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Marshall Island Study. k indicated that the two current t“i~e~?ind~.= for the ship ~$er~: I explained that each research suzvey woulcl tak.c6-7 t:ee’ks,with a team of 12 professionals (a 30% illcrcase in time due to the rcd~lctionin te.anrsize full l?ongela.p-Utiriksuuvcy~ in the remainder of calendar 1980 to examine first, humanitarian medical reason but- not to gather research data. I suggc=ted the Kwajclcin qro~lpplus a lcacler (? Dr. Conard) and strongly rcconmrenckda DOS representative go along. llC!Sf2C?ill~Cl to agree. The fjt]a].cliscussi.ol~CO-VCYCd the dcv:..lop!nentof the Encwetok Survey.
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research protocol to bring it up to the current take about two and a half months to develop. He ; He then asked how soon we would be able see to accept this as ~. to mo&t the survey after. ,. that. I pointed out that the the for the BNL staff was almost fully committed 1 for the rest of this year and suggested that some contract group might be 1 utilized. In addition, I asked for all of the demographic and Iogisticdata , we would need to begin to plan such a survey. He state& he would contact i P.A.S.O and get the information back to me as soon as possible. All in all, ! I think Bruce is beginning to understand how this program works, and the ] operational constraints that make it e:<tremelyunwise a prime example. The Marshallese are still very zngry and rushed effort. to respond to the DOE .
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It has been my personal impression, over the last two years, while working with the MIS, that a large communications gap exists between the administrative links of the 1“11Sand the,policy base at the Department of My perceptions of this lack of communication and resultant misunderstaadiny have rapidly increased over the last year, after assu,ming the role of Principal Investigator. I have attcnpteclto close this gap repzatedls by a series of “PosiLion P.lpers”,expansion plans, contingency plans, mwnoranda, p!xmc calls anclpersonal ccmferenccs with limited success. the progrm to many of the smallest details. The primary goal of. this study act~tcan(llo[igkrm effects (both external and internal) of ionizing radiation mxlc a numhcr of Cx:cr)[..ions,to the rules for patient inclusion
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eumtm of 1978, a %kmorandum of ,iagreement”b&?eYI the Department of had assured future.medical care for the Biki&ns, after evacuation from their home atoll. The Department of Eneqy (presumably the WL/MI medical group) were apparently tasked with that responsibility. I found a copy of that agreement in the Department of Energy/PASO office in the surrmerof 1979 - (a year later). Since the early summer of 1978, I have repeat~~ly rcquestea both orally and in writing, the 13NLgroup in respect to by car”. This inability to the people of Bikini- 1 was advised to “play it resolve a rapiclly escalating problem led to a serious decrement in the rcsearcl~ effort, i-e., funds ancltime were diverted to the care of Bikinians along our examination route. The pcoplc~of the study group pcrccivcd that “their care” was incrcrncntally rccluccdby the assumption of the responsibil~ty for the !dikinipeople and they cxpxesscil their concerns about the dilutions of our efforts. In summary the DOZ/DOI inability, extcnclinqover more than a year, to give us clear programmatic guidance made me skeptical of tl]eir ability to make important management 2. ‘rl~eseconclmani.fcsta{..ionof the impact of high level indecision usc of an unsuitable ship for the program. I clearly poinl.cd out the unsuitability of this ship more than a year a~]o, yet the problem remains unrcrolvcd ancl is now conl:rolling tllcprogram, with potentially very serious consequences for the program in t.lle yet thi$,w&k I rcccivrd an inquiry coming Inontl ):;. This is fully documfmted,
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) year, what additional resources and staff SUpport would be needed to provide I ~e types of exiansion they are projecting. In essence we have already enswered their questions and obviously they have either overlooked or ignored those documents. In summary, they have again demonstrated their lack of \ knowledge of the information we have furnished them to be used as management - planning documents. This pattern of management is best categorized as “crisis management” in the managccnent literature. This philosophy of management, on demand or by expeclicmcy,is almost certain to fail in light of thz co:nplcx political, culturccland scientific variables controlling this program. These are only two of many examples of lack of/vr pocm management techniques. In light of these sccmingl.yunrc?sdvirblcmanagement problems, I Institutersof Ilcalkhmanagement study of the Itum.nnEffects of Ionizing Radiation Procjram~and in light of current congressional interests in “the ass.igtlmzntof departmental responsihil.itics for those programs. A number of influential congrcssnren (plcaw sce cnclosurc 1) feel that such programs shoulclbc run hy a division of NI1l. I agree. The logical home would be on 011 exigtilltl t.cler:or!lllll]r)ici]t.i.on links
