Letter to a W Mathies, Subject: Problems of Field Medicine Among the Marshallese People (Encl: Research Plan)

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Dean, University of productive meeting on for not responding more promptly to o~~~ very Youii understanding and enthusiasm for the problems of field medicine were greatly apprccia”ted. Relatively few ptiysicians have a realistic perspective on the practice of medicine in such areas- It’s a real” challenge, but very rewarding. Both Susan and I have really been turned. on to see these people moving from the 18th century to 20th centuxy One of the older Robert Wood Johnson puograms (called the “Clinical Scholar” program) really intrigued me. Did Southern California work with that prograh? AS you know th”e graduates had advanced training in sociology, economics, anthropology systems analysis, healt’h care planning, etc. , in addition to their basic medical education. I think it really takes that type of Renaissance physician to deal effectively with.n-.edicine emerging in a third world nation. We find that we must constantly place ourselves in context with their indigenous medicine and work with it. Folk nmclicine still exists h the tiar.shalls,but it is very difficult to identify, particularly after 30 years of occupation and the credibility gap that has been generated by the accident in 1954. Durincj the last year, by brir.gi.ngmore Marshallese into the program, in responsible p~sitiofis, the culture has begun to open up to us. The whole social sett-.ingof medical care delivery is changing as we ~.iork toget’her with I appreciate your offer to join one of the surveys (schedule per-

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January 10 to Honolulu January 12 to Najuro January 20 to Kwajlein January 27 board ship to outer islancls (Rongelap, Utirik) February 5 ship to Utirik February 17 return to Kwajalein February 20 return to Honolulu February 21 return to home Since this spans alrnost.6 weeks, we have been dividing consultants into two groups - tha first group covers the islands of Ilajuro and Ebeye (unfortunately much like Tijuana) - leaving the U.S. on 10 January and 23 Januar>~, returning or. 21 Febzuary. “This triu is rcaiiy our basic adult screan~ng progrcam (please seethe enclosed research plan) . In addition vie deliver” primary care. as needed at sick call - a very busy spotThe }lay-June survey will be very sim,ilar but the emphasis is on pediatrics and will cover the period from 13 IwLIYto 27 June with about the same amount of time spent on each islandSeptember-Ott.ober trip in 1980 will conccn-trate on dental problems, diabetes. and a variety of substudies. Again az well as primary care. The dates are ten-tativcly set for 4 September through 10 October. I hope this will provide you with adequate informa~ion for advance planning. In respect to the possibility of establishing a formal affiliation between the Medical SC11OOI of the University of Southern California and Brookhaven National Laboratory-Marshall Islands study, I have tried to present the advantages of such an arrangement to Southern California and then to BNL. These factors are included’.in the text of my letter to Brian Henderson (please see enclosure), but in addition, during our discussion we expanded the concept to encortpass a.broader training spectrum. If the anticipated expansion and concomitant funding develop as all signs indicate, the Brookhaven National Laboratory/Department of Energy Marshall Islands study will be in a position to offer paramedical tr”aining scholarships to carefully screened Marshallese. In fact v7e have two SC/D1\!Lfield program would offer a.uniq~!e field training setting for a wide spectrum of students from a pre- to postgraduate levels. We would like to support a multidisciplinary approach, where the teams could see tho synthc:sis of sociology, medical economics, and health care systems. planning as it. impacts upon medical practice. be a xntich more that tl~is is a very sketchy outline of what v70uld need detailed presentation but I tho~lght I shoulcl jot these gc?t them to you a!; soon as pO:;S:LblQ- 1 have discussed

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these ideas with the senior administrators of both BNL and the Department of Energy and they have indicated a sincere interest in further exploration of such an affiliation. You realize of course that the further development of these plans is contingent upon approval by the Department of Energy and adequate funding from Congress- All indications that we have at the present time encourage us to believe that both DOE * and Congress w-ould support such a concept. I an in frequent contact with who is the DOE coordinator for all &larshall Island programs, and will send a copy of this letter to Bruce. The next move is obviously up to the DOE and to the funding authorities to clear the , way for all the plans we have outlined. I certainly hope that such an affiliation can be established.. I tlzink it would be tremendously productive again for your warm reception and hospitality. Susan and I fc:wazd to seeing yoi; agzin in California. Marshall Islands Programs

