IN THE last 30 y, the magnitude of radiation exposure to the U.S. population has grown substantially, primarily due to markedly increased use of ionizing radiation in diagnostic and interventional medical procedures (NCRP 2009). Over that time period, the annual average effective dose from medical exposures in the United States has increased from 0.5-3.1 mSv and now represents ∼48% of the total annual effective dose per individual in the population (NCRP 2009). There is no question that the justified and optimized use of radiation has had a beneficial impact, most notably in medicine, energy production, basic science research, and industrial applications. However, with the benefits of using radiation also comes a responsibility to continually advance the knowledge of radiobiology, radiation physics, and radiation protection—a responsibility that our nation is no longer adequately fulfilling. Expertise in these fields is essential not only to protect workers, members of the public, and the environment from potential harm but also to further the development of radiation-based technologies in medicine and industry. Unfortunately, demographic trends indicate that the supply of radiation professionals in the United States—which is already insufficient—is shrinking, while the need for such professionals is growing. This paper will briefly outline these trends and discuss their implications for the medical, energy, security, and research arenas, drawing on a growing body of literature highlighting the urgent need for action. It will also summarize previous recommendations and propose a path to more aggressively address these trends so that the United States can safely reap the benefits of existing and future radiation-based technologies in the years ahead.
TRENDS AFFECTING MEDICINE
Demographic shifts in the U.S. population are expected to contribute to substantial increases in the incidence of cancers and other diseases over the coming decades. It has been estimated that by 2030, the incidence of cancer in the United States will have increased by ∼45% over its 2010 level due to the aging of the “baby boomer” generation as well as the growth of minority populations, some of which have high cancer incidence rates (Smith et al. 2009). It has also been projected that the percentage of the U.S. population with some form of cardiovascular disease—which was 36.9% in 2010—will rise to 40.5% by 2030, with a tripling of total direct medical costs (Heidenreich et al. 2011). Thus, although the cancer-related and cardiovascular disease death rates have been decreasing as a result of improved diagnostics (including imaging) and better therapeutic approaches (Jemal et al. 2013; Edwards et al. 2014), a considerable increase in the use of radiation in medicine (e.g., increasing use of diagnostic imaging and treatments that use radiation or radioactive material) will be needed to continue fighting these diseases in the future. Accordingly, the need for radiation protection for patients, staff, and members of the public will also increase (ICRP 2007; NCRP 2009; Dauer 2014; Thornton et al. 2015). A growing body of professionals trained to work with radiation will be essential not only to expand access to existing diagnostic and treatment approaches that use radiation but also to develop new ones. For example, the development of agents that employ radionuclides to image cancer at the molecular level, treat cancer, or do both simultaneously is expanding and offers great potential for improving the precision of cancer care (CSSNM 2007). However, alongside the use of such agents comes increased radiation exposure.
Academia, government, industry, and professional societies must work together on strategic, comprehensive efforts to advance medical radiation protection. These efforts should focus primarily on four areas: understanding radiation risk, justification of use, dose optimization, and communication of benefit and risk (Dauer and Hricak 2014). The International Atomic Energy Agency’s and World Health Organization’s recent “Bonn Call for Action,” which arose from an international conference held in 2012, lays out an extensive list of actions needed to strengthen radiation protection in medicine over the next decade (IAEA 2015).
TRENDS AFFECTING ENERGY PRODUCTION
It is projected that from now through 2040, U.S. energy consumption will continue to grow, while rising costs for electric power generation, transmission, and distribution will increase the average price of electricity by 18% (USDOE 2015). The United States will transition to being a net exporter of natural gas by 2017, with export growth continuing through 2040, requiring ongoing development of safe technologies, including fracking, manufacturing, and refining. Each of these industrial applications requires the use and management of radiation, industrial radiographic applications, and technically enhanced naturally occurring radioactive materials (USEPA 2015; Nelson et al. 2015; Tribbett 2015). Given these changes, the increasing concerns about climate effects, and the resulting shift toward greater use of renewable resources, it will certainly be necessary to maintain or increase the availability of nuclear energy in the United States as well as develop new technologies by 2040 (Fountain 2016). These endeavors will require excellence in professional and scientific leadership in radiation sciences.
