Europe and ESTRO moving East. A story of betrayal and redemption—Candid observations by a privileged witness

Abstract

After briefly looking into the dramatic twist of history that caused Central- and Eastern Europe to be separated from the West, the author observes the impact of 40 years of cold war and isolation on the state of radiotherapy (RT) in Central Europe. From her privileged position as a staff member in charge of public relations and society development at the European Society for Therapeutic Radiology and Oncology (ESTRO), she witnesses and helps drive the “rapprochement” between radiation oncology professionals from both sides of the former iron curtain. Thanks to substantial support from target tailored EU projects, ESTRO was in a position to give a powerful impulse to the re-integration of Central European RT in the mainstream of European health care. The author describes from her own and privileged perspective the excitement of discovering the rich heritage of a shared common past and expresses her concern that in the dynamic repositioning of Europe's point of gravity towards the East, the multiple but still fragile links between Central- and West European radiotherapy, tied within ESTRO, should not get dissolved in transition.

1. The antecedents

Both the terms of the World War II peace settlement in Yalta that locked Central and Eastern Europe into 40 years of isolation and the paralysis of Western Europe in the face of the brutal suppression of uprisings behind the iron curtain had left the West with a pervasive feeling of impotence and collective guilt.

This feeling of guilt was never shed completely even when in 1989, to Europe's immense relief and joy, timid whispers of freedom (Leipzig, Gdansk, Prague, Berlin, etc.) gathered into a powerful storm sweeping from the Urals to the Carpathians and from the Moskva River to the Rhine, trashing borders, iron curtains and Berlin walls.

One can only imagine what Europe might have looked like if the exhausted allied forces had not stopped in Berlin in 1945. No “Midnight at Noon” (A. Kustler), no “Unbearable Lightness of Being” (M. Kundera), no treason, no terror, no cold war and … perhaps, a United Europe with borders stretching from the Urals to the Atlantic Ocean (as General De Gaulle once conceived them). Unfortunately, that was not to be.

2. The first emissaries

Thus, just a few radiotherapy persons from behind the iron curtain had been seen at ESTRO events. All from Poland. (Was their regime perhaps less oppressive than that of the others?). That was to change in 1991. That year still young ESTRO was to organise the 2nd edition of its “Modern Brachytherapy Techniques” course in Norway. Venue: Soria Moria, a conference centre in the Holmenkollen hills overlooking Oslo. The local organiser informed us that the Norwegian Medical Association, owners of the conference centre, offered to make 3 fellowships for the course available to colleagues from Central Europe, all costs paid except travel. Eventually, 3 clinicians, practicing brachytherapy in Prague, were identified. It was March. Still winter in Norway. A country packed in a thick coat of snow. Registration day passed. Except for some moonlight reflected by the snow, darkness enveloped Soria Moria. Our Prague guests had not yet arrived. Some meals were set aside. For sure, the narrow gauge train linking the place to Oslo would not run this late… And then, when most participants had already retired to their warm beds, they stumbled in. Covered in snow and totally exhausted after a train journey of 48 hours! At the time, trains were still incredibly cheap in Central Europe but so was the paycheck of medical professionals in the former East block. After a warm welcome, we looked forward to 5 more days to bridge 40 years of separation. The start of an enriching experience! And the promise to organise the next BT course in Prague.