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The primary objective is the determination 6f the life-tine effects of radioactive fallout on the Marshallese who were accidentally exposed. on 1 March 1954. : This study focuses on the acute and Iong- tern radiation effects on a popu-” lation of Marshall Islanders inadvertently exposed to fallout. . “ The acciden~ occurred on March 1, 1954, when ari”unexpected shift of-winds, to be deposited on several inhabited islands to the”easE- Evacuation of tha expose~ group was accomplished within two days. The estimated whole-body gamma doses to the Acute effects of gamma exposure were noted in the P.ongelap and Ailinguae groups, but not in the Utirik group. Mother source of exposure in all the island groups was due to internal absorption of radionuclides from inhalation an-d ingestion of contzainated food and water as determined by radiochemical urine ~n.alysis. only the isotopes of iodine, stront-ium and barium were absorbed to any significant degree. NC acute symptoms were noted from this internal absorption and by six months= urinalyses indicated these isotopes to have been virtually eliminated. Nevertheless, early . exposure to radioiodines resulted in delayed but serious injury to the thyroid glands and hematologic depression for 15 years. The thyroid dose was estimated to be considerably higher in the children due”to the smaller size of the thyroid glands. In the Rongelap people, the thyroid dose to be about 335 rads in adults; In small children, the doses ranged from 700 toFollowing the initial studies, annual examinations, and more recerttly, quarterly examinations, of the exposed people, as well as an unexposed comparison Marshallese population, have been carried out. In the first ten years after the accident, few findings were noted that could be related to radiation exposure. During the second decade, however, serious l~te effects developed related primarily to the thyroid gland. In addition, a Rongel~p man who had been exposed at 1 year of a~e died of acute myelogenous leukemia which was likely related to radiation exposure. Nodules of the thyroid gland began to develop in Rongelap children, and to a lesser extent, in adults, be~innin~ about nine years POSC exposure. These nodules h~ve c.ontinucd to appear over the subsequent fifteen years and virtually all”of these have been rcsectcd surgically.

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! The high incidence of th~oid modularity in the irradiated subjects is in d&elopment of thyroid nodules or carcinoma. Since ~~~1 iS considered much less tumorigertic for thyroid tumors than x rays, it is rather surprblng that> in view of the large contribution of radio iodines to bh~ thyroid’dose Of the I<krshallese, the be related to the presence of more potent short-lived isotopes of iodfie present iiL the fallout which accounted for two to three times the close from ~3~1. Two boys who developed mjcxedema received an estimated thy-roid dose of ~.50 rads. In addition, at least five of the Rongelap population wbo had appropriate testing prior to surgery had either biochemical hypothyroidism or decreased thjcroid reserveBecause of the suspicion of possible.hypoth~oidism in individuals exposed to even lower calculated doses, a series of studies of thyroid reserve in previously unSince the most sensitive index of impaired thioid ~function is an eI.evatio~ in serurizTSH which occurs through the hypothalmic-pituitary-thyroid feedback axis, serum TSH concentrations and their response to tltyrotropin-~eleasing hormones (TRH) were measured in both the comparison and the exposed Rongelap population. On the basis of these studies, criteria ~-ere established for classification of patients as having biochemical c’vidence of finpaired thyroid fuiictionIn a control group of 115 who,were not exposed to radiation, 10? had a serua In the exposed Utirik population, 1224of the subjects tested had at least on= basal serum TSH greater than 3 vU/rul, though none of these was h excess of 5 pU/rLL. The prevalence of elevated TSH in this population is not siawificantly different frcm that of the unexposed group. In the Rongelap and liilingrrae population, 25Z of the subjects were found to have at least a single elevated basal serum TSH greater than 3 pU/ml. In two cases,. the serum TSH was in excess of 7 I.IU/uiL.-This is a si~nificant~y higher prevalence than in the other EWO ~~OUpS pooled. An association of thyroid modularity and cancer with prior r~diation of the thyroid gland, particularly in younger patients, is well–recognized and the asso– ciation has recently been reviewed by Maxon et al. @n-.I-Med- 63: 967, 1977) and De In adclit.ion,it has been recogylizeriChat radiation to the thyroid delivered in the course of trea-tment of patients with thyroid hyperfunction is associated with hypo– tliyroiclismin a significant fraction of the patients (a< highas 50Z) aC the higher

