Letter to G Stemple, Subject: Medical Surveillance of the Marshallese

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Attorney at Law Beverly Hills, California 90212 At your request I have prepared a suzr,ary of ,my tieeply i~,pressed by the kindness of the people and by ness of che ~-ice speaker and the president to spend time with us and listen to us. i;y r.edical background should be set out so that ‘Jese cpinions may be judged. I have practiced internal nedicine for thil-ty-five years. I have been accredited by the Atcmic Energy Corr.missionmany yeers ago to use radioactive isotopes in medical przctice for”tzeatment of certain thyxoid diseases, including hypexth~roidisrn, and 1 of the first doctoxs to be so licensed for use of radioactive isotopes in their office in Los Angeles. There may have been ten or fifteen others of us at the same time. In preparation fox this licensure I studied about six ~,onths at UCLA, taking courses in radioactive @~~sics and radiation in general. I used r&dioisotGpes for the diagnosis and treatment of thyroid disorders up until about five years ago, when space >ec=me crowded and the large scanner and the devotion of a rocm in my office was BEST COPY AVAILABLE

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no longer desirable. I am certified by the American Boards of Internal Medicine, and am a Fellow of the American Occupational Medical AssOCidtlOn. I am registered in the states of California, Texas, and Illinois to praCtiCe medicine. Finally, as part of my internal medical training, I did one year of intensive pathology. Now for my obsenation: I was immediately struck by ‘the remarkable frequency of visual difficulties and the frequency of thyroid tumors. The frequency of thyroid turlors was shorn by the e.~amination of a n~~ex of patients WhO de,~,onstrated thyroidectomy scars; by the examination of ~ome hospital record, and most important by the history cf ‘de people telling me of the epidemic of these disorders ~arled from two hundxed to moret often, particularly in t.be ~r,aller islands, the individuals who spoke to me :,”hezeable to giveme a pretty fair idea of the number of :~+y~o~~ t’~mors and visual difficulties that Zppeared on Since the nuclear explosions there has been a remarkable epidejnic of thyroid tumors in the i“;arshallIslands, -- to ny k..owledge a singular epidemic since I have never seen its like before, -- starting about fifteen years or so after the onset of the atcmic explosions, and continuing to the present. Some of the victims apparently were in their teens or pre-teens duuing the e~plosicns . and were most characteristically female but some of the victir,s were prob~bly not >“et born at the time of the explosion, although I do not have such a concise chronology that I can szy this with absolute certainty. I recall seeing one patient j.oung encugh so that it wculd be ha=dly likely that she ~ould have been born duxing the The t.hyroidectcmy scars t!!at I saw on these patients h’ere large scars, and for the most part it seems to me that the entire thyroid had been xemoved. Tl~is was borne

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out both by palpation of “Je glands of some of these people, and also their dose of thyroid replacement drugs. Since~ some who had run out of thyroid replacement medication clinically appeared thryroprivic therefore I feel usually the entire thyroid was removed, a type of surgery cor.monly performed for thyroid cancer and not a simple benign adenoma. However I understand from several sources that the Brookhaven Institute under the name of Dr. Conard and his associates reports that in the Marshall Islanders tiere are only very few cancers of the thyroid found, but tia.t almost all of the lesions of the thyroid were benign adeno+~,as. This creates a conflict in my mind, since of the. patients, perhaps eighteen to twenty, who had demonst:-aced to me thyroid scars, one of them was identified histologically as a papillary adenocarcinoma of the thyin case of he presented an unduly hard nodule in t!!e lower portion of one of the thyroid lobes, and so well set apart from the thyroid tissue its-elf, ‘ =!at I fear thi s also might be a carcinoma. That radiation “culd produce. so many benign adenomas and so relatively few carcinomas as I am led indirectly to believe is difficult for me to accept. I should, were I involved in furr}.er st’~dy, like to see sections of all the thyroids -e~]o~eda One should know that there readily arises an ;cnest difference of opinion that occurs between pathologists as to t~hat constitutes malignancy in thyroid tumors and microscopic re-evaluation will be useful. A second is justified by the very high incidence of benign tumors effects of radiation in producing malignancy. There appears to be little doubt that the tumors, just too many of them to be anything else. Othe~vise one zbly high incidence racially of tumors of the thyroid, this existing before” 1?46, =nd the old people I spoke to denied this. They denied that prior to the bortis there was any particular epidemic of lcu,ps in the neck. I cannot thexefore accept the belief that the Narshall lslanrie~s simply by virtue of their heredity have a tenk-as the frequency of