TRENDS AFFECTING NATIONAL SECURITY
There is, unfortunately, a real and mounting specter of terrorism. As noted by Rose Gottemoeller, the U.S. Under Secretary for Arms Control and International Security, “The successful detonation by a terrorist group of even a crude and improvised nuclear device in a major city could result in the deaths of thousands and have significant, if not unfathomable, economic and political global consequences” (Gottemoeller 2015). In fact, President Obama made preventing nuclear terrorism one of the top U.S. foreign policy priorities, labeling it “the single most important threat” to U.S. national security (Gottemoeller 2015). Responding to a major United States radiation accident or terrorist attack will require a huge surge in support from the existing body of radiation professionals (Dynlacht et al. 2015; NCRP 2015a). However, the National Council on Radiation Protection and Measurements (NCRP) Statement No. 12, Where are the Radiation Professionals (WARP)? notes, “As the number of radiation professionals decreases, the nation’s resilience and ability to cope and manage a catastrophic nuclear or radiological event is severely degraded” (NCRP 2015a).
THE NEED TO INVESTIGATE LOW-DOSE RADIATION EFFECTS
Significant information on the biochemical and biophysical effects of low doses of radiation has been obtained over the past two decades. Nevertheless, considerable uncertainty remains regarding the incidence and biological relevance of low-dose and low dose-rate radiation, including the shape of the dose–response relationship and the levels of risk at low doses (NCRP 2015b). This uncertainty can impact actions taken with regard to radiation protection, the level of radiation use in medical practice, environmental contamination issues, compensation programs, and communication to the public. Thus, innovative approaches to reduce these uncertainties must be found and implemented.
Some have suggested that the fundamental models underlying radiation protection philosophy (USNRC 2015) still need to be evaluated, and it is only just becoming possible to carry out studies for this purpose (Boice 2014; Bouville et al. 2015). It is important that we identify new means to integrate results of basic science studies in radiation biology with findings from epidemiologic studies on human health effects of low doses of radiation (NCRP 2015b). Major advances in the understanding of the etiology of diseases, host susceptibility, and the cellular processes affected by radiation, as well as the rapid development of new technologies, have created a new opportunity to integrate information from multiple disciplines to improve risk assessment. Such integration will require significant experience and knowledge from across the broad spectrum of radiation professionals in biology, physics, epidemiology, radiation effects, medicine, and protection.
To advance the science of beneficial uses of radiation and the field of radiation protection, it is important that the United States maintain and develop the specialized facilities required for studies conducted at low doses and low dose rates. In addition, the United States needs to promote and expand interdisciplinary training and integrated cross-professional research programs devoted to understanding and quantifying radiation health effects at low doses (NCRP 2015b).
SHORTFALLS IN EXPERTISE AND INFRASTRUCTURE
To meet the growing demands for radiation expertise enumerated above, the United States must find a way to reverse the current and ever-increasing deficit of radiation professionals. This deficit extends across many interrelated disciplines and has been extensively documented.
The age distributions for workers in radiation protection, medical physics, radiobiology, radiation-epidemiology, and nuclear power are heavily and increasingly skewed toward the higher end of the spectrum.†‡ For example, the U.S. Government Accountability Office (USGAO 2014) estimated that 41% of engineering and technical professionals would be eligible to retire by September 2017. Similarly, a survey of the Conference of Radiation Control Program Directors predicted that over 50% of the technical staff in state radiation control programs would need to be replaced in the next 10 y (NCRP 2015a). The U.S. National Academies/National Research Council has noted a specific concern about the future supply of radiochemists (NA/NRC 2012).
