Field Task Proposal/Agreement: Medical Studies of the People of the Marshall Islands Accidentally Exposed

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U, SO APARTMENT OF ENERGY 1 WORK PACKAGE NUMBER 2. TASK NO. 3. RNEOV. 4. PROJECT NO. 5. OATE PREPARED 6. CONTRACTOR NUMBER 7. TASK TITLE fileaicaLS’iudles Or he the hlarshall Islands Accidentally Exposed. BUDGET AND REPORTING CODE 1!3. ‘TT;nKTERtv! 11. CONTRACTOR NAME Marshall Islands lnsrllulional Plan> The primary objective is the determination of the life-time effects Ooes this task include fallout radiation on the Marshallese who were accidentally exposed to radioactive fallout on ?farch 1, 1954. Medical Surveys of these prople have been conducted at quarterly intervals, and an unexposed Rongelap population is examined for comparison. The surveys, carried out jointly by Brookhaven National Laboratory under the auspices of the Department of Energy, and the Trust Territory of the Pzcific Islands, are of great importance in view of the development in this population of growth impairment in some exposed children, thyroid lesions, and one case of acute leukemia. 19. CONTRACTOR TASK MANAGER

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TASK REQUIREMENTS FOR OPERATING/EQUIPMENT COSTS AND OBLIGATIONS Associated Universities, Inc. IWRK PACKAGE NUMBER TASK-NO. [REV.No.~oA~EpREpAR~D CONTRACTOR NUMBER b. OTHER DIR EAT ......... 7.0 9.2 c TOTAL DIR EAT, ........ 10.4 ~ PRO POSEO SCHEDULE

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TITLE Human Health Effects from Energy BUDGET AND REPORTING CODE DATE PREPARED Generation: Medical Studies of the HA-02-01-01 03131/80 People of the Marshall Islands CONTRACTOR NAME CODE WP NUMBER TASK NO. It is anticipated that work for this proposal will use existing Laboratory facilities and site utility services. In addition a doc?or’s office and laboratory has been established on Kwajalein and Ebeye Islands in the Marshall Islands and shipboard support for the medical teams will be required as they visit the outlying islands. The ship provided for the previous year has proven to be inadequate for medical purposes and active consideration is being given to the procurement of a different vessel. The currently used ship is 115’ long and is prohibited from ‘Icarrying passengers”, however when a field survey is conducted up to 35 passengers including patients and medical personnel may have to be carried. Consultationswith shipping experts have indicated that a ship of approximately 185’ in length would provide adequate living space for a party of this size. In addition, the ship requires a double (parallel) multiphasic screening examination facility for male and female patients, laboratory space and x-ray area. Ac tive negotiations are underway with the Department of Energy to provide such a vessel. None in FY 1979. In FY 1980, the 25th be published as well as the 26th year Annual year Report now in preparation will years. In addition to the 244 Marshallese are examined for a racilztion from fallout. the Marshall Islands have been conducted for 25 persons originally exposed, a group of unexposed “comparison population” to assess late effects of The continuing development of thyroid neoplasms, biochemical hypothyroidism and the appearance of one case of acute leukemia, indicate the need for frequent examinations . In addition to routine physical, hematological, and other laboratory examinations, the surveys involve special studies related to aging, malignancy, reproduction, and measurement of body burdens of radionuclides resulting from the slight contamination remaining on the islands. Patients wit!] thyroid nodules are returned to the United States for complete hospitalization and surgical treatment as indicated. In view of the diverse medical problems and their management, a physician, a Marshallese nurse–practitioner , and a laboratory technician are in residence at Kwajaleln and make regular trips to Rongelap, Fiajuro, and Utirilk to supervise care and perform interim examinations of the The R&D work contemplated shall be conducted in conformance with generally accepted methodology for scientific investigations of this character, as practiced at universities and large independent laboratories including Brookhaven National

