Moly-99 suppliers refute the report's findings, a position echoed by the Nuclear Energy Agency, which has fostered closer ties among producing nations. Reactor operators, the suppliers say, work closely to stagger maintenance shutdowns to minimize shortages and respond to disruptions in production, and producers have increased the number of uranium targets.
"We're describing a glass that is half-full," Charlton said, "whereas the National Academy of Sciences sees the glass looking half empty."
Still, nuclear medicine physicians and nuclear pharmacists charged with filling patient orders each day say the supply remains fragile, especially for smaller pharmacies where the moly-99 imaging agent can account for 95 percent of their business. "It is inconceivable to believe that an outage will never occur on any of these old reactors in the future," said Dr. Joseph Hung, director of radiopharmaceutical operations at the Mayo Clinic and a member of the government committee.
Wendy Galbraith, a clinical associate professor at the University of Oklahoma College of Pharmacy in Oklahoma City who runs the university's pharmacy, said she frequently doesn't know if moly-99 is going to be available until the wee hours of the morning. Even when there are no major outages, she said, "it's a scramble."
That uncertainty means delays and on-the-fly triage for patients. "If we have a patient who can wait two days for their cardiac stress test, we'll put them off," Galbraith said.
Suppliers want to tamp down fears about reliability, physicians and pharmacists say, to dissuade them from seeking alternative imaging methods when possible, like positron emission tomography, a costly and complex type of medical scan.
"It's hard to stay relevant in an environment when things are not available every now and then," said Iagaru at Stanford.
Even more troubling, critics say, is the lack of redundancy in the supply chain. Of the four global suppliers, two rely on a single reactor. "If anything goes wrong with the reactors in South Africa and Australia," Dr. Hung said, "it will be deja vu again like in 2009."
If the United States is to grow a domestic moly-99 supply, it will probably rise from the corn and soybean fields in America's Dairyland.
Rock County, Wis., has become the unexpected home to two of the three companies vying for control: NorthStar Medical Radioisotopes in Beloit, which has been awarded $50 million in federal grants, and SHINE, or Subcritical Hybrid Intense Neutron Emitter, in Janesville.
Backed by $25 million in federal support, Piefer, SHINE's chief executive, has promised to build a nuclear accelerator and produce moly-99 by 2020. (The previous deadline was 2015.) In early 2017, the company opened its headquarters in Janesville above the Time Out Pub & Eatery and down the street from a fishing tackle shop and Speaker Ryan's district office.
Nuclear engineers have moved en masse to Janesville in recent months, decorating their cubicles with hand-painted signs with sayings like, "Think like a proton, stay positive."
Piefer zips along Highway 90 in his Model S Tesla between Janesville and Monona, a Madison suburb where his research lab, Phoenix Nuclear Labs is located. There, engineers have built a ghostly particle beam that looks like a giant, purple lightsaber.
Eight particle accelerators have been designed for the Janesville plant, which the Nuclear Regulatory Agency approved for construction in 2016. Piefer still needs to raise considerable private capital, a challenge with eager entrants like NorthStar and Nordion, an Ottawa-based company also with aggressive plans to enter the Moly-99 market.
"If we don't have significant production soon, we will continue to export highly enriched uranium," Piefer said. "And the National Nuclear Security Administration will have failed their mission."
The city of Janesville is banking on Piefer. Its economy reeling from the closing of the General Motors plant in 2008, the City Council aggressively pursued SHINE with a generous economic development package, besting two other Wisconsin cities.
In 2011, over the objections of some residents opposed to a nuclear facility in the town, the council authorized $1.53 million to buy 84 acres of farmland, which it has agreed to turn over to SHINE for $1. The city has also agreed to pay $345,000 to extend utilities to the site, provide $2 million in forgivable loans and co-sign a bank loan with SHINE for up to $4 million that it would have to pay should the company fail, a first for the city.
Gale Price, economic development director for the city of Janesville, said that although it was unusual to put public money into a startup, the city expected to recoup its investment within 10 years. "That's how we measure whether we're giving away the farm," he said.
Ryan has championed the project and spoke at a celebration marking nuclear regulatory approval. But Piefer said, except for the initial phone call urging him to come to Janesville, Ryan has played no part in the federal grant and construction approvals.
SHINE jumped at the chance at federal money for the private plant. But Piefer isn't solely focused on the need in American hospitals. The company has already announced lucrative deals to ship moly-99 to Chinese hospitals.
But first, it needs to start producing.
"You cannot just open a shop down the street and start nuclear medicine," said Iagaru, of Stanford. "The public comes with an expectation that if my oncologist wants me to get a bone scan, it's not big deal. But the truth is, it's a big deal."
(Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation which is not affiliated with Kaiser Permanente.)
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