Part 2: Recognizing the Unique Set of Challenges Impacting Cancer Care within the Broader Context of Radiological Security. Radioactive sources are used in essential applications in our everyday lives. Cancer treatment is one such application where targeted treatment is provided via a device called a teletherapy unit. Two categories of teletherapy devices exist, radioactive source-based and non-source-based units to provide radiation therapy. Used clinically since the 1950s, both technologies are effective in treating cancer but cobalt-60 based units are considered an older teletherapy technology provided to patients in many low-and-middle income countries (LMICs). This is due to cobalt-60 based radiation therapy technology being less expensive, less dependent upon local infrastructure and easier to operate and maintain than non-source-based technologies like linear accelerators (LINACs). However, “[cobalt-60 units] do not have the advanced features of modern [LINACs]” and have added costs of source security and end-of-life disposal, the latter being increasingly expensive. Non-source-based radiation technologies such as medical linear accelerators have seen a greater degree of advancement in capability, particularly in the new era of image-guided radiotherapy. Nevertheless, given the absence of supporting system requirements posed by current LINACs, cobalt-60 technology has been more easily adaptable in LMICs. While the operational needs of source-based units are simple and robust, they are subject to regulatory requirements due to the potential of the source “being mishandled, particularly with malicious intent, or improperly disposed of.” Further complicating this matter is the fact that LMICs do not have adequate, “or, in many cases, no radiation therapy [centers]” so the rationale remains that sourced-based serve a clinical need. The issue is, then, how can this paradigm be changed. LINACs are a superior technology for cancer treatment, but for the reasons mentioned above, they fall short in low-resource settings requiring additional support. Momentum continues to grow across disciplines in improving cancer care in LMICs but there are complexities in tackling this challenge, especially when coupled with broader issues such as the safety and security of radioactive sources. Two critical underpinnings of this discussion are the lack of radiation therapy results and expectation that LMICs will have access to high-quality equipment and technology used in resource-rich settings as detailed in the Global Task Force for Radiotherapy for Cancer Control (GTFRCC). As such, this article will provide recommendations to strengthen the nexus between security and health by addressing the need for innovative and affordable non-source-based technologies within the broader security context. LMICs require tailored solutions in implementing LINACs for radiation therapy and collaborators across the globe who support the broad-scale solution of the current shortage are gathering on-the-ground data regarding the associated challenges. There are, however, a limited number of groups that have proposed and designed solutions to meet both technical and capacity needs for LMICs. In December 2020, the World Institute for Nuclear Security (WINS), an international non-governmental organization held its first Virtual Roundtable with an objective to bring experts together from multiple disciplines to further the conversation on non-source-based technologies. The meeting covered a breadth of topics including a focus on “strengthening of the coordination of various national and international stakeholders involved in the adoption or development of alternative technologies.” This virtual meeting also initiated a global dialogue on current initiatives and provided an opportunity to identify areas where there may be “overlap, duplication of efforts, or conflicting priorities” with ongoing international efforts. Particularly, much progress has been made since the establishment of the Joint Statement on Strengthening the Security of High Activity Sealed Radioactive Sources, which transformed into an International Atomic Energy Agency (IAEA) Information Circular/910 (INFCIRC/910). INFCIRC/910 is endorsed by 32 IAEA Member States and INTERPOL, where subscribers have expressed a commitment to managing source-based technologies safely and securely by following the “recommendations of the Code of conduct of safety and security of radioactive sources as well as its related guidance.” Furthermore, INFCIRC/910 demonstrates progress in encouraging the consideration of non-source-based technologies for applications where source-based technologies have been used historically, such as those used for cancer therapy. As such, the related establishment of INFCIRC/910 has helped pave the path for initiatives and guidance documents that reaffirm a global commitment in strengthening the international framework on the security of radioactive sources. An element however, that has yet to be fully integrated in a commitment of this type is how to initiate coordinated international engagements on “the development of technically and economically realistic and acceptable non-[source-based] technologies.” While stakeholders involved in these conversations are aware that “alternative technologies can simultaneously support public health needs and risk elimination to build a healthier, more secure world,” the approaches to attaining positive security and health outcomes varies broadly on geographical location. A separate but related challenge with international nuclear and radiological security commitments is the ability to measure progress in an era where the potential of radiological “sabotage or terrorist acts” are ever-evolving. A real-world example of these growing risks is in Ukraine. Since 2014, Ukraine has become vulnerable to the “risks of terrorists using radioactive materials in an attack as well as the illicit trafficking of radioactive materials.” While there is a strong commitment to the physical protection of nuclear and radiological facilities in Ukraine, Russia’s recent invasion has forced facilities to become “caught up in the midst of conventional warfare for the first time in history.” Given this changing nuclear and radiological security landscape, it stands to impact an already complex public health situation in Ukraine. In 2020 alone, Ukraine’s cancer burden was high, with more than 160,000 new diagnosed cases and the “country also has one of the highest childhood cancer mortality rates globally.” As such, “disparities in cancer care in Ukraine were already high…and will now undoubtedly worsen as a result of the current conflict.” Furthermore, cancer networks were already fragmented in Ukraine but with the onset of “violence, shelling, and destroyed hospitals,” this ongoing security crisis is shedding a renewed spotlight on the nexus between security and health. In parallel with efforts to “[strengthen] international nuclear and radiological