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Ahhood Mohsen and Saad Selim

Despite ongoing medical attention, radiologist Omar Al-Radayda unfortunately passed away a month and a half after we met him during his treatment for bone cancer, and did not live long enough to read this investigation.

Al-Radayda worked in Jordanian Health Ministry hospitals for 19 years, during which he bore witness to the violations of the technical conditions of medical devices, technical protocols, and their workers and health safety procedures, putting them at risk.

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685
Diagnostic Radiology and Nuclear Medicine and Licensed Radiology Departments
Have worked for
15+
years
191
radiology technicians
32
Diagnostic Radiology and Nuclear Medicine and Licensed Radiology Departments

Dr. Khaled Rababaa, head of the radiology department at the Hashemite University, states that in the event of continuous exposure to radiation, a genetic mutation may occur on the DNA strip, causing cancer.

Abnormal exposure to radiation results in mutated cells on the body, such as uncontrolled bone cancer cells, which can be fatal.

Radiation Protection Officer

The qualified technician in facilities with radioactive resources that is designated to oversee the application of radiological/hazardous resources protection systems, and to assist in providing advice on health and safety precautions.

The Jordanian Ministry of Health, in a written response, confirmed the implementation of approximately 300 periodic examinations of these facilities on an annual basis. Additionally, the ministry implemented three radiation protection training courses, which benefitted 60 technicians with over 15 years of service.

During 2019, the examinations confirmed five cases of employees at the radiology departments of the Ministry of Health hospitals were diagnosed with various diseases. This included thyroid cancer, bone cancer and bronchial diseases. During the interviews, the employees pointed to the weak preventative controls of the Ministry of Health over the safety of their departments and the use of medical devices.

Dr. Ahmed Suwaidat, head of the radiology department at Jerash Government Hospital, believes that the Ministry of Health’s oversight is insufficient. He adds that "the goal is to not find any medical devices that do not comply with best practice causing hazards or leaks."

Dr. Suwaidat doubts the ministry’s assurances that there are no hazardous leaks and that all facilities and machinery comply with best practice and health standards.

The Jordan Standards and Metrology Institution confirmed, by investigating the compliance of radiology equipment with health standards in Jordanian hospitals, that quality and health controls were not in line with health standards.

A Story of Chance

In a chance encounter, Saleh Samreen, a radiology technician at the Department of Chest Diseases and Tuberculosis at Al-Bashir Hospital, discovered that he had developed thyroid cancer. He had met a doctor working on a thyroid study that gave him a medical examination and asked him to perform additional checks and scans.

Samreen confirms that "the department was suffering from a surplus of referrals (approximately 300 to 400 per day)” which exposes them to more radiation. This is in contravention of the standard radiation dose limit system recommended by the International Radiological Protection Association.

According to the hospital’s Director Dr. Mahmoud Zureikat, 86 radiologists work at the Al-Bashir Government Hospital, which receives 1,200 to 1,600 referrals a day. Further, they are stationed at other hospitals when numbers are low and they are needed.

Cancer: Ineligible for Compensation

Samreen was devastated to find out that cancer is not included in the list of diseases eligible for retirement and compensation; such as heart diseases and back injuries. Despite being subjected to three catheter operations, eight spinal fractures, curvature in his back leading to a change in height (158cm from 171cm), and extreme weight loss (24kg), Samreen was not entitled to an increase in his pension because cancer is not considered a “liability”.

Samreen's application for retirement, after 26 years of employment at the Ministry of Health, was initially denied. Consequently, Samreen was forced to submit medical reports with the help of the head of the Radiology Department to help him retire in order to avoid exposure to more health risks given his condition.

Dr. Khaled Rababaa indicates that the ideal work cycle for radiology technicians ranges between 10-15 years and should not exceed that in order to avoid cumulative exposure to radiation. Further, Dr. Rababaa considers this to be a dangerous profession when taking into account the age of the radiology technicians.

Ibrahim Shehadeh had worked in the radiology department of Al-Bashir for 25 years before his passing after being diagnosed with thyroid cancer in 2011.

Shehadeh’s work was marred by many difficulties and problems as reported by his son Ahmed. His father suffered from long working hours, weak supervision of medical equipment, and radiation leaks due to poor maintenance of devices and facilities.