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TITLE Human Health Effects from Energy Generation: Medical Studies of the People of the Marshall Islands Accidentally Exposed to Fallout Fiscal control will be exercised costs incurred against corresponding 1: BUDGET AND REPORTING CODE DATE PREPARED in the form ne items in progress shall be monitored through a periodic rev] by the Contract Task Manager. WP NUMBER TASK NO. REV. NO of monthly comparison of actual the budget. Substantive ew of accomplishments conducted Zof. Technical Progress. In response to requests by the people of Rongelap and Utirik, the Department of Energy agreed in February 1977 to assist the Trust Territory in an expanded health care program for the people living at Rongelap and Utirik Atolls. Accordingly, during the January - February 1979 survey (25 years post-exposure),, all Marshallese living on these atolls, who wished it, were given complete medical and laboratory examinations similar to those in the exposed group. Greater physician-patient relationship was attained by lengthening the stay on the Islands, which necessitated doubling the size of the medical team by releasing one team after 2 1/2 weeks to return to the United States and utilizing a second team for the second half of the survey. A 2nd survey covering 4 weeks in May and June concentrated primarily on pediatric evaluations and sick call plus a reevaluation of those thyroid nodules found on previous surveys. On the final three days of that survey Dr. Brown Dobyns, thyroid surgeon, flew out to Kwajalein and the entire team evaluated the 14 prospective surgical candidates. All were cleared for transfer to Brookhaven National Laboratory for medical evaluation and t!]en on to Cleveland Western Reserve for definitive surgery. The group was dividea into nine pat].ents who underwent surgery in early July, and a group of five who underwent surgery in September. A third survey was conducted in September and October covering a five week period. ‘IIis survey was directed towards the treatment of dental and ophthalmologic problems and the treatment of intestinal parasites on the major Islands. Thyroid abnormalities continue to be the only definitive findings related to radiation exposure. During the past year! thyroid surgery was done on seven of the exposed group and five of the unexposed comparison group. In addition, surgery was performed on two Marshallese from Wotje Atoll who were not in the long term study groups; one of these lesions turned out to be a carcinoma. There have now been 48 thyroid abno~alities (41 with surgery) among the 246 exposed Marshallese (ii% of the Rongelap people and 8% of the Utirik people). The occurrence of three thyroid cancers in the exposed Utirik population (compared with four in the Rongelap group) appears to indicate radiation exposure in the etiology, but the high incidence is puzzling since it is greater than would be predicted based on Rongelap and Japanese data and there does not appear to have been any increase in benign thyroid tumors in the Utirik group compared to the greater prevalence in the Rongelap group. Because of the uncertainty of the incidence of thyroid tumors in unexposed Marshall Islanders and in order to obtain better statistics, thyroid examinations were included for all unexposed Rongelap and Utirik people on any of the Marshall Islands visited. This study has been extended to include thyroid surgery when indicated. Also, in order to help solve

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TITLE Human Health Effects from Energy BUDGET AND REPORTING CODE DATE PREPARED Generation: Medical Studies of the HA-02-01-01 03/31/80 People of the Marshall Islands Accidentally Exposed to Fallout CONTRACTOR NAME CODE WP NUMBER TASK NO, REV. NO. 2c!f. Technical Progress cont. Technical Progress in BY-3 (FY 1979) cont. the Utirik dilemma, reevaluation of radiation doses from fallout to the Uti.rile people, including the thyroid, is in progress. The bill authorizing compensation to certain of the Rongelap and Utirik people for radiation injuries was signed by the President and payments were completed during FY 1979. A study of diabetes, a serious disease in the Marshall Islands, was initiated several years ago and the data collection has just been completed. A report of the results of this study will be iss~ed shortly. During this fiscal yesr an intestinal parasite survey was completed on Rongelap Atoll and at Utirik with studies of stool specimens and serologic testing, by immunofluorescence. .4nthelminthic therapy (Vermox) was started on nearly the entire population. A large percentage of the people had positive stools for parasites. The majority of the parasites were eliminated in this island group by the treatment regimen. As part of the expanded medical studies a trailer was obtained for laboratory purposes at the Hospital at Ebeye and a small clinical laboratory was established to support the resident M.D. A Brookhaven National Laboratory laboratory technician/administrator was transferred to Kwajalein to support this A pro~ram to educate the people of Rongelap and Utirik regarding radiation and its effects was continued during the past year. During the time of the annual surveys lectures were given to the people by members of the medical team and, in addition, Dr. Naidu, of Brookhaven, remained on Rongelap and Utirik for z ten–week period indoctrinating the people about radiation. The attitudes of the Rongelap and Utirik people towards the examinations improved , due partly to a better understanding of the objectives of the medical team as a result of the increased educational program, and partly to an improved attitude of the Marshallese politicians, Following the September-October survey of 1979 the inadequacies of the support system and the vessel became the controlling factors. Currently, no vessel is available for support of the surveys. Both the Department of Energy and BNL are actively trying to resolve this problem. When a ship is obtained the survey schedule for.FY 1980 will be completed. The planning cycle will probably allow time for two full surveys during this period. In addition, an epidemiological survey of Likiep will be performed, under contract with Tabershaw Occupational Medicine Consultants, to assess the validity of a Marshall Island Government medical questionnaire which indicated an unusual incidence of thyroid pathology in that population.

