Position Paper for Marshall Island Study

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INTRODUCTION AND STATEMENT OF PROBLEMS On October 3, 1978, a meeting was held at the Department of Energy (DOE) Headquarters in Germantown. Maryland, t.odiscuss a number of problems related to the DOE position in relation to several different programs in the MArshalJ. The Medical Program, under the auspices of Brookhaven National Laboratory (BNL), generated a great deal of discussion, concerned primarily with the 1. The research mandate of BN’Lfor the study and care of radiation related diseases in the exposed populations is clear. However, over a period of twenty-five years, that mandate has been expanded to include care for non-radiation related diseases. This evolution has been necessitated by the virtual absence of adequate primary care in the Marshall Islands. The BNL 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 mbrbidity and mortality in the exposed and control 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 -/fiJf the ability to resolve all “abnormal” findings and to assure the patient of referral to an adequate primary care center.)

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B. The difficulties are compounded by the fact that valid pre-exposure 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 ,~-@is pathologic condition is or is not related to radf.ation._~xposure,! ;jfl)fi since a cause--effectrelationship is impossible to establish definitely for any given case. c. The people are intellectually and emotionally unable to deal I with the concept of “probability” without an intensive, highlysophisticated educational program designed not CIrtl.y1:0transfer the information intellectually regarding the role of radiation 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 Ehe future. Such a . program has already been initiated by Jan Naidu, Ph.D., BNL, with 2. The Marshall Islands medical “system” underfinanced. The professional staff is usually not available. under the Trust Territories is undertrained and overloaded. Critical In the absence of a satisfactory primary care referral.base, the ~&tfi’ ~ Medical Program has expanded its mandate to include such things ; as a “diabetic study” (which has revealed a high incidence of “maturity onset diabetes”) but has set up no mechanism for treatment and follow-up of this disease. B. In addition, at the request.of the people, a large number of Marshallese who were not in the exposed or control groups l~ave gone through the screening examination with the detection of a variety of pathologic conditions. An attempt has been made in

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each case to provide immediate treatment if possible, and to refer the patients to the TrLrstTerritories health care system. lJnfortunately,litt?.ehas been done to treat and to has become the de facto primary health care provider to an fiti,ticfl~ ever expanding group of Marshallese. The rationale of the . for all medical care” is their association of~ractically~,$;~~]~lcd illness with radiation. 3. The BNL medical team, because eyes of the Marshallese, come the islands. The BNL Medical 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 of the Medical Program. Two major problems of health care deliv&y for all of the Marshallese involve: (a) communications, and (b”)transportation. To the best of our knowledge, these problems have not been addressed independently as health care problems. With the slow growth of the medical program and the devt~lopmentof paper that would outline for DOE the alternatives for the support of a stud~f ‘t?~fi,~ radiat,~ogrelated injuries in the Marshall Islands. These options should inelude a wide spectrum “of alternative programs, keeping in mind the inextricable

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between BNL screening and the health of We feel a failure to deal effectively, finally, litigation and a call to foreign and national anti-nuclear groups ~ to witness the “mistreatment” of the Marshallese by the U.S. government. Since primary medical care ‘isclearly not the mandate of the DOI?, perhaps some 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 provfde health care but the utilization of those funds leaves much to be desired. The analysis of options open to DOE-B~ has been approached in a system analysis format, utilizing an outline as developed by Gordon A. Friesen, cf . the General Electric Company, Re–Entry Systems Department (Figure 1, page 5). As in any general systems analysis format, some of the elements will be on the basis of available information. In the analysis of to the-various options, two important facts should be kept in there will be a common group of constraints applicable to— These constraints will be listed at the end of this section. Pertinent general constraints will be listed by number in Column 11 (Iabelled constraints) on the flow sheets for each option. Secondly, constraints shoxld be considered in two categories: 1. Absolute - by definition, an absolute constraint offers no alternatives; in effect, it totally blocks an objective or element of an objective (e.g., no funds);