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visual difficulties. I am not an ophthalmologist, and brought no instruments to visualize fie lenses of these’s people’s eyes. However, I learned that on one Island about fifty per cent of the population is losing its vision. This does not come to me frcm one informant, but comes to me from three or four ir.formants. One informant actually said that most of the adults were losing their vision. Sometimes it was occurring in children. This again does not seem. to be concomitant with the blast or follow shortly on it. one would expect the cataract changes sooner if it was due to looking directly at the blasts, and I would not expect it in individuals unborn at the time of the blasts. This appears” to be perhaps one of the most disabling disabilities on the island of Utrik, and if not for the apparent willingness of the island to take care of its om there would be many people on this island suffering by reason of their dimming sight. In a colder, crueler society these people would not be able to sunive. .. The frequency of eye problems is complicated by also the notable frequency of diabetes. Diabetes is an adequate cause of cataracts, and older diabetics mey develope cataracts . However I asked very carefully of those patients whom I saw with visual difficulties, -- I assume they had had cataracts some had been operated on and had cataract removal -- whether they were dizbetic and I understand that while several were, just as many were not, and the diabetic explanation for all of the cataracts and loss of vision does not seem credible. Asain this seems to be a radiation effect. I As another radiation effect there was a period of time when there were an unusual nurher of stillbirths or the birth of monstrosities. I have heard this called ‘the year of the animal, although I understand this phrase to be offensive to those women who bore such offspring and I heard the particular phrase only from men and not connonly used. “ It was the time when children were born with incompletely formed bodies, inccnpletely formed arms or legs, or deformed heads. This occurred late, and not in the nine months after a near-by explosion when one would expect radiation effects. Noreo>-er it occurred in islands distant enough so that direct radiation effects governed

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by the universe square ration ~let emanatin9 immediately from the bo~ wculd be highly unlikely. ~ think the ill effects still persisting on these islands is not only due to soil contamination but is also due to entry of ‘de radioactive elements with a longer half life into the food, where it has been biologically concentrated, and is eaten by the people. Whether the material that contains the radioisotopes is in one particular vegetable or several or whether it is in the fish or birds, I simply do not know. One would think, that if ‘de. lagoon fish were involved, the food-chain exposure would involve only a few islands since I ~ told mat lagoo”n fish usually stay in their lagoon. If the-large fish on the seaside that swim between atolls are involved and carry radioactivity in their flesh, these fish-also being eaten by the islanders, one would expect a wider diffusion of the effects of the radioactivity, -- which is what has happened. There certainly would be diffusion by birds and actual transfer from one atoll to another of radioactive material in the excrement of birds flying between the attols. The wide diffusion of radioactive effects among the islands of the Mirshalls, strongly suggests entry into ‘the food chain with transportation between islands. This is as yet only an opinion. Yet otherwise one must assume that the fallout just sinply was so high, and has spread so far beyond that estimated by our finest nuclear scientists that distant islands and distznt atolls in the l;arshalls were ir.volved, bringing about the radiation effects that To my knowledge, two cases of leukemia k-ere found, one in a high government officer, and the other in a boy. There may be others. I a suspicious also that radiation plays a part here also because of the frequency of leukemia in the Nagasaki-Hiroshima sunivors. 1. think that these three: the tumors of the thyroid

