Memo to M Biles, Subject: Meeting to Discuss Next Survey in Marshall Islands (2 Attachments)

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Division of Operational Safety MEETING TO DE5CUSS THE NEXT SURVEY XN THE MARSHALL ISLANDS Z%ose listed in Attachmexd 1 met November 27, 1973, to dimuos plans for ln environmental survey of Bikini Atoll to be performed in conjunction with Dr. Bob QonaJIs medical mmrey. Attachment 2 was prepared by Dr. Conard to describe the proposod medical axxiradiological survey activities for the March ’74 field trip. Of major concern to Bob is the arrangerno* for an LCU vessel *ch ho considers almost imiispensable for obtaining whole body m~etaromonts. (The whole-body counting Yacility would be let up in a traib that would be loaded on tha XAXJ. ) B@ urged that atathoritY ba - ta go ahead with preparation of such a trailer even though negotiatidu for the LCU are not completed. DBER attemleea agreed to look int6 thfa Tho group discussed the problem of attainbg an adequated level of calmcommexxlation was dtrectod at b need for this meaaur~ Bob reported that his experiezbce wi@s the Marahll Idmd Peoples ahowa tiq is possible they do not digest well such milk Ho msggested t?w bod 8pproach may M to look for eemo ~ of dessert the Bikid people aomosam folbwun for the Ad Hoc ~’s ree oauaeuiatien@ to correlato lwels colbcted by U*w3reky of Wmhington and l re trying

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Bob was shown a copy of Attachment 3 which is l letter recently received from Al S .orvices of Vic Nelson to participate in tlm wrvey. Note that AL would need rnore~ a large number OS samples l m to b. In discussions with Bob - other BNL staff, it was stated that l major purpose for an environmental rummy group participation along with the medical eurvey waa to gain fir* hand experiessca useful for planning and conducting lates followup sumeys to which AEC is committed. W. stated interest in increasing the data buo for plutonium levels ad uxternal gamma Ieveia recogahing that Bikini Island is now esse~ally cleared of the dense vegetation it onao contained. We recalled the coneidorable effort required to field ld support high volume ga.okte powered air samplers. It was etated that a Gmatl battery-powered low -urn. lir sampler may be availablo to collect mmh samples. We augge.ted that patt - of& effort be devoted to remonitoring thoa, l reas hi tho interior of Bikini XaAandthat pwsviouely dwwed higher external gamma Iwel. ld that thought be given to how such monitoring could be performed in the .hture in a way that will shcw how lemls of radioactivity in Z’ho pcmeible public relations ad public imfmmationd spts of rrmwtb. @d tbeo l reas ia plamdng tho trip. Devolopmo* of l Noti to Kilt wlmro qmstlone lsked by the Biktnt pooplo woro vhmu mxvey and proos-related fidd trips. Dmeion of O’poratid flklety

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Ihe 1974 l%xiical Survey will begin about the middle of March and include examinations at Ilonnelao. Utirik. Bikini. Ebeve ard ~+llra- ‘lheRongelap people , exposed and unexposed, are examined completely annually, iJtirik people every 3-4 years. In addition, following the death of a 19-year-old e~.~ased Rongelap boy last year with acute leukemia, hematological examination in the exposed !longelap people ncw takes place twice a year. On the forthcoming survey the exposed and unexposed Rongclap people will be examined completely (except for some of the unexposed examined recently by Dr. Knudsen, our resident physician in the islands). Ihe Rongelap and Utirik populations under study are scattered largely between their home islands, Ebeye and Majuro, the district center. ViSitS tc all these islands will therefore be necessary. Utirik will be visited for purposes of general health care, radiological monitoring of personnel and environment, and for a diabetic survey. Bikini will be visited at the end of the survey for radiological monitoring of personnel and environment. Some 50 uorkmen are there and it is possible that by the time of our survey some of the Bikini people will have qeturned. It is hoped that an LCUwill be assigned to the AEC by the Arq for t our use for medical visits and radiological surveys in the Marshalls. If this nmterializes we plan cn having on the LCU a’ trailer set up for whole body countiilq (lead shadow shielded gauuna spectrographic instrument). incluiing x ray. l%is vessel, though slow, could be beached conveniently near the villages. Except at Rongelap and Ebeye, we would live aboard the lieu. A “bunkern trailer would be brought on the vessel for sleeping( purposes and an eating facility would be established. If the LCU is not furnished we will have to charter a “Trust Territory” cargo vessel. Thmgh faster, such a vessel leaves much to be desired. (I’m sure that those who have been on previous surveys will say that this is putting it mtldly. ) In addition to the routine history, physical e-mination and laboratory work, this survey will be highlighted by several other special examinations oi thyroid reserve in the exposed people who have not had i+survey, a genetic study of children of exposed and ~r~nd radiological monitoring of personnel ana environment* 8$ and Bikini. ‘l’he procedures for these examinations or doing them will be described below. mely fortunate in having k. James Held to h-d uP the We are also most fortunate in having the cooperation and support from the In this brief communication time does not’ permit a discussion of background information concerning political trials and tribulations which our team has had to face during the past several years. Suffice it :0 za? that we are pleased chat certain misunderstandings have been cleared up and I think we can count on full cooperation from the Micronesia ConSrcss and Lccal politicians. Scnat@r Q. Borja, who headsup the investigational ~great help in accomplishing theconrnittee for the Congress, has been o improvement in the situat~on and he may be accompanying us on the stirvey.