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FLOW DIAGRAM FOR AN ANALYSIS OF THE OPTIONS — ESTABLISH RESTATEMENT l WHAT s THE AFTER l WHO CRITERIA TO THE APPROACH OR APPROACHES INTO A SYSTEM MODEL OR

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2. Relative - these constraints impose a varying degree of modification on the objective, proportional to the power of the constraint (e.g, 20% of the funds necessary to reach the objective). Using this fo~~t , we will examine four options relating to and treatment of: Thyroii and other radiation-related diseases in the All of A plus other patients already taken into the non-radiation relate: diseases (e.g., diabetes). This would include exposed and control group All o: A and B plus all low level have gane through full screening, disease,(e.g., the Bikini group). radiation exposed patients who irrespective of findings of on, or scheduled to be repatriated to, the Marshall Islands ~j-y;; conttinated by atomic fallout; i.e., background radiation higher than median for all Micronesia islands. 1#&, ,:~ , With these’four options in mind , we must first consider the common con- . straints impingtig on the subheadings listed under Column II of the flow sheet (see Figure I). llieunique constraints for each option will be listed as The commog constraints Under current operating include health care for policies, DOE responsibilities do not The definition of “radiation-related” pathologic conditions is not clear. There is uncertainty among radiation experts as to

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the biologic effects of long-term “low-level” radiation. The status of acute and long-term effects of higher levels light of the dose for the offers a greater consensus by t:leexperts. In possible change in ICRY individual, the size of the study group may change in 3. The dosiraetryof the islands involved in the March 1, 1.954 accident is uncertain. It has been restudied and revised repeatedly as new technology and new data become available. Under the circumstances, only population dosimetry is possible. It would appear from the pathologic results, at least to the thyroids of some of the children of Rongelap, that the individual variations might be considerably higher than was previously estimated (private communication with and Allied Diseases, National Institutes of 4. Irrespective of the calculated doses to the the development of radiation-related disease far which the DOE/BNL/DOI has accepted moral and fiscal responsibility has fixed in the minds of the Marshallese the fact that they and emoti.unalset is deep–rooted and probably cannot be erased. 5. The Marshallese consider themselves a “unique” subpopulation by anti-nuclear world opinion, gives them great political

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and economic leverage. Their recent movement for “free association*’will probably not progress to independence, without firm guarantees, in writing, by the United States= that we will continue to compensate the people for injury and damage to their land. Their current concept includes the descendants of those people who have been identified as “injured” through property and/or physical loss. Conversely, the U.S. would like to resolve these claims equitably and to place some reasonable time limit on U.S. liability. The current Trust Territory health totally inadequate to serve as the the BNL team. The reasons for care delivery “system” is primary care referral base poor liaison with their source of funds, i.e., Trust Territory; @+ load (high incidence of a wide spectrum of very poor facilities and upkeep. current “power base” in the Marshall Islands lies in the hereditary leaders and their appointed followers. They have assimilated themselves into the modern (free association) government and exert considerable influence over the territory. They have vested interest in protecting their own wealth and positions and the people have little voice in the actual process of “self-determination”. These leaders are the people with whom we must deal to resolve our problems, but we must understand their orientation and goals. One of these followers recently

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advised his constituents to refuse U.S. compensation payments be:ause he interpreted the payments to be a final settlement for all future claims. We feel the leaders realize the possibility of the potential closing or significant reduction in the government investment in Kwajalein, which is their major financial base. Therefore, they will probably demand continued reparations for their land and people. Due to the wide dispers~on of the islands (atolls) and people, transportation for the medical team, as well as for the Communications among the widely-scattered islands is nonexistent or poor at best. This results in a fractionation of the people, poor flow of information, reliance on rumor, and little or no health care in emergency situations. The solutions— _ inexpensiv~. Yet somehow they have not been implemented. High volume screening of patients for specific data has become a highly--specializedarea. Improvements can be made in screening facilities and methodologies, and these are The recent repatriation of the people of Bikini, who were noked to be accumulating an increased body burden of 137Cesium,