3. 1991: ESTRO's first stride behind the former iron curtain: Budapest

We, at ESTRO, were proud to know already 3 more persons from the deep red centre of Europe, but out of the blue emerged a real expert: Hans Svensson, the iconic director of the very first ESTRO course (Radiation Physics for clinical Radiotherapy – Leuven 1985). He put his career at the Umea (S) Radiation Physics Department on hold to head the Dosimetry section at the International Atomic Energy Agency (IAEA) in Vienna. From there, one could just leapfrog over the border and be directly confronted with the dire state of RT after communist occupation. Besides, he knew a physics professor, not really linked to RT, in a research institute in Budapest. Hungary Great! It was time to open ESTRO's window to Central Europe. So Budapest was to become the venue of the 1st ESTRO Biennial Physics Meeting. Local Organiser: “the” physics professor (sorry, I forgot her name). ESTRO organiser: me. In those days, ESTRO had no money for site visits. The only compass to go by for organising congresses was instinct and imagination. Postal exchanges were too slow for the purpose. But never mind: right in that year ESTRO – always at the forefront of progress – acquired a revolutionary new device: the fax. And – a true miracle – also “the professor” could access one. In addition: we had still plenty of time. Well… 5–6 months. Negotiations were not easy. “The professor” had absolutely no concept of reasonable prices for a venue and of the exchange rate of forints to ECU's (precursor of the EURO) but together we managed. The conference venue was brilliant: a scientific institute right opposite the awesome Budapest town hall. The leap of enthusiasm from the side of ESTRO physicists was overwhelming and – most importantly – Hans Svensson had secured funding at the IAEA to sponsor an equal participation of physicists from Central Europe. They came – again by train – from every and each country from Central Europe. With 250 participants, the conference was a huge success. Now in 2013, after a time lag of almost 22 years, one can hardly imagine how charged with emotion that first major encounter with Central European colleagues was. Feelings of guilt redeemed by an enormous sense of relief and elation for the reunion. Some Dutch participants had learned about extreme poverty in Romania and came with loads of clothes discretely deposited in the registration area and as discretely as swiftly accepted. The combined physicists were exhilarated by the success of their first own and joint meeting. And Budapest revealed itself in all its stunning beauty. A true metropolis. A wealth of monumental architecture mirroring itself in the stately Danube. Time to adjust our mental map of the most beautiful places in Europe. As organisers, we faced only a single but rather embarrassing problem: the absolute scarcity of toilet paper. It took each time 3 steps up in the hierarchical ranking of the local staff to secure a replacement for the single roll of paper in the only lavatory of the congress venue.

During a guided visit of the oncological institute – owner of the only linear accelerator of Hungary – we were shown an amazing RT contraption. Once the patient was set up for treatment in one room, technicians had to rush to the adjoining room and turn a big captain's wheel to crank the radiation source out of the wall and back into its nesting place after treatment. I also saw how many patient beds might be stowed in a single hospital room.

4. And then Prague

The next year we were to discover another jewel of the Austro-Hungarian empire: Prague. Another city. Another glorious beauty. (to be followed later by other stars: Ljubljana, Gdansk, Bratislava, Zagreb, Krakow, BRNO, Warsaw, Poznan, etc.) More intimate than Budapest but as protective of its historical heritage. And, just like Budapest, home to famous composers, a mighty stream and a citadel: Prague's imposing castle watching from a hilltop over the city at the opposite shore of the Vltava (known in the West as the Moldau). Prof. Chodounsky, whom we had promised in Soria Moria to organise the next “Modern Brachytherapy” course in his city, was a most gracious host. Low dose brachytherapy used to be very popular in Central Europe and the visiting ESTRO teaching staff and participants were warmly welcomed. There are few persons I hold in as high an esteem and affection as late Prof. Chodounsky. Zdenek for his friends. Having been dispossessed of his home in Prague and banished to a far outpost in his country during Soviet times, he was, as chairman of the National Radiation Oncology Society, the first one to reach out to colleagues who had been more accommodating to the regime. His goal: to unite Czech radiotherapy and heal it from a divisive and traumatic past. I remember the many paediatric patients in the waiting room of his resource-starved department – space doubling up in the evening hours as brachytherapy operating theatre-, his tenderness towards the little ones: fishing up a candy from his pocket with one hand and with the other gently stroking their bald little heads.

During that week I got to meet radiotherapists and physicists not only from all the departments in Prague but from the whole country. I found a lot of parallels with my own country. Prague and Brussels were the first cities on the continent to industrialise. Before Slovakia became a separate country, they were the same size. Both countries were an unwilling part of the Habsburg empire. Both were early adopters of RT, hence their many (more than 20! Perhaps too many?) RT departments. Only their chances of development had been unequal. We visited all RT departments also that of Prof. Jan Bauer, ending in the basement. What we saw there could have been the setting for a science fiction film. In the middle of a room, filling it almost from wall to wall, a huge computer with hundreds of blinking lights. Well before the generalised introduction of computers in RT, (I remember the heavy main frames of the early treatment planning systems in Leuven 1985!), isolated ambitious physicists in this department had been creating this huge machine for the calculation of their treatment planning algorithms. They were still using it in 1992! Later I was to learn that Poland had even developed its own early linear accelerator. Unfortunately, it did not stand a chance to survive in the competitive environment of Western technology. In Prague I also noticed that the work distribution within the RT team was different from that in my home base. After a long day's work, physicians had still to type their own reports. No well organised patient throughput here but waiting rooms crowded beyond capacity: just too many patients for too few staff and too few machines. Only 1 institute was reasonably well equipped. The others had to make do with old to very old cobalt machines of which the shelf life had expired in a distant past. The course went flawless notwithstanding a major technical hiccup. In the morning of Day 2 the slide projector died down. Replacement bulbs had run out in Prague. By day 3 we wrecked the projectors of 3 institutes. A problem? No! First, the video projector still functioned and secondly: course director Alain Gerbaulet – never to be caught off guard – had prepared overheads not only for his lectures but also for those of the other teachers!