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DCK to NIN would be & evaluate the mechanisms of Such a transfer. ,I%feel balloon” for a dispersion of the ku=gement base for scientific p+ograms. It is obvious that some deftiitive steps should be taken soon by Brookhaven National Laboratory to insure the via~ility of this program. On 25 January 1980 Dr. Eorg asked me informally, “Should the Narshall Islands Study continue?” I i“ntcrprctcdhis question as presenti.n9 a matrix 1. Should the study be revised/maintained with the 2. Should the study continue at BXL, or elsewhere, x feel the study must be continued because: 1. It is an absollltcpolitical ncccssity. The US govcrnmsnt has a pmral and a fiscal mandate to continue to follow and c:are for the people of the Marshall Islancls exposed to “above ambient” levels of io~izing radiation from weapms testing in.the Narshall Islands. Roth the United Nations and indcpeniknt 2. This is a unique irradial.cdpopula~ion with both internal and cxtcrnal contaminaLiorL# 26 ycaru of continuity of sound data. 3. With refinement, the study could }JncoNm a colul(lscicntifi.c 4. 13illScott has 22 years of invaluable expcricncc with this
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obtain any reasonable -timatc of when a ship will become available. When I aq given a date by DUE headquarters, it will take from 3-6 months tonmunt In addition, we have a large and defined amount of and clinical care) to provide to the study.group, this calendar year. That work will be condensed into 6 months or lCSS and will require some degree of modification, but the basic elements must b= maintained. During the period while we are awaiting notification of ship availability, we will continue to prepare the 2G-year report, develop a system for extensive chart review anclrevision, attempt to recruit.a ncw new$lcttcr to update our associates and collaborators. wc hspz to circulate this letter, cluarterlyz to inform and t.oseek commenlx and suggestions from
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concurrently, we,must’have, in writing, the DOE headquarters “brie-shot”or is this the initial examination of a longitudinal ,. study of a population which m,iqhtbe analagous to the Bikini 1 population? b) If this is the beginning of an epidemiologic study, a detailed state-of-the-art protocol must be developed outlining exactly what is to be done, how often the population will be examined, and a clear definition of the nonresearch political responsibilities interacting with the Marshall Islands health care delivery system. c) The development of this protocol will require time (I question how much). I doubt t.lr~t schcxlulc. We will be playing “catch up ball” Ior t.hcrcsk of this calendar year. It would bc very difficult to cover the added rcspmwibilitics in 1980. d) As an altcrna~ivc, the DOE hcadquartc!rsmight contact some contract group (multiphasic plan to be intcgrat.cdinto Lhc program at some time in the futllrc. ‘Ihcse same planninq ccn]strain~sshoul.cl also tlpply b
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fmmce se: up as a litxJof .fJiLntpmty line of disease, mrdttms proper treatment, In, - The Pacific islarxl symposiums rxc ati
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I attempted to present a spectrum OC solutions, ranging from purely a reseb “’L. to total medical care For the Marshallese affected by atomic weapons their islands. Since that time, a number of new problems have should be addressed in the context of the original systems analysis format. These new problems will not basically change the options presented in the flow sheets but will modify some of tileconstraints,and require a reassessment and/or restatement of the priority of some of tileobjectives. lIistorically, this program has had rather a narrow focus, looking for Anton Deurum, Secretary of State of the ncw ~!~rsball Islancls~o~,crnment, results of that qucstio[lnairc!:ercdc]ivcrwl to tileU.S. covcrnnlent and the birth defects or sclcc:tcd(:a[lccrs,tlll>ntllo1)0[1feels il (1111 mrclicalsurvey Lhe islands in tile].ikicsl)AL(I1lsllouhl1)[!uncl(,rt;ll:c,ll.
