovascular and other non-communicable diseases in the country. To this end, factors which impede the smooth running of nuclear medicine services at these centres are discussed.”
What next?
All eyes are on the Presidency to get the CBN to exclude these centres from this policy, which is doing harm to cancer patients across the country.