5. The big breakthrough: the EU PHARE-TEMPUS Programme

Also at the European Commission level things were moving. As of 1990 substantial budgets were freed and programmes designed to put the former soviet republics on a path towards re-integration in the European family. One of them, the PHARE-TEMPUS (Trans European Mobility Programme for University Students), was launched in 1990. Exactly what we needed. ESTRO participated successfully for 3 consecutive years, each time growing more ambitious in its proposals. Each time they were fully granted. In the last year, 1993–1994 we secured the largest but one grant ever paid out by the scheme, the other being a consortium of university administrations. By 1995, when multilateral projects involving more than 1 country were phased out, irreversible bonds had been established at both sides of the former iron curtain.

The Consortium or rather the people:

From the EU side: a strong network of 50 university departments who participated in successive ERASMUS mobility projects.

From the Central European side: all the countries eligible at that moment:

• -Poland: we had to obtain a special permission from the Polish government to include, besides the university hospital of Gdansk, the 3 Maria Sklodowska Curie Cancer Institutes not linked to a university but treating a large proportion of the country's radiotherapy patients.
• -Hungary: the Radiology Departments (Radiotherapy was not yet recognised as an independent specialty) of Budapest Debrecen, and Pecs.
• -Czech Republic: Prague (3 partners), Brno, Olomouc and Ostrava-Paskov.
• -Slovakia: the Bratislava Oncological Institute and Kosice University Hospital.
• -Slovenia: the Oncological Institute of Ljubljana with the only RT department in the country.

First ESTRO-TEMPUS network meeting, Krakow 1991

From the onset we redefined the word “university student” as a “postgraduate learner”, even if – as was often the case – the student was already a tenured university professor. It looked logical to start with the teachers, those in charge of updating practice. As long as one stayed within the logic of an EU programme, there was some space for stretching concepts. Also the term “university” was redefined in the broadest sense as a “teaching institute”. This was consistent with the TEMPUS intent. Actually TEMPUS benefits were extended well beyond the TEMPUS beneficiary partners thanks to the generosity of the wonderful people I had the privilege to work with. I think here especially of Andrzej Hliniak, Zdenek Chodounsky and definitely Prof. Kuhelj (Ljubljana). He readily adopted colleagues from the former Yugoslav Radiation Oncology Society, be they from Zagreb Skopje, Sarajevo or Belgrade (then still excluded as countries at war) to let them benefit from some of the fellowships his Institute, as the only partner for Slovenia, was unable to absorb. This largesse was definitely not foreseen in the TEMPUS guidelines but all the more effective in achieving our TEMPUS goals: to speed up the integration of Central Europe in mainstream European RT.

6. TEMPUS JEP's (Joint Education Programmes) had both a structural and a mobility component

The structural programme

• -In year 1 and 2 we focused on teaching and communication aids which were in acute shortage: copying machines and toner, overhead-slide- and videoprojectors, PCs, fax machines as well as software packages. The challenge was that only equipment of European origin was accepted (while Japanese products had virtually crowded out all EU brands) and that in addition VAT was not allowed. Eventually, the Commission accepted also Japanese products supplied from a European subsidiary.
• -In year 3, with a much larger budget, the focus was on upgrading departmental libraries. A list of books compiled from the proposals of the partners was rejected by the ESTRO Committee on Education because most titles were out of date. Clearly, our partners had no access to information on up-to-date publications. Running out of time – each project had to be completed and reported on within 1 year – I decided on a pragmatic approach. Each of the radiotherapists as well as the physicists and technologists of the Leuven University department was asked to show me which of the books in their cabinets they used on a daily basis. The list compiled on that basis covered not only general principles of RT but also organ specific information. It passed the Education Committee without problems and was welcomed by the partners.