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has compromised, in the eyes of the Marshallese, the safety of living on “contaminated” islands. They ignore or reject background and ecologic measurements of radiation. The same (@ ~~..— apple the people on Eniwetok 13. Personnel ceilings, currently in effect at BNL, prohibit any significant expansion cf the programz e.g., the addition of the These constraints are put in~o context and dissected, in detail, in the follcwing four flow sheets where the significance of their impact on the objectives can be related to the various approaches open to us. The flow sheets . are detachable so that they can be placed in vertical sequence for comparison of each facet under each option. VI. Trade-off or Synthesis We realize that options A and B would in fact, represent a reduction in the level of health care delivery currently available. A review of the most recent “189” for FY’79 and ’80 reveals that in February 1977, DOE agreed “to assist the TT in an expanded health care program for the people living at .,. Rongelap and Utirik. ~;,?’p This included complete medical and laboratory examinations ~ of ...al.lMarshallese living on these atolls.” The problems inherent in that :! agreement were the inability of the TT to follow-up on the diseases discovered in this expanded screening. The BNL field team has limited resources to adequately diagnose and treat primary med-icalproblems. As a result of intensified screening, a large number of “abnormal” findings have been identified.

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These demand further study and resolution if we are to meet the basic tenets of screening: Do NOT screen unless: 1.. You are prepared to follow-up and false negative findings. and resolve false positive 2. The screening process will result in some benefit for the From a moral and medic~legal standpoint, we should insure adequate follow-up and treatment of all treatable conditions. To. identify disease, inform the patient of the disease and then fail to treat it, would run the risk of a serio~s J.ossof credibility for the medical team; and more”fiportant]y: a disservice to the patient. For example, if a patient is told he is hypertensive (e.g., diastolic over 105 nmdig), and is not treated, he can assume that: 1. the findiags are of little importance because...’’thedoctors did nothing about it...”; 2. the doccors don’t care enough about the patients to try to “ treat the condition. Either result is undesirable.. not be ignored in planning this program. A close examination of Ehe ac&a.1 . field conditions reveals that the unavailability of adequate treatment and foil.owup is the c~itical preliminary determinant of exactly wh.ac should be done i.n planning the details of medical and biochemical screening for primary care.. Screening for research operates under different constraints, usually protected by a committee to inform and protect the research subject (A Human Studies F.eview Committee). Failure to comply with either the research or primary care requisites

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of screening is to invite patient dissatisfaction, litigation, IOSS Of credibility and poor medical practice. We have emphasized ‘the problems inherent in “expanded” screening because Lhe research goals of the radiation related diseases are clearly defj.n~d in “- the “189”, but the “expanded health care program” is relatively undefjaed. We have attempted to define the basic “189” in Option A and the spectrum of The synthesis we are attempting to achieve is the full.mandate of Option A, plus as much of Optio~~ as is feasible under present juiisdfc~ionaI and funding constraints. DOE clearly has and the Trust Territories {under DOI) the care under Options C and D. However, with responsibility for Options A and B remainder of primary and secondary the new movement to “fr”eeassociaticm” the responsibility will shift to the administration and people of the Marsha’1. Islands. We would suggest some initial interdepartmental funding to suppo-rt whichever option DOE/DOI desires until the status of the “free association’ is clarified. After a responsible governing body is identified in the Marshalls a new “sharing” of primary and secondary health costs might be negotiated with the Marshalls, that would health care. We feel the exist in the Marshalls to direct an adequate percentage of their budget inta implement and manage this new system and would strongly urge the interested parties to obtain the best available health care system analyst to develop r~alistic cost/effective short and long term plans for adequate health care with existing and expected resources. This is the optimum time to perform this type of study and planning and the outcome will greatly influence the scope of the BNL medical effort. Serious consideration should be directed toward the utilization of existing expertise . in developing health care systems for the South Pacific. The University of—.

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Hawaii has developed well-recognized and highly-effective programs to deal with many of the basic problems confronted by the Marshall Tslands. Those problems are basically a maze of arlthrOpOIOgiCand sociologic characteristics determining tne health …