He said that his father contacted the Ministry of Health as well as the head of department about the issue more than once. However, none of the relevant parties listened to his complaints and concerns.

In terms of radiation exposure, Shehadeh's son confirms that his father's radiological scans (which were examined by the investigative committee) exceeded 50 millisievert. This is the highest permissible amount and limit of radiation according to the International Committee for Radiation Protection (ICRP).

Ibrahim's story did not end there however, as Ibrahim's mother stated that the Ministry of Health did not consider his illness a work injury and therefore did not provide any financial compensation. She stressed that the pension received does not cover her, or her five children’s, financial needs.

Medical Protocol

Based on the previous cases, a question may be raised surrounding the extent to which the hospitals associated with the Ministry of Health adhere to the appropriate treatment and health protocols, specifically for radiological safety requirements. Further, one may question the adequacy at which the Ministry provides its employees with the necessary general safety requirements.

Interviewees from the radiologist department indicated that there are various issues surrounding the safety requirements, the most important of which is the absence of periodic examinations of the facility and the measurement of radioactive contamination.

Omar Al-Radayda says, "throughout my whole employment, I would hear that tests and examinations on the equipment have been conducted, but the whole time I had not seen anyone conduct a single test (unless we report a faulty device or a problem with the equipment)".

According to Article 13 of the insurance regulations for social security, institutions have an obligation to provide occupational health and safety standards and tools at workplaces. Further, they are required to identify, mitigate and prevent occupational hazards by implementing adequate control measures.

Occupational Safety and Health Standards

Documented policies
Implementing prevention methods
Risk assessments for work facilities
Employee efficiency
Training employees
Emergency preparedness, prevention and response
Periodic medical checks for employees
Continuously monitoring, developing and evaluating safety and health performance
Managing and documenting the number of work-related injuries; the number of deaths resulting from them; their frequency in the facility; and how this compares to normal levels.

According to the Ministry of Health, there are no official records documenting the number of radiologists whose work has caused diseases or health issues. The Ministry of Health confirmed through official correspondence the presence of radiation protection measures in hospitals and health centres.

Additionally, they have denied the presence of x-ray devices that do not conform to the required specifications and standards, and denied that their technicians are at risk of excess exposure (above the Ministry’s standards) to harmful materials. Further, they ensured the commitment of all technicians to following the appropriate radiation health and safety protection methods.

Dr. Rababaa comments on the dispute between Shehadeh’s (the radiology technician) son and the Ministry of Health. He suggests that the Ministry is playing a role in keeping technicians safe, however this falls short of what is required. He adds that the current number of employees is “insufficient” and “more should be hired to protect the existing workers against excess exposure by reducing their working hours.”

On the other hand, Dr. Suwaidat does not see any correlation between developing cancer and prolonged exposure to radiation. Dr. Suwaidat ensures the availability of protection measures and suggests that it is largely up to the employees to adhere to these measures to reduce their exposure to radiation.

Employee Protection

Radiology technician Jalal Al-Shraideh previously worked at the Radiology Department of Al-Bashir Hospital. He confirms that the 21 years that he worked consisted of 5-6 working days per week. This resulted in an issue with his thyroid gland, which had to be later removed. He says that the operating age of the devices and equipment used puts him and his colleagues at risk of radiation leaks.

Radiology Consultant and Executive Director of the King Hussein Cancer Centre Dr. Assem Mansour, confirms that the operating life of these devices from a commercial point of view is 10 years. As for the medical aspect and the continuity of work, it can definitely reach 15 years with routine maintenance and adequate care.

From Dr. Rababah’s perspective, radiography, despite its importance for detecting and diagnosing diseases, only causes damage to cells.

Radiation dose limits according to the International Committee for Radiological Protection

Doses of
20 mSv* in a year

distributed on average over five consecutive years (100 mSv in 5 years). In all cases, the doses must not exceed 50 mSv in a single year.

Equivalent doses recorded in the eyes
of 20 mSv annually

distributed on average for 5 consecutive years (100 mSv in 5 years). In all cases the equivalent doses must not exceed 50 mSv in any single year.

An equivalent dose in the limbs or in the skin of
(500) mSv per year.
*millisievert

If these limits are surpassed, the radiology technician will be exposed to a higher degree than permitted, and a variety of symptoms will appear that will vary in severity according to the amount of exposure.