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Protocol 1973 Continued Page IVo the AEC Honolulu Office, has agreed to accompany us on the survey in order to help answer any AEC-directed questions from the Marshallese. Mr. Streenan has always been extremely helpful in logistic support of our surveys. In addition to the above personnel, Mr. Qrl Thien, a BNJpublic relations rwin and Mr. Douglas Humphrey, photographer, may be accompanying the team to document various aspects of the survey. The following is a tentative roster of personnel participating in the survey with possible assignments: Administration Assistant, Routeing of people: Mr. Bill Scott (BNL) Medical Histories: To be designated (T.T.)* Dr. Knud Knudsen (Bk and Marshall Islands) Genetic Survey: Dr. Robert Conard Mr. Robert Brown (BNL) indefinite as yet. Urine Analyses: Mr. Bill Scott Radiological Surveys: UPersonnel Monitoring: Dr. Stanton Co n ,..” Environmental Surveys: To be designated (BN’L) Possible guests from Micronesia Congress: Senator Olympi.oBorja *To be approved by Trust Territory

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Protocol 1974 Continued Page ‘J%ree ‘he pecple to be examined will usually be brought into the examination area by automobile. Various Marshallese personnel will assist with interpretation and roueing for the examinations. Bill Scotc will handle the administration and routeing of the people for the various examinations. Each person will be given a routeing sheet which will designate the various types of examinations to be done. Routine Exams: Copies of the previous examinations and/or a summary of each case will be available. The history and physical exam forms have been revised ana copies of the revised ferns are attached. Ihe history will be ?aken tiya member of the Trust Territory Medical Personnel yet to be designated. l%e examining physicians should refer to the history and enlarge upon it through the interpreter as indicated. ‘ihephysicians carrying out the exams other than the diabetic and genetic surveys are: Drs. Wolff, brsen, Knudsen and Riklcr.. Dr. Riklon will interpret as necessary. A complete physical exam vill be carried out including SKG and oscillometric exam~cadcns on certain cases. Routine laboratory ;:ork will inclcdc: complete blood study (WBC, differential blood chemistry), urinalyses and microscopic as indica~ed, chest x rays snd other x rays as indicated. Cancer: Car?ful exam~aation for possible malignancy will include pelvic exam with Pap smears, rectal exams in all people over 40 yezrs of age, skin exams, particularly of residual beta burn scars with CO1OY photography as indicated, sputum exams if indicated, x rays as indicated. Leukenia: lhe hemogram will be carefully evaluated and differential smears scrutinized. Bone mrrow eyam will be carried out if indicated. Blood smears for alkaline phosphatase will be returned for analysis by Dr. Moloney of Boston. ~yroid: Revious drawings of thyroids with questionable or positive findings will be ~vailable. From the history careful assessment of thyroid medication adherence should be evaluated. This is of paramount importance in the operate. cases who are nearly all hypothyroid without Synthroid treatment. For the thyroid reserve study (see below) all of the exposed people in that groxp should be checked to be sure that they have been off Synthroid treatment for the previous 2 months. Thyroid exam should include a sketch of the gland on the neck drawing on the back of the physical exam form in those cases where there are positive or questionable findings. Plasma samples will be obtained routinely for T-4, T-3 and TSH on all exposed and possibly some control people. Thyroid Reserve Studx”: ‘here are 41ARongelap people now living who have not developed any significant thyroid abnormalities. It would be of advantage to know what the thyroid reserve status is in this group since it is difficult to nuiintain a strict treatment regimen and this informatic~