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TITLE Human Health Effects from Energy BUDGET AND REPORTING CODE DATE PREPARED Generation: Medical Studies of the HA-02-01-01 03/31/80 People of the Marshall Islands CONTRACTOR NAME CODE WP NUMBER TASK NO REV. NO ~of. Technical Progress cont. Expected Progress in BY-7. (FY 1980) cont. During FY 1980 all research records are being reviewed and condensed for transfer to microfiche and finally for computerization. This process requires restructuring the charts in a problem–oriented forma~ to provide the structure necessary for flexible clinical and research utilization in a computerized format. “During the last two surveys of FY 1979 there was an obligation to examine and care for the people of Bikini. This endeavor greatly expanded the patient load without supplemental funding, and it is anticipated that continuation of these examinations will be required. Funding, responsibility, and authority for this activity has been under discussion at the Department of Interior and the Department of Energy for a number of months but the problem remains unresolved. In addition, if the Likiep survey reveals an increased incidence of thyroid pathology, as is suspected, a medical survey of that island and possibly of Wotje, Ailuk, and Mejit may be required. If these incremental increases occur, the stuciy population would be more than tripled. Emphasis on health and radiation education will be continued and increased to place radiation in its proper perspective in a matrix of health risk for the Marshallese . Continued monitoring of all populations determined to be at Increased risk from radiation–induced diseases will continue, focusing primarily on the thYroid7 hematopoietic system, breast, lung, stomach, and colon using suitable screening tests. In view of the serious late effects of fallout exposure, continued medical surveillance of the exposed populations is mandatory as the studies are still in the latent period of a n~lmber of significant carcinomas. Special examinations for the thyroid abnormalities, as well as for neoplasia of other organs and tissues and other late effects must be continued. In light of the recent renewal of Interest of long term effects of “low level” radlationj the data from this study, even though the population is small, should serve as one of the longest piO– spective studies of the effects of both acute high level and long term low level external and internal radiation. Other studies to be pursued include: a) thyroid comparison studies-– it is hoped that the Department of Energy funds will continue to be approved for carrying out thyroid surgery in the United States on unexposed Rongelap and IJtirik people in the~extended comparison study where such surgery is indicated; b) reevaluation of dosimetry of the Utirik people, including thyroid doses; c) study of the nature and the treatment of diabetes in Marshallese to include trace element analysis of the people and the ecosystem; d) studies with Dr. Raymond A. Popp of Oak Ridge (for frequency of isolucine substitution in hemoglobin of Marshallese blood as an index of somatic mutations associated with radiation exposure and aging; e) studies of polymorphism and rare protein variance In the blood cells of children of exposed and unexposed parents––I)r. James V. Neel at the University of Michigan has expanded his battery of tests for these variants and has agreed to continue these studies on Marshallese children; and f)

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TITLE Human Health Effects from Energy BUDGET AND REPORTING CODE DATE PREPARED Generation: ~iedical Studies of the HA-02-01-01 03/31/80 People of the Marshall Islands Accidentally Exposed to Fallout CONTRACTOR NAME CODE WP NUMBER TASK NO. REV. NO Associated Universlfies, Inc. BNL o 2of. Technical Progress cont. Expected Progress in BY-1 (FY 1981) cont. the process of reducing old charts to the problem-oriented medical records system and the transfer of records to computer storage. Expected Progress in BY (FY 1982). Continuation of the medical surveys and limited primary care of the Marshallese is anticipated on an indefinite basis. Emphasis will be placed on examinations for thyroid abnormalities, the previously mentioned cancers, hematologic disorders and other possible effects of radiation exposure. Coordination with the patient and ecosystem monitoring teams from the Safety and Environmental Protection Division will continue. Chart reduction will be completed and computer storage and medical records will be continued. Zog. Future Accomplishments. Data obtained from this study will continue to provide baseline statistics for all studies of human health effects of acute high level and long term low level internal and external radiation. The studies of the exposed Marshallese are closely related to the Radiation Effects Research Foundation studies in Japan and to the studies of the 23 Japanese fishermen exposed at the same time as the Marshallese to fallout. Acute and long term low level radiation ranks as one of the most important hazards that must bc cons~dered in the DE medical programs. The effects of fallout exposure in the Marshallese provides valuable information, particularly with regard to thyroid effects from radioiodine exposure, that may relate to future reactor accidents. The longitudinal Marshallese data have been used in the analysis of such accidents. The data are also quoted in other reports such as those of the NCRP, ICRP, BIER, and the United Nations. The Safety and Environmental Protection Division of this Laboratory conducts radiological personnel and environmental surveys of contaminateci Marshal] Islands and their inhabitants. These studies are closely coordinated with the Work done under this task proposal has either no environmental impact or has impacts similar to those described in and …