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including cancer, disturbances in vision probably cataracts, and deformities of birth are a part of radiation” injury, and that the continuing injury is in active elements. I strongly suspect that the leukemias were radiation induced. There are otlber areas about which I wonder and about which I am suspicious, but as yet have formed no firm opinion. I am told by the islanders Lhat ditietes has become very conmon. When I spoke to the old people who remember the k’ay the islands were before the nuclear testing, they all routinely deny that diabetes was a great problem for the inhabitants. How as I speak to the Marshallese, I think that.they have more diabetes than the Navajo Indians, and I had always thought the highest incidence was among the Navajos. Although know of no direct radiation effect that causes diabetes. Cn the other hand, I do not know all that is to be Mown about food chain radiation injury and neither does anybody else. our particular human experiences on radiation have been either with therapeutic radiation or the exterior - t~~e of radiation at Hircshima and Nagasaki. Knowledge about food-chain radiation ‘is scant and I am unable to say whether the di+etes is related to the radiation or There are some sexual problems among the males of the island, or among the females. A nunber of men from one atoll had told me that they developed a failure of sexual interest after the explosions, this persisting, and in several cases their families did not expand after the bomb blasts. This also is likely radietion itiduced hut I cannot say whether this is food-chain or whether t this is perhaps external radiation coming frcm the soil, since the testicles are in an exposed posit-ion, particularly in people who so cmmonly sit on the ground or squat as do the people of the Xarshall Islands. Immediate effects of the radiation occurred in scme individuals who spoke to me, these changes consisting of hair loss, and burns of the skin. The burns of the skin occurred in Iihose islanders in which there k.as a dusty, powdery fallout after the explosion called Bravo, %’hich was ef$ected by metereolcgic or inadvertence. There were

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these ulcers, according to the memory of that I spoke to. Startlingly, I was told repeatedly of deaths-on Utric in the month following boh blasts. Several people from Utric told me of three in the month following the first blast, at least two of them being in children and one, to my memory, in a Youn9 woman. One suspects that this imnediate type of response is due to direct radiation connected directly with the fallout, and probably not food-chain, although *solute certainty is not available. All of the people have consistently told me that the damage to the vegetation and the foods that they eat, -- extremely limited to start with -- has been devastating. The Marshallese eat a limited diet consisting of fish, breadfruit, coconut, and,arrowroot. The most sensitive to radiation of the plants proved to be arrowroot. But this was a highly inportant foodstuff on these small isl.mds. As I understood from the Narshallese that I spoke to, before the blast the arrowroot grew as a tuber or rhizome on the root of a,bushy t~e of plant. A healthy arrowroot plant would have six or so tubers, and ~’ould yield a good deal of nutritious food. After the blast, the arrowroot plants themselves started to diminish and the nw~~er of tubers on the roots decreased until the point came at which the arrowroot has almost been lost on scme of the islands and no longer series as a staple in the diet. The Iflarshallese describe to me the tubers shrinking to tb*o to three on a bush, and then to sm~all tubers, and ‘then to the plant just not groxing at all, or growing in a deformed manner. similar effects occurred in the coconut trees. The tops of the coconut trees turned red or brokm after the blasts, and many coconut trees have not borne as well since. The breadfruit trees have borne smaller fruit and often deforned fruit. Scme of the trees themselves have become defomed. I am also struck by the high incidence of h~ertension in the people of the Narshall Islands. The incidence . of hypertension in the average white American male goes up to about five per cent depending on age. The frequency of h~ertension however among the Marshallese far outnumbers that, and judging from the hospital records that I looked

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at when I visited the hospital, and the ans”~ers to the questions that the people gave me, the incidence of hypez - be in the older people as high as forty per cent. some years now general medical opinion indicate that h>~ertension is a stress disease. It can be induced in animals by crowding. If one takes experimental animals of small size, -- rodents, for exanple, -- and puts them into large cages where t!!ey are free to move about, there is no particular increase in h~ertension. If one puts them in small cages where they are crowded a good deal, and particularly puts them in positions where, because of inadequate space or, inadequate food, competition between “&hem for sustenance and living space developes~ then the incidence of experimental hypertension increases very qzeatly. It has increased in western peoples m time of stress. A study in Texas City in our own naticn some fifteen years ago found that when a ship blew up in the harbor, the ship carrying ammonium nitrate, and much of dence of hypertension in the tom rose greatly. been …