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Pr~tocol 1974 Continued Page Four may be important in cases that might develop cardiac problems. l%erefore this group will be taken off thyroxine prophylactic treatment beginning January 15, 2 months before the survey. (The 23 people who have had thyroidectomys including the 2 boys with thyroid atrophy, will not be inc~~bciedin this study since it is already known that their thyroid function is -norrral and continued thyroid treatment is of great importance in this group.) In order to test thyroid function in this study it is planned to measure thyroxine (T-4 and T-3) and TSH levels on an initial blood sample followed by administration of 10 units of TSH and another blood sample drawn 24 hrs later for measurement of thyroxine levels and clinical exam of the thyroid. About 10 unexposed Rongelap people will. be similarly Dietary Iodine and Iodine Excretion Levels: Iodine in the diet may be evaluated by testing the level of this element in representative meals which will include local fruits and marine life. It has always been thought that the iodine level in their diet should be high and this will test this assumption. Urinary excretion of iodine, tested some years ago, was in the low-normal range and this test will be repeated on aliauots of 24-hr urine samples being collected for radiochemical analyses. Ihese I studies may also be done in some of the Utirik population since their diet is preswnably less “westernized”. l%ere are two other thyroid studies which may require some supplementary information: (1) excretion rate of iodine in children using 1291 is in progress. Activation analysis for measurement of urinary iodine on urines from 2 children given this isotope is being measured up to 16 days. This study is designed to help evaluate the thyroid close received ‘by children which has been based on an excretion rate of 0.1% of thyroid burden being excreted in the urine at 15 days after exposure (the time of the first urine collections). The other study (2) is an evaluation of iodoprotein levels which are unusually high in the Marshallese people. Jack Robbins, Ed Mll and I are particularly interested in investigating the environmental and genetic aspects of this finding. Other ethnic groups are under study. One study in progress concerns the use of orally administered 1291 with plasma collection before and at 2 and 4 days- to determine possible incorporation of orally ingested iodine in the various serum iodine fractions. %is and depending on the outcome, further Diabetic Study: Diabetes in the is considered to be of unusually high study is of a preliminary nature sampling of the population may be Marshall Islands, along with cataracts, incidence. Ihe Trust Territory Medical Personnel at the district centers have been quite concerned about the problem and have requested our help in any way possible. In response to this request, although we have not seen any connection between diabetes and radiation exposure in the Rongelap people, we are anxious to help if possible. We are therefore fortunate in in this field, participate in the survey procedures for evaluation and therapy of having Dr. James Field, an expert and perhaps suggest further this disease in the Marshalls.

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Prot9ccl 1974 Continued Page Five Since only a limited number of people can be examined during the MarchApril visit, it is deemed advisable to concentrate on the Marshall Island populations, principally the Rongelap people living at Rongelap Islaati, Ebeye and !hjuro. Sampling of the L!tirik population will be carried out to the extent possible. In order to evaluate the genetic coinpment, sampling of other ethnic grouFs would be desirable hut the logistics and time involved in a study at a distant island preclude feasibility zt this tire. Of course, other studies of diabetes in Micronesia and other Pacific Island groups will be used for comparison. Dr. Kasino, a TYust Territory practitioner, has a strong interest in diabetes in the Flarsnalls and may assist Dr. Field in this survey. A hematological technician (Nelson Zeditka) will also assist. From discussions with Dr. Field the folluiiing procedures are being considered: Ideally a fasting blood sugar specimen would be drawn follcwed by a Slucose meal and 2 hrs later another sample drawm for blood sugar. However, only a limited numbs-of people can be tested in this fashion since such samples -rest be obtained reasor.ably early in the day. At later times the samples are subject to uncertainty regarding food consumption. Dr. Field believes that if sampling only after the glucose meal means substantially larger numbers of people sampled (which seems likely), then this procedure should be considered at Utirik and where extra numbers of people are wanted. He believes the results using the l-stick method may tend to slightly underestimate the incidence of diabetes. It is h~ped that urine samples for sugar zest can be obtained before and after the glucose meal. Obesity and cataract formation as related to diabetes will be evaluated. Obesity may be further evaluated in a limited number of cases by whole-body counting of 40K measurements to obtti lean-mass-fat ratios on those people with positive urine sugars. In the Rongelap series cholesterol and triglycerides will be run on plasma samples returned to BNL. Samples of diet being obtained for radiochemical analysis and iodine content may also be examined for carbohydrate, protein, fat concent. Dr. Field is working on a questionnarie to be filled out by all subjects in this study concerning family histo~ of diabetes, dietary habits, etc. &-netic Effects of Radiation: The generally negative results of the ABCC genetic studies of first generation children Japanese exposed to the A-bombs quelled our interest …