The mobility programme:

We proposed 3 action lines: travel grants for ESTRO courses, fellowships for study/training periods in western departments as well as teaching visits to the partner institutes.

The course grants were very popular. Each participating department could select 2 candidates for the different ESTRO courses. In the registration fee we included ESTRO membership which meant access to the Green Journal and a tighter link to our Society.

While in year 1 and 2 only some 50 applications for study visits were received, year 3 produced a bumper crop of no less than 118 mobility requests ranging from a full year to a few weeks. Sending out so many staff members within a single year was a huge burden on the sending departments. But they did realise that this was an opportunity not to miss. Receiving trainees on the other hand was an equal burden on the host departments: settling migration formalities, finding accommodation, organising a coherent programme for the visitor, access to white coats, the cafeteria and the library, etc. The most difficult job for me was the transfer of the grant. Not simple, considering the rigidity of the banking systems 20 years ago. Sending money to the partner country did not work. In addition there was the risk of a grantee cashing his grant, getting sick and not completing the envisioned visit. Often “foreigners” were not allowed to open bank accounts in their destination countries and some hosts, especially in France, were reluctant to channel grants through their own bank accounts fearing unwanted attention from their tax collectors. The most risky transaction, however, was trying to funnel the money through university channels. This way 2 grants got lost beyond retrieval in the labyrinths of university financial departments. Another challenge was to match potential host institutes to the 1st, 2nd or 3rd choice of the candidates. Although we had a network of 50 ERASMUS institutes, very few visitors had a command of another language but English. In Belgium, the Netherlands and Denmark this was not an issue, used as these countries with minority languages are to switch to foreign languages. But in France, Germany, Italy or Spain hosts themselves had often a limited command of English. That meant that many candidates ended up heading for the UK. In any other circumstance it would have been totally impossible to find host institutes for even a fraction of their number. A first visitor was very welcome. A 2nd one was already more difficult but requests to receive a 3rd visitor in the same department in the same year was raising resistance from the host staff who, being already overburdened, had to share their time between patients and visitors. But the knowledge that this was the very last year ESTRO would be able to offer TEMPUS fellowships and the wish to reach out to colleagues who had for 40 years been denied access to exchange of knowledge was such that ultimately nobody was left in the cold. 8 candidates were able to complete successfully the full year Royal Marsden Clinical Oncology course. Even with a free registration offered graciously by the hosts, candidates had to scratch the bottom of their pockets to make ends meet in expensive London with their maximum grant of 14.000 ECU. I felt really concerned when receiving a collective appeal from 4 trainees in London asking for more money which I was not able to send. The Arhus Oncology Institute (Dk) to the contrary, offering free full board, managed to make 1 fellowship stretch for a full 2-year PhD course. Many grantees keep a fond souvenir of nice hosts such as a professor in Glasgow who offered full hospitality to grantees in her own home, taking them in addition on weekend excursions.

Personally, I have a special souvenir of 2 brave TEMPUS visitors. One evening I drove to Brussels to pick up 2 Czech technologists heading for the Leuven University Hospital. I waited for them for hours at the bus terminal. In vain. But no sooner had I eventually returned home than I received a phone call from the Leuven RT department. It turned out that the terminal for long distance busses had been moved to another location in Brussels and our guests, not seeing anyone waiting for them, had simply taken the train to Leuven. Arrived at the Leuven station, the 2 adventurous ladies did not recall the name of their host institute, but asked a taxi driver to bring them to “a very big hospital”. How they found the RT department in the 2000 bed hospital is still a mystery to me but they did find someone who found someone who knew me and my telephone number. By the time I reached the hospital, gentle nurses were just about to install them in 2 of the rare hospital beds of the RT department. (in crowded Belgium you find guaranteed an RT department within 20 km! So in-patients are really rare).

A very special TEMPUS event was also the Warsaw Summer School in Radiation Physics in 1992. The mobility costs for a top notch faculty were covered by generous TEMPUS grants for teaching visits. However, since the Warsaw Cancer Institute offered the faculty decent meals at very low cost and free accommodation in a student residence, they agreed to make part of their grant available to sponsor some extra participants. We were in for a big surprise when entering the lecture theatre. Not 25, not 50 but some 125 participants! With their small budget our hosts realised a miracle comparable to the “multiplication of the breads”. This time participants came, of course by train, not only from Poland and other TEMPUS countries, but from Poland's near and far neighbours and beyond: the Baltic countries, Byelorussia, Ukraine, Bulgaria, Romania, Moldova, Armenia, Georgia and even from St-Petersburg! A culture shock! Suddenly, it dawned on us that the geopolitical position of Poland was not at the fringe of the EU but right in the middle of what once was (and hopefully once will be again) Europe. Although Poland was still desperately poor at that time, something became very clear: Europe was definitely moving East and had still a long track ahead.