Replacement of retiring radiation professionals has already become difficult, and yet the current demographics and expected retirements are such that the demand for replacement radiation professionals will increase substantially from 2015-2025 (NCRP 2015a). The Health Physics Society called the human capital shortage in radiation safety “critical” and stated that the shortage was “overwhelming” the Society’s efforts to address it (HPS 2008, 2013; NA/IOM 2014). Similarly, an analysis of labor market trends published by the Oak Ridge Institute for Science and Education (ORISE) in 2009 projected that the number of job openings for new graduate health physicists would likely continue to surpass the supply of new graduates available (ORISE 2009; NA/IOM 2014). In fact, in 2014, the number of graduate-level enrollees in health physics programs was the lowest reported since the early 1970s, and further declines in the numbers of master’s and doctoral degree recipients are expected (NA/IOM 2014; ORISE 2015). There are only 22 U.S. academic programs with students and staff involved with health physics education, including 12 small programs that graduate fewer than six students per year (ORISE 2015). Only 12 of 22 U.S. programs have sufficient faculty and staff to train future students of all degree levels (NCRP 2015a).
A survey of faculty members working in radiation biology in U.S. and Canadian residency programs found similar causes for concern about shrinking numbers of radiobiologists. The survey showed that faculty members with degrees in radiation biology were scarce; that those who taught radiation biology to radiation-oncology and radiology residents were aging; and that the quality of the didactic radiation biology education radiation oncology residents received was threatened (Rosenstein et al. 2009; NA/IOM 2014; Dynlacht et al. 2015). As noted by NCRP (2015a), the loss of research funding has decimated the ranks of university radiation biologists and related academics needed to teach the next generation of radiation professionals.
A study by Wogman et al. (2005) found that aging was producing substantial attrition of the workforce of nuclear scientists and engineers in the United States. Based on retirement eligibility figures, they projected that the Pacific Northwest National Laboratory (PNNL) of the U.S. Department of Energy (DOE) would experience a significant loss of senior nuclear science and technology staff by 2015, and they concluded that efforts to ensure an adequate supply of personnel to support nuclear science and technology programs at PNNL were urgently needed (Wogman et al., 2005; NA/IOM 2014).
The U.S. Institute of Medicine (IOM) (now the National Academy of Medicine) recently performed a detailed review of the radiation health and radiobiology workforce and determined that the supply of professionals would not meet the demand in the coming years (NA/IOM 2014). In addition, the recent American Association of Physicists in Medicine/Society of Nuclear Medicine and Molecular Imaging joint task force report (Harkness et al. 2015) on the current state of nuclear medicine physics training emphasized that nuclear medicine needs well-trained medical physicists to meet the complex requirements of quality patient care and to advance the field; the authors expressed a specific concern that if there are not enough qualified nuclear medicine physicists, nuclear medicine as a whole will suffer.
In 2003, the Radiation Research Program and American Society of Therapeutic Radiology and Oncology held a workshop addressing “the need to establish a sustainable pool of expertise and talent for a wide range of activities and careers related to radiation biology, oncology and epidemiology” (Coleman et al. 2003). They provided a number of specific recommendations for accelerating this process, including developing a strategy for increasing the number of radiation scientists that could include the National Institutes of Health training grants, interagency cooperation, interinstitutional collaboration among universities, and active involvement of all stakeholders (Coleman et al. 2003).
Thus, for more than a decade, researchers and professional societies have been sounding alarms about the increasing inadequacy of the radiation health and biology workforce. However, there has as yet been no concerted, comprehensive effort to respond, and the infrastructure and resources needed for research and education in radiation sciences continue to decay and decline.
The radiation brain drain is real and requires immediate attention, as the workforce in radiation sciences is insufficient to fill its various roles in academia, medicine, and the energy and defense sectors. This problem is made more acute at a time when emerging science, medical applications, and emergency response readiness increasingly require advanced radiation knowledge.