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Ron&clap-Utirik axis will need to be studied. “andnUejit Island. In addition, Wotjc should probably also be &creened in an . attempt to find a base lime perimeter with ambient Micronesia radiation background. I uttdcrstand data exists relating to radiologic surveys u~ade throughout the weapons-testing period for many of the Marshall Islands. A second, independent but related yroblan has arisen from recent studies in low-level radiation. The program, up until .Jartuary1, 1979, was orlentcd primarily toward the study of acute radiation effects catlsedby exposure to external and internal radionuclides in the st.uctypopulation. The comparison population, defined in 1957, consisted of Rongelapese who were not acutely exposed b~ltreturned to Rongel.apin 1957 with the exposed group. Since Utit-ik had only received about l!}rads of external gamma, the people were returned to the island four months after contamination and no l;tirik control population was exposed uroup. Quite unexpectedly, three cancers have been confirmed at {, Utirik in the exposed Croup, and there arc two additional cancers in people who have spent much of their time on Utirik since 1 March 1954. In addition, one
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becomes important. We know that the only remaining nuclicfe of iodine on both active). The active nuclides have been primarily C@137 and SrgO. Their ~ impact on the thyroid deserves further study. A third problem concerns the administration of the program. During the last year, the logistic support for the medical program has been marginal to unsatisfactory. (I?lcasesee Cnclosurcs 1 through 16 for details.) The problems may be divided into: (2) Administrative, i.e., responsibility vs authority for making substantive changes in the mmlica] program. (Sew?enclosures 1.7-19). in the MarsfjallIsl.’nndsancl its impact on tileU.S. Con~rcss, the enclosed
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DEPARTMENT OF ENERGY MARSHALL ISLAND STUDY BROOKHAVEN NATIONAL LABORATORY (REVISIONS INDICATED BY SPACING AND ASTERISK)
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., - m. Headquarters in Germentok, Maryland, to diecuss a number of problems related tod,! J the DOE position in relation to several different programs in the Marshall :.. The Medical Program, under the auspices of Brookhaven National Laboratory (BNL), generated a great deal of discussion, concerned primarily with the follow1. The research mandate of BNL for the study and care of radiationrelated diseases in the exposed populations is clear. However, over a period of twenty-five years, that mandate has been expanded to include care for nonradiation-related diseases. This evolution has been necessitated by the virtual absence of adequate primary care in the Marshall Islands. The ENL medical team has responded in a humanitarian manner to diagnose, treat, and follow-up a number of pathologic conditions which, if untreated, would have led to increased morbidity and mortality in the exposed and comparison groups. A. Basically, the BNL Medical Program is a medical research program. Its original goal was to “screen” for and detect the earliest changes suggestive of radiation-related pathology, and to treat those lesions as indicated. (The World Health Organization (WHO) states the primary responsibility of any screening effort is the ability to resolve all “abnormal” findings and to assure the patient of referral to an adequate primary care center.) B. The difficulties are compounded by the fact that valid preexposure health care statistics are difficult or impossible to obtain. The Medical Program is in the untenable position of having to deal often with the probability that a specific pathologic condition is or is not related to
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‘,-%: rsdiation exposurol dues l cause-effect relationship ia impossible to estats~ish ~.,4 c. The people are intellectually and emotionally unable to deal with tional program designed not only to transfer the information intellectually regarding the role of radiation in their lives, but to concomitantly incorporate that new understanding into their behavior, i.e., the ability to place radiation in its proper perspective for the present and the future. Such a program has already been initiated by Jan Naidu, Ph.D., BNL, with promising results. 2. The Marshall Islands medical “system” under the Trust Territories is underfinanced. The professional staff is undertrained and overloaded. Critical supplies are usually not available. A. In the absence of a satisfactory primary care referral base, the BNL Medical Program has expanded its mandate to include such things as a diabetes”) but has set up no mechanism high incidence of “maturity onset for treatment and follow-up of this B. In addition, at the request of the people, a large number of Marshallese who were not in the exposed or comparison groups have gone through the screening examination with the detection of a variety of pathologic conditions. An attempt has been made in each case to provide immediate treatment if possible, and to refer the patients to the Trust Territories health care system. Unfortunately, little has been done to treat and to follow-up these patients.
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Consequently, the BNL medical team has become the de facto primary health care—— provider to an ever-expanding’ group of Marshallese. The rationale of the Marshallese in the BNL program for their claim to the “right for all medical care” ia their association of practically= illness with radiation. 3. The BNL medical team, because of its frequent surveys has, in the eyes of the Marshallese, come to represent the U.S. “presence” in the islands. The BNL Medical Program has, therefore, become the target of many attacks directed towards the United States agencies responsible for other programs in the Marshall Islands. These unwarranted attacks have, on several occasions, seriously compromised the goals health care delivery for all of and (b) transportation. To the been addressed independently as of the Medical Program. Two major problems of the Marshallese involve: (a) communications, best of our knowledge, these problems have not health care problems. With the rapid growth of the med;cal program and the development of this matrix of compounding variables, Dr. Burr and Dr. Wyzen requested a position paper that would outline for DOE the alternatives for the support of a study of radiation-related injuries in the Marshall Islands. These options should include a wide spectrum of alternative programs, keeping in mind the inextricable interrelationship between BNL screening and the health of the people of the Marshall Islands. We feel a failure to deal effectively, in some way, with the primary care requirements of the people will lead to further ill will, failure to comply with the research protocol (e.g., thyroid therapy), and, finally, litigation and a call to foreign and national antinuclear groups to witness the “mistreatment” of the Marshallese by the U.S. government. Since primary medical care is clearly not the mandate of the DOE, perhaps some
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interdepartmental agreement could be reached with the Department of Interior. and/or the Department of Defense to answer this very pressing problem. U.S. monies are already going to the Trust Territories to provide health care but the utilization of those funds leaves much to be denired. The analysis of options open to ~E-BNL has been …
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