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apparently not been sign-ificantly severe to result in clinically evident hypotllyroidisx but by currently acceptable criteria, there is evidence of impaired thyroid reserve in these individuals. If left untreated, it IJould be anti.cipat~d that th~oid functior would continue to decrease in this group to the point of clinical. hypothyroidism. The data also indicate that the frequency of an el’evated serum TSH, the earlies~ biochemical evidence of impaired thyroid function, is also significantly more common in the Rongelap population than in the control-unexposed group. There are several other exposed,Rongelap individuals in whom results of basal TSH, and at least one TRH test, - have suggested the possibility they may also have evidence of impaired thyroid functicn:” These data indicate that in addition to thyroid modularity, which is a well- -- recognized manifestation of exposure to radioactive iodine or external radiation, biochemical evidence of thyroid dysfurtccion can appear 25 years or longer >fter an in-itial thyroid dose of as low as 350 rads.(Conard, R-A. et al. BNL Report 50424, Brookhavert :.— The exposed Marshallese constitute a unique population accidentally exvosed to “ The radiation characteristics are “different from those uyder observation “in Japan and in other nuclear reactor or weapons-test accidents. This prospec~ive studY, now in its twenty-fifth.year, has provided unique epideniological data. on 244 exposed individuals, particularly in relation to th]-roidpathology. In-recent years, we have an unusually high prevalence of biologic hypothyroidism, previously- unsuspected. Although a significant number of people suffered beta burns, no skin cancer has detected, but continual monitoring is necessary. .- One man, exposed at one year of age, died of acute nyelogenous leukemia at a~e Since pre-accidentv ital statistics are almost totally unreliable= one of the important goals of the study is to establish the incidence ancI/or prevalence of those pathologic conditions most frequently associated with radiation in 2 control/comparison group of Marshallese. Due to cultural, geographic and political problems, the accumulation of this type of data is proceeding very slowly- The lack of reliable vital statistics, coupled with the small size of the exposed group, ma’kes:the statistical - analysis of the dats very difficult. culture. following the accident, consumption and/or exposure to z number of potent carcinogenic agents has occurred. These other independent variables, i.e., smokins, chcwical carcinogens etc., should not be underestimated in the analysis” of selected cancers, for example, lung, GI, CU. In the case of thyroid neoplasia, Lhese carcino~ens would have IittIe effect-

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Post-ex~osure surveys in the Marshall Islan& have been conducted for 25.years -In qcidition to the 244 people originally exposed , a group of 209 unexposed Xarshalles a-re examined as a comparison population to assess late effects of radiation from fall out. The continuing development of ‘thyroid neoplizsas and biochemical hypofunctionz and the appearance of one case of acute leukemia , indicate the need for frequent exIn addition to physical, hematological. ,= and””other laboratory exarniuatior. the surveys involve special studies related to agiugz malignancy reproduction and measurement of body burdens of radionuclides resul.t.ingfrom the slight conta~finatiort remaining on the islands. .Thyroid patients are return.ed’~cothe United States for hospitalization and syrgical treatment. In view.ofj the diverse nedic~ problems and Eheir management, a physician, nurse practitioner, and Iaboi%tory assistant are “irt residence at Kwajalein and make regular trips to Ro-ngelap, Najuro and Utirik to supervise care ar.clperform inte”rim examinations of the exposed Marshallese. Medic~ surveys of these people are conducted at frequent inte~als. “The surveys are carried out jointly by Brookhaven National Laboratory under the auspices of the Dapart~.anE of Energy and the Trust Territory of the Pacific Islands. The progress relative to the research objectives for this twenty-five-yeer follow-up is best presented in the 20 Year Report There have now been 39 thyroid abnormalities {35 v7ith surgery) among the 244 exposed Marshallese. Tine occurrence of three thyroid cancers in the exposed Utirik pOPU– lation (compared with four in the Rongelap group) appears to implicate re.diation exposure in the et.ioloO~, but the high incidence is puzzling since it.is greater than would be predicted based on Rongelap and Japanese data; there does not appear to be any increase in benign thyroid tumors in the group compared to the nuch greater incidence in the Rongelap group. Because of the uncertainty of the irrcidence of thyroid tumors in unexposed Marshall Islanders and in order to obtain better statistics, during the past MJO years thyroid examinations were include: on all uuekposed Rongelap and Utirik people on any of the Marshall Islands visited. This study has . been extended to irrcl~}dethyroid surgery when indicated. Also , in order to help solve the Utiri’k dilemma, re-evaluation of radiation doses from fallout to the Utirik people, including the thyroid, has begun. In 1977, a bill authorizing compensation to certain of the Utirik and Rongelap people for radiation injuries was signed by the President and in FY 1979 payments A study of the high incidence of maturity onset diabetes in the study group ~~as initiated several years ago and continues. During che past year a“n intestinal parasite survey WE completed on Rongelap Atoll with studies of SEOOL ,spscimens and entire population. A large percentage of the people had positive stools for para— sites. The parasites have beeh virtually eliminated in this island ~roup by the tre<lrx?nt’ regimen. A .simllar stucly is under way in Utiri!c, using a different agent

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.“ During FY 1978, and 1979, a comprehensive health education toward instructing’ the people of Rongelap and Utirik about the effects of radiation was carried out by Dr. Naidu of BNL (Safety and Environxnental Protection Division). A booklet on radiation and its effects was developed and Dr. Naidu established a residence on each island for at least a mont~. His command of the lan&age and integration into their society resulted in a significant transfer of …