The importance of public support for radiation research is highlighted in the North American Energy Security and Infrastructure Act of 2016, which calls on the DOE to carry out a research program on low dose radiation and requires a study assessing the current status and the development of a long-term strategy for such research (U.S. Senate 2016). In addition, the NCRP “Where Are the Radiation Professionals (WARP)?” initiative lays out a practical approach to addressing radiation science and workforce needs (NCRP 2015a). However, solving the problem will require a much stronger, unified approach. As indicated by repeated messages from IOM, National Academies/National Research Council, NCRP, and professional societies, the crisis is no longer looming - it is here, and the need for action is greater than ever. We need to “wake up” and form a multiagency committee to design a comprehensive action plan, supported by significantly increased federal and state funding as well as formal partnerships and initiatives among academia, professional societies, government, and the private sector.
Are we at a point where “rationality will not save us” (McNamara 2003)? We do not need more reports or analyses; we need to take concrete action now—as our future, and our children’s futures, are at stake. While solving the radiation brain drain will require perseverance and creativity, it will not only allow us to maintain national security and the many current beneficial uses of radiation—it may also lead to remarkable advances we are, as yet, unable to imagine.
Boice JD Jr. The importance of radiation worker studies (editorial). J Radiol Prot 34:E7–E12; 2014.
Bouville A, Toohey R, Boice J, Beck H, Dauer LT, Eckerman K, Hagemeyer D, Leggett R, Miller D, Napier B, Pryor K, Rosenstein M, Schauer D, Sherbini S, Stram D, Thomspon J, Till J, Yoder C, Zeitlin C. Dose reconstruction for the million worker study: Status and guidelines. Health Phys 108:206–220; 2015.
Coleman CN, Stone HB, Alexander GA, Barcellos-Hoff MH, Bedford JS, Bristow RG, Dynlacht JR, Fuks Z, Gorelic LS, Hill RP, Joiner MC, Liu FF, McBride WH, McKenna WG, Powell SN, Robbins MEC, Rockwell S, Schiff PB, Shaw EG, Siemann DW, Travis EL, Wallner PE, Wong RSL, Zeman EM. Education and training for radiation scientists: Radiation Research Program and American Society of Therapeutic Radiology and Oncology workshop, Bethesda, MD, May 12–14, 2003. Radiat Res 160:729–737; 2003.
Committee on State of the Science of Nuclear Medicine. Advancing nuclear medicine through innovation. Washington, DC: National Academies Press; 2007.
Dauer LT. Exposed medical staff: challenges, available tools, and opportunities for improvement. Health Phys 106:217–224; 2014.
Dauer LT, Hricak H. Addressing the challenge of managing radiation use in medical imaging: paradigm shifts and strategic priorities. Oncol 28:243–246; 2014.
Dynlacht JR, Zeman EM, Held KD, Deye J, Vikram B, Joiner MC. Education and training needs in the radiation sciences: problems and potential solutions. Radiat Res 184:449–455; 2015.
Edwards BK, Noone AM, Mariotto AB, Simard EP, Boscoe FP, Henley SJ, Jemal A, Cho H, Anderson RN, Kohler BA, Eheman CR, Ward EM. Annual report to the nation on the status of cancer, 1975–2010, featuring prevalence of comorbidity and impact on survival among persons with lung, colorectal, breast, or prostate cancer. Cancer 120:1290–1314; 2014.
Fountain H. Amid a graying fleet of nuclear plants, a hunt for solutions. NY Times 21 March 2016. Available at http://www.nytimes.com
/2016/03/22/science/nuclear-energy-power-plants-advanced-reactors.html. Accessed 30 March 2016.
Gottemoeller R. The threat of nuclear terrorism. Under Secretary for Arms Control and International Security. The Citadel’s Intelligence and Security Conference “Achieving a Higher Degree of National Security;” Charleston, SC, 18 September 2015. Available at www.state.gov/t/us/2015/247083.htm
. Accessed 17 March 2016.
Harkness BA, Allison JD, Clements JB, Coffey CW, Fahey FH, Gress DA, Kinahan PE, Nickoloff EL, Mawlawi OR, MacDougall RD, Pizzuitello RJ. AAPM/SNMMI join task force: report on the current state of nuclear medicine physics training. J Appl Clin Med Phys 16:3–13; 2015.
