Protocol for the 1974 Medical Survey in the Marshall Islands

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PROTOCOL FOR THE 1974 MEDICAL SURVEY IN THE MARSHALL ISTANDS The 1974 Medical Survey will begin about the middle of March and will include examinations at Rongelap, Utirik, Bikini, Ebeye and Majuro. The Rongelap people, exposed and unexposed, are examined completely annually, Utirik people every 3-4 years. In addition, following the death of a 19-year-old exposed Rongelap boy last year with acute leukemia, hematological examination in the exposed Rongelap people now takes place twice a year. On the forthcoming survey the exposed and unexposed Rongelap people will be examined completely (except for some of the unexposed to 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 dizbetic survey. Bikini”will be visited at the enci of t’nesurvey for radiological monitoring of personnel and environne?,t. workmen are there and it is possible that by the time of our survey the Bikini people will have returned, is hoped that an LCU will bc assigned to the AEC by the Army for for medical visi~s and radiological surveys in the Marshalls. near Ll)cvillugcs. lixccptat l{ongelap and Ebcye, we would live :]boarclthe LCU. A “bunker” trailer would be brought on the vessel for sleeping purposes and an ezting facility would be established. If the LCU is not furnished we will have to charter a “Trust Territory” cargo vessel. ~ OU gh faster, such a vessel leaves much to be desired. (I’m sure that those who have been on pr~vious surveys will say that this is putting it mildly, ) In addition to the routine history, physical examination and laboratory work, this survey will be highlighted by several other special examinations including a study of thyroid reserve in the exposed people who have not had surgery, a diabetic survey , a genetic study of children of exposed and unexposed parents, and radiological monitoring of personnel and envirorimznt at Utirik, Rongelap and Bikini. The procedures for these examinations a~d the reasons for doing them will be described below. We are extremely fortunate in having Dr. James Field to head up the diabetic survey and Drs. Reed Larsen and Yon Wolff, the thyroid examinations. We are also most fortunate in having the cooperation and support from the Trust Territory, particularly Drs. Kumangai, Iaman and Riklon. 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 to say that we are pleased that certain misunderstandings have been cleared up and I think we can count on full cooperation from the Micronesia Congress and local politicians. Senator O. Borja, who head~up the invcscigational committee for the Congress, has been of great help in accomplishing the improvement in the situation and he may be accompanying us on the survey. L Mr. Bryan Farley, an advisor, may also be along. Mr. William Strcenan of {,;

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the AEC Honolulu Office, has agreed to accompany us on the survey~n order to help answer any AEC-directed questions from the Marshallese. . Streenan has always been extremely helpful in logistic support of our surveys. In addition to the above personnel, Mr. Carl Thien, a EM public relations man and accompanying the team to document various aspects of the survey. Contative rostor of personn~l participating in the‘LIIGfollowin~ is a Administration Assistant, Routcing of pcoplc: Mr. Bill Scott (E~~) Diabetic Survey: Dr. James Field (U. Pittsburgh) To be designated (T.T.)* Reed Larsen (Univ. Pittsburgh) Knud Knudsen (BN_Land Marshall Islands) Cenetic Survey: Dr. Robert Conard Urine Analyses: Mr. Bill Scott Environmental Surveys: To be designated (BNL) To be designated (Univ. Washington AEC Representative: Mr. William Streenan (AEC, Honolulu) Possible guests from Micronesia Congress: Senator 01ympi3 Borja *To be approved by Trust Territory

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Protocol 1974 Continued Page ‘I%ree ‘ll~cpeople to bc cxaminccl will usually be brought into the examination area by automobile. Various Marshallese personnel will assist with interpretation and routing for the examinations. Bill Scott will handle the administration and routeing of the people for the various examinations. Each person will bc given a routeing sheet which will designate the various types of examinations to be done. sunmiafy of each case wi~i be available. ‘he his~~ty and physical exam forms have been revised and copies of the revised forms are attached. ‘l%chistory will be taken by a member of the Trust Territory Medical Personnel yet to be designated. The examining physicians should refer to the history and enlarge upon it through the interpreter as indicated. ‘he physicians carrying out the exams other than the diabetic and genetic surveys are: Drs. Wolff, Larsen, Knudsen and Riklon. Dr. Riklon will interpret as necessary. A complete physical exam will be carried out including L~iSand oscillometric examinations on certain cases. Routine laboratory work will include: complete blood study (WBC, differential slides, RBC, platelets, hemoglobin, hematocrit, plasma collection for blood chemistry) , urinalyses and microscopic as indicated, chest x rays and other x rays as indicated. Chnccr: Careful examination for possible malignancy will include pelvic exam with Pap smears ~ rectal exams in all people over 40 years of a%e~ skin e~ms~ Particularly of residual beta burn scars with color photography as indicated, sputum exams if indicated, x rays as indicated. Leu!{emia: The hemogram will be carefully evaluated and differential smears scrutinized. Bone marrow exam will be carried out if indicated. Blood smears for alkaline phosphatase will be returned for analysis by Dr. Moloney of Boston. Thyroid : Previous drawings of thyroids with questionable or positive findings will be available. From the history careful assessment of thyroid medication adherence should be evaluated. This is of paramount importance in the operated cases who are nearly all hypothyroid without Syi-ithroidtreatment. For the thyroid reserve study (see below) all of the exposed people in that group should be checked to bc 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 Studv: ‘here are 41,~Rongelap people now living who have not developed any significant thyroid abnormalities. It would be of advanta;c ;r,ow what the thyroid reserve status is in this group since it is diii~c-lc to maintain a strict treatment regimen and this information