security cooperation,” the international community requires closer coordination on understanding clinical preferences and issues with access to non-source-based technologies such as LINACs. In LMICs in particular, there is not only a need to raise awareness of available alternative technologies for cancer therapy but an equally important need to develop a coordinated approach internationally to develop and improve radiation therapy capabilities across LMICs. A recent publication from the National Academies of Sciences, a collective scientific national academy in the United States, compiled findings from an assessment of “the status of medical, research, sterilization, and other commercial applications of radioactive sources and alternative (nonradioisotopic) technologies in the United States and internationally.” The report expands on the current status of cobalt-60 and linear accelerator implementation across high, medium and low-income countries and notes the challenges associated with international coordination in adopting safe and secure alternatives. Many national and international government and nongovernmental organizations have contributed to the increasing visibility of alternative technologies as a way to reduce security risks from radioactive sources. However, no organization is currently equipped to promote the broad range of alternative technologies and address adoption issues in a global context. Such an organization or network of organizations could unite technical, regulatory, financial, policy, and country-specific resource information to influence decisions about adopting alternative technologies and facilitate the transition to alternative technologies for medical, research, and commercial applications, where appropriate. Healthcare issues are already subject to scrutiny but adding an overarching security context creates another layer of complexity, requiring the need for broadening leadership across disciplines. There are many great examples to follow, including alternative technology advocacy efforts in phasing out the use of cesium-137, a radioactive isotope used in another medical application to sterilize blood. However, in the context of cobalt-60 based devices used for radiation therapy, there is a need for increased collaboration and network building. There is also a strong need to recognize that non-source-based cancer therapy technology investments cannot be sustained long-term in LMICs without establishing education and training opportunities for end-users. Health experts also contend that experiences “from the past and current radiation-therapy initiatives suggests that successful radiotherapy [programs] require secure local resources, adequate planning, local commitment and political stability.” As such, newly defined approaches are needed in improving cancer care in parallel with radiological security. The lack of significant progress in solving the shortage to almost a total absence of LINACs in LMICs speaks to the need for substantial innovation in technology and implementation strategies. There is a need for global collaboration which must be inclusive of the LMIC users who experience challenges and they must also be a part of the solution. Given the growing global burden of cancer, approaching cancer care logically and early on, is a critical need for the healthcare system. There is also a strong need in defining and understanding the technical challenges at the grass-roots level and how they can be addressed and overcome to narrow the current shortfall, which is more of a chasm than a gap. Not only are the health benefits substantial but it is worth emphasizing the broad societal benefit from sufficient radiotherapy and cancer care described by Atun in the GTFRCC. In that people, not machines treat cancer, sustainable capacity-building is essential. Sustainable success relies on a robust mentoring network to help build and sustain capacity that is anchored on effective, enabling technology suitable for the local environment. While the problems of affordable technology, sufficient expertise to properly use it and the security of potentially highly dangerous radioactive sources are by themselves daunting problems, their nexus may be a way of bringing together novel solutions for global cancer care. The general conclusions include: Few would argue against the premises of safe and secure technology. The reasons for the current situation in the use of source-based radiotherapy is due to infrastructure shortages in utilizing the high complexity of current LINACs, which is understandable. So, developing a LINAC that can function effectively and reliably in challenging environments solves the source-based security issues and the need for cancer care in LMICs equivalent to that available in better resourced countries. This is a healthcare issue where cancer care is often considered too expensive, as such, there is a need for a global non-source-based technology approach that recognizes the need for more investment than just the machine as people treat cancer not machines. Sustainability is key. The need to sustain the in-country expertise and allow career growth and development can help mitigate the “brain drain.” Thus, the solutions require education and training. Machines are around for quite a while and maintenance and upkeep may be far more costly than the sales price. Similarly, the disposal cost of cobalt-60 and the potential that it might become an “orphan source” must be factored into the “price.” Reducing the differential between a source-based and non-source based machine. Security and health have often been considered separate disciplines, but the rise in global terrorism has created an unintended intersection between both areas. Progress is being made by the international community in raising awareness of non-source-based technology options such as LINACs but there is more to be done in making non-source-based technologies available to “cancer patients in LMICs and other geographically underserved regions.” Important international commitments are being made in encouraging end-users to consider transitioning to safe and secure non-source-based technologies given the potential risks associated with cobalt-60 device usage. As such, security and health needs are better served by being coupled together. These challenges should be tackled at a grass-roots level as low-resource settings are complex environments that are not equipped to operate LINACs unless the design and development of the radiation therapy device is refined to meet the needs of a LMIC. This global issue persists, with much more standing to be achieved in building a stronger nexus and further progress awaits. Sandia National Laboratories is a multimission laboratory managed and operated by National Technology & Engineering Solutions of Sandia, LLC, a wholly owned subsidiary of Honeywell International Inc., for the U.S. Department of Energy’s National Nuclear Security Administration under contract DE-NA0003525.