Heidenreich PA, Trogdon JG, Khavjou OA, Butler J, Dracup K, Ezekowitz MD, Finkelstein EA, Hong Y, Johnston SC, Khera A, Lloyd-Jones DM, Nelson SA, Nichol G, Orenstein D, Wilson PW, Woo YJ. Forecasting the future of cardiovascular disease in the United States: a policy statement from the American Heart Association. Circulation 123:933–944; 2011.
International Commission on Radiological Protection Radiological protection in medicine. Oxford: ICRP; Publication 105; Ann. ICRP 37(6); 2007.
Jemal A, Simard EP, Dorell C, Noone AM, Markowitz LE, Kohler B, Eheman C, Saraiya M, Bandi P, Saslow D, Cronin KA, Watson M, Schiffman M, Henley SJ, Schymura MJ, Anderson RN, Yankey D, Edwards BK. Annual report to the nation on the status of cancer, 1975-2009, featuring the burden and trends in human papillomavirus (HPV)-associated cancers and HPV vaccination coverage levels. J Natl Cancer Inst 105:175–201; 2013.
McNamara RS. As spoken in: the fog of war. Documentary film directed by Errol Morris. Sony Pictures Classics; 2003.
National Academies/Institute of Medicine Research on health effects of low-level ionizing radiation exposure: opportunities for the Armed Forces Radiobiology Research Institute. Washington, DC: National Academies Press; 2014.
National Council on Radiation Protection and Measurements Ionizing radiation exposure of the population of the United States. Bethesda, MD: NCRP; Report No. 160; 2009.
National Council on Radiation Protection and Measurements Where are the radiation professionals (WARP)? Bethesda, MD: NCRP; Statement No. 12; 2015a.
National Council on Radiation Protection and Measurements Health effects of low doses of radiation: perspectives on integrating radiation biology and epidemiology. Bethesda, MD: NCRP; Commentary No. 24; 2015b.
Nelson AW, Eitrheim ES, Knight AW, May D, Mehrhoff MA, Shannon R, Litman R, Burnett WC, Forbes TZ, Schultz MK. Understanding the radioactive ingrowth and decay of naturally occurring radioactive materials in the environment: an analysis of produced fluids from the Marcellus shale. Environ Health Perspect 123:689–696; 2015.
Rosenstein BS, Held KD, Rockwell S, Williams JP, Zeman EM. American Society for Radiation Oncology (ASTRO) survey of radiation biology educators in U.S. and Canadian radiation oncology residency programs. Int J Radiat Oncol Biol Phys 75:896–905; 2009.
Smith BD, Smith GL, Hurria A, Hortobagyi GN, Buchholz TA. Future of cancer incidence in the United States: burdens upon an aging, changing nation. J Clin Oncol 27:2758–2765; 2009.
Thornton RH, Dauer LT, Shuk E, Bylund CL, Banerjee SC, Maloney E, Fox Lindsey B, Beattie CM, Hricak H, Hay J. Patient perspectives and preferences for communication regarding medical imaging risks in a cancer-care setting. Radiol 275:545–552; 2015.
Tribbett Z. 2016 HPS midyear meeting. Health Phys News XLIII 1–3; 2015.
U.S. Government Accountability Office Federal workforce: recent trends in federal civilian employment and compensation. Washington, DC: GAO; GAO‐14‐215; 2014. Available at www.gao.gov/assets/670/660449.pdf
. Accessed 16 December 2015.
Wogman NA, Bond LJ, Waltar AE, Leber RE. The nuclear education and staffing challenge: rebuilding critical skills. J Radioanal Nucl Chem 263:137–143; 2005.
†Personal communication, responses to questions posed by the IOM Committee on Research Directions in Human Biological Effects of Low Level Ionizing Radiation to the Center for American Association of Physicists in Medicine by Lynne A. Fairobent, Manager of Legislative and Regulatory Affairs of AAPM, 21 November 2013.
‡Personal communication, responses to questions posed by the IOM Committee on Research Directions in Human Biological Effects of Low-Level Ionizing Radiation to the Health Physics Society by Barbara Hamrick, JD, CHP. Irvine, CA, 15 November 2013.