At higher levels of exposure, technicians may develop multiple health problems including sterility, blindness, cataracts, and various forms of cancer. Additionally, women may experience premature aging and miscarriages as a result of direct exposure to radiation for long periods.

Marginal Controls

Another issue identified by radiologist Basil Al-Wazani since the beginning of his employment in the radiology department, is the non-authoritative and dismissive role of control officers. He indicates that their role is limited to the regulatory side and the issuance of reports without any executive powers, resulting in protocol-like reports.

Al-Wazzani added that he developed asthma and chronic chest infections during his work in radiology: “From 1990 to 2005 we processed and developed the photographic films manually because of an absence of specialised employees and routine maintenance and inspections of the equipment. Additionally, the materials and their viability were not inspected and harmful exposure was left undetected. We were thus exposed to harmful fumes for extended periods due to the working hours. Especially after the removal of the 14-day break period that was previously granted to workers.”

Dr. Rababaa finds that reducing the radiation dose requires reducing the dose exposure time, increasing the distance between the radiation source and the radiologist, and narrowing the radiation beam. Also, thermoluminescent dosimeters are required for radiologists to measure the amount of exposure they receive on a monthly or annual basis.

Radiological Licenses

The technicians interviewed for this investigation all agreed that Health Ministry hospitals have not committed to renewing or obtaining the appropriate licenses for hospitals (and personnel) within the radiology departments as issued by the Radiological and Nuclear Regulatory Authority. Further, they failed to abide by the radiological protection requirements for devices, equipment, workers, and patients as well as refusing to appoint a Radiation Protection Officer, as recommended by the Authority. This was denied by the Ministry of Health without an alternative statement to explain the current situation.

Licensing requirements for doctors in the nuclear medicine or radiology departments:

- Completed a residence period of not less than a year as documented by a certificate from the appropriate body.
- Holds a radiological license from the authority responsible for therapeutic radiology, diagnostic radiology, and nuclear medicine.
- Holds a university degree in a relevant subject.
- Holds a diploma or college level certificate from a university that qualifies them to work in their specialised field.

Licensing requirements for a radiologist, diagnostic radiologist, nuclear medicine physicist, or any other kind of radiology technician:

- Must pass a training course in their field of specialisation approved by the relevant authority.

- To pass a training course (approved by the relevant authority) in the health and safety protocols for radiation protection. The course must extend a period of at least 30 hours. Alternatively, they may attach sufficient proof (e.g. safety course qualifications) of their knowledge of radiation protection during their study period.

It is apparent that prior to 2002, the Jordanian curriculum for graduates in this field and the Ministry of Health’s policies and procedures are contradictory. Specifically, the diploma did not include a radiation protection course or equivalent health and safety awareness. However, the Ministry of Health still ensures that 97% of its employees have all the licensing requirements to work in the radiology departments. Further, the Ministry aims to amend the curriculum in line with their health and safety protocols and licenses.

Reports issued by the Radiological and Nuclear Regulatory Commission, which were examined during this investigation, indicated that two hospitals (associated with the Ministry of Health) were non-compliant with the health and safety protocols and had unexplained levels of radiation in their radiographic chambers. The report also requested that work be suspended in the affected department until action is taken to resolve the issues identified in the previous reports.

Summary of the Regulatory Authority’s reports

- Not to link the warning light signals with the radiology apparatus to avoid the risk of radiation exposure in several hospitals.
- Storing photographic films inside imaging rooms, despite the fact that it is considered a wrong way to preserve and store film.
- Failure to perform quality checks for radiology equipment, which guarantees patients safety from excessive radiation doses.
- Exceeding the maximum dose allowed in the imaging rooms, which necessitates the maintenance of doors and an increase in the shielding capacity and thickness of the protective barriers.

Unionisation

Workers in the Radiology Sector in different locations have demanded the establishment of a Union, specialised for radiologists or for general technicians, to represent and defend them. Their demands are, firstly, a duration of employment (in years) similar to the rest of the world and according to best practice. Secondly, they are requesting that the 14-day vacation, that has been suspended, be brought back.

Radiologists have revealed a variety of health issues through pictures and reports. Their suffering is largely due to repeated exposure to radiation and the absence of necessary protective measures and equipment. Consequently, they have found themselves without compensation or income for the rest of their lives.