After the opening session and dinner a bus delivered us at our residence. It was only 6.30 pm and too early to go to bed, but we had no clue as to where in Warsaw our residence was located. The caretaker-lady who spoke only Polish could not help us either. But then appeared ever wandering Ben Mijnheer. He had arrived early and had already found out where to take a bus to the City Center. It was winter and really dark in the streets. We saw vaguely the contours of a castle and of the old city, rebuilt lovingly stone upon stone after world war II modelling the cityscapes painted in more prosperous times by the Italian painter Canaletto. But the city was sombre and dark. Who visited bustling rejuvenated Warsaw just some years later, cannot imagine how dead and dreary the place still was at night in 1992. We found 2 scarcely lit restaurants but absolutely no life, no people in the streets not even a dog barking, until, on our way back, we stumbled into a glitzy bar with loud music and very, very expensive beer. It was run by an American who must have seen in a crystal ball how fast Warsaw would raise from its ashes.

7. Preparing for the Post-TEMPUS period

There was one element missing in the TEMPUS Programme: support for ESTRO Membership. For this and covering part of ESTRO's 25% own contribution to the huge JEP's, we turned to the “Flemish Cooperation Programme for Central Europe” which invested no less than 280.000 € between 1993 and 1996. Later on, membership would find yet another sponsor for 2 additional years: the Scott of Yews Trust in the UK, subscribing the fees for 150 individuals.

1994 meant the definite end of the ESTRO TEMPUS projects. Multilateral JEP's were no longer possible. Yet, there was still so much need and so much to do. With the end of the scheme already in sight we investigated possibilities in the EU COST Programme (Cooperation in Science and Technology) meant exclusively for Joint Research Projects. We nevertheless did apply for funding for teaching courses in Prague and Gdansk, respectively, arguing that before embarking on joint research, east and west had to learn first a common language for scientific cooperation. The fact that these applications were granted is testimony to the fact that the European Commission is by far not as bureaucratic as some pretend it to be.

By the time the different assistance programmes had run out, solidarity with the colleagues from Central Europe was deeply ingrained in ESTRO procedures. A lower rate for ESTRO membership was introduced as well as reduced registration fees for courses and congresses on the basis of the per capita income of each country. Central Europe became a regular destination for the ESTRO courses. The absolute highlight was the Annual ESTRO Meeting in Prague. In areas where ESTRO could not help, the IAEA stepped in 2000 with a network of quality assurance labs. Very soon, the most dynamic countries in Central Europe such as Poland will no longer need such amenities. Their economies are steaming ahead and their RT departments are already in a position to reach out themselves to those who joined the EU at a later date and are still struggling and left behind, not forgetting either the countries of Greater old Europe, east of their borders.

8. And now ESTRO and Central Europe: Quo vadis?

By 2013, ESTRO has had several Board Members from Central Europe, 1 course director, several teachers, winners of Varian, Accuray and Nucletron Awards, the Life Achievement and Van der Schueren Awards as well as partnerships in education- and quality assurance programmes and strategy- and national society meetings. However, Central Europe has yet to see a Breur or Regaud lecturer and, why not, an ESTRO President. Too early or too late? Leaders of Central European Radiotherapy should be vigilant not to let ESTRO slip away and to conquer their rightful place at the heart of the Society. Times are changing fast and the Centre of gravity of Europe is irrevocably moving East again, exactly to where it was for many centuries in a not so distant past. And ESTRO had better be aware of this…

I am most grateful to Prof Julian Malicki for having given me this opportunity to express my warmest thanks to all the persons I had the privilege to collaborate with in the framework of the ESTRO move into Central Europe. Much coveted souvenirs of too many persons to mention here. The enduring warm friendship, honorary memberships and gold medals bestowed on me remind me every day of a great time of encounter and pioneering discovery, some of the most exciting years in my varied career.^1,2

Conflict of interest

None declared.

Financial disclosure

None declared.