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Protocol 1974 Continued Page Four may be important in cases that might develop cardiac problems. Therefore 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 included in this study since it is already known that their thyroid function is “arinormaland continued thyroid treatment is of great importance in this group.) In order to test thyroid function in this study it is planned EQ measure thyroxine (T-4 and T-3) and TSIilevels 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 Dictc:-y 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 though: 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 aliquots of 24-hr urine samples being collected for radiochemical analyses. l%ese studies may also be done in some of the Utirik population since their diet is presumably less “westernized”. There 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 ~rinary 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 dose 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). ‘he other study (2) is an evaluation of iodoprotein levels which are unusually high in the Marshallese pc?oplc. Jack Robbins, Ed Rail and I arc particularly interested in invcsti};ating tllccnvironlnental ancl genetic aspects of this finding. OEllcr ctllnic groups arc under study. Onc study in progress concerns the use of orally tldminis~erecl1291 wi~]~ plasma collection before and at 2 and 4 days to determine possible incorporation of orally ingested iodine in the various serum iodine fractions. Thj.s study is of a preliminary nature and dcpc!nding on the outcome, further sampling of the population may bc Diabetic Study: Diabetes in the Marshall Islands, along with cataracts, is considered to be of unusually high incidence. The 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 diabe:cs and radiation exposure in the Rongelaz people, we are anxious to help if possible. We are therefore fortunate in having Dr. James Field, an expsrt in this field, participate in the survey and perhaps suggest further procedures for evaluation and therapy of this disease in the Marshalls.

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Protocol 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 Rongclap people living at Rongelap Island, lZbeyeand Majuro. Sampling of the Utirik population will be carried out to the extent possible. In order to evaluate the genetic component, sampling of other ethnic groups would be desirable but the logistics and time involved in a study at a distant island preclude feasibility at :~:;s time. Of course~ other studies of diabetes in Micronesia zci other Pacific Island groups will be used for comparison. Dr. Kasino, a Trust Territory practitioner, has a strong interest in diabetes in the Marshalls ant :::yassist Dr. Field in this survey. A From discussions with Dr. Field the following procedures are being considered: Ideally a fasting blood sugar specimen would be drawn followed by a glucose meal and 2 hrs later another sample drawn for blood sugar, However, only a limited numbaof people can be tested in this fashion since such samples must bc obtained reasonably early in the day. At later times cl-.,.samples arc subject to unccrcainty regarding food consumption. Dr. Field believes that ii 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 hoped that urine samples for sugar test can be obtained before and after the glucose meal. Obesity and cataract formation as related to diabetes will be evaluated. Obesity my be further evaluated in a limited nunber of 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 content. Dr. Field is working on a questionnarie to be filled out by all subjects in this study concerning family history of diabetes, dietary habits, etc. Genetic Effects of Radiation: ‘ihe generally negative results of the ABCC geaetic studies of first generation children Japanese exposed to the A-bombs quelled our interest in such studies on the small Rongelap population. However I recently wrote Dr. James Ne~-l at the University of Michigan who had been in charge of the ABCC studies for his opinion. Tnough he agrees that it is quite unlikely that such studies in the Marshallese will be fruitful~3~nce he is carrying out a battery of tests for metabolic defects in the red cells and serum of blood in the Japanese children, he is willing to carry out these same tests on the }larshallese children of exposed parents and the parents and also on an equal numbsr O: children of unexposed parents and their parents. In addition he recommends analysis for sex chromosome aberrations in buccal smears. \Je would obtain the smears and they would be analyzed by Dr. Art’nur Bloom, also at the U. Michigan. Dr. Ne~/ also recommends that at che time of the blood drawing a brief physical exam for gross abnormalities also be carried out on i:e children. I will attempt to conduct this study which

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Protocol 1974 Continued Page Six As a result of the nuclear bomb testing at Bikini, slight amounts of residual radiation exist in the environment of the atolls of Utirik, Rongelap anti 3ikini. The amounts are least on Utirik and most on Bikini. ‘l’hepeople living at Rongelap and Utirik absorbed internally slight amounts of radiolevels have been far below the doses set as ~midelines by the International commission on Radiological Protection and otheragencies. l%ere has been nG indication of any ill effects from these exposures, ncrare any expected. A peak dose Gf about 130 mr/year was estimated for the Rongelap people in 1958 with declining doses subsequently. ‘Ihus the accumulated bone marrow dGse Ovcz the years has most probably not been more than a couple of rads froii, internally absorbed emitters. The return of the Bikini people to their home atoll in the near iuture will no doubt attract considerable attention. The radiological safety of their habitation on Bikini has been verified by numerous radiological surveys Gf the atoli includ~ng plant and marine life and an ad hoc committee on which I served years ago reviewed the then available data and decided that the return of the people “did not offer a significant threat to their health and safety”. Recommendations were made to further reduce radiation levels on At Rongclap annual assessment of the body burdens of radionuclic?cs have been carried out largely but by whole-body councing for ganuna emitters have also been made including external radiation measurements, assays of Rongelap diets, edible plants, land crabs, soil, ~rine life, etc. me latter have provided valuable information concerning the transport of imnincnc return of tl)e llilcinipeople, a more up-to-date asscssmtint oi cl]c raciation status of that island and the people living there is of im?ortar.ce and the forthcoming survey will afford an opportunity to accomplish this. F~rthermore the input information on transfer of radionuclides froa enviror.- ment to man on Rongeiap and Utiri’k will be of great value in t’n.sassessment of the Bikini situation and now also Eniwetok. Ihe following procedures are planned:

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Protocol …