Field Task Proposal/Agreement, Subject: Medical Studies of the People of the Marshall Islands Accidentally Exposed to Fallout

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I wCIRK PACKAGE NUMBER 2. TASK NO. 3. REV NO 4. PROJECT NO. 5. DATE PREPARED G. CON ~_~TOR NLil;EfI 7 TASK TITLE Medical Studies of the people & WORKPACKAGE TITLE 9 BUDGET AND REPORTING CODE 10 &A:”UTERM 11 CONTRACTOR NAME 12. CODE IP Code 16 lsth!sra$~ 17. Ooes rhi$ task include The primary object Lve is the determination of the life-time effects of fallout radiation on the ~rshallese who were accidentally exposed to radioactive fallout on March 1, 1954. Ffedical surveys of these people have been conducted at quarterly intervals. In the future, surveys will be semiannual in view of the improving medical care by Marshall Island Health Service under the direction of the Seventh Day Adventists (SDA) and the bpending ~P~ementation of the Burton Bill. In the event that either or both fail to perform as expected, it will be necessary to revert to quarterly surveys. h unexposed Rongelap population is examined for comparison. The suweys, carried out jointly by Brookhaven Xational Laboratory under the auspices of the Department of Energy, and the Trust Territory of the Pacific Islands, are of great importance in view of the development in this population of growth impairment in some exposed children, thyroid lesions, and case of acute leukemia. 79. CONTRACTOR TASK MANAGER

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TASK REQUIREMENTS FOR OPERATINGI’EQUIPMENT OBLIGATIONS AND COSTS Associated Lniversicies, Inc. 3 ECU IPMENT OBLIGATIONS 6 9 9 34 b, TOTAL OPERATING COSTS . TOTAL EQUIPMENT OBLIGATIONS

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TITLE Medical Studies of the People I BUDGET AND REPORTING CODE [ DtiE PREPARED of the Marshall Islands Accidentally CONTRACTOR NAME CODE WP NUMBER TASK NO. REV. NO. Awxtated Uniwrsihes, Inc. ONL o Although the Liktanur 11 does not fulfill all the requirements for the BNL medical team, the Marshall Island Airline will be able to transport personnel to Rongelap and Utirik commencing in H’81 and, in part, fulfill the necessity of having a larger ship. Since there is adequate air transportation from Kwajalein to Majuro, the Liktanur II will not be required after a Medical Facility is built on Majuro next to the new hos~ital site. Recent discussions with Marshall Island Government officials indicate that the new hospital will not be constructed for at least three years. Since its laboratories and x-ray facilit’:o will be used, the services of Liktanuz 11 will be required to provide laboratc -es and x ray until the new hospital and the BNL Medical Facility are constructed. None in W 1980. In the interest of economy, the 25th year Report will be combined with the 26th year Annual Report and published in W 1981. c Post-exposure surveys in the Marshall Islands have been conducted for 26 years. In addition to the 244 persons originally lxposed, a group of unexposed ?larshallese are examined for a “comparison population” to assess late effects of radiation from fallout. 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 with thyroid nodules are returned to the United States for 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 Kwajalein and make intermittent trips to Rongelap, Majuro, and Utirik to supe-ise care and perfonu interim examinations of the exposed Marshallese. The work is conducted in conformance with generally accepted methodology for investigations of this character.

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TITLE Medical Studies of the People BUDGET AND REPORTING CODE DATE PREPARED of the Marshall Islands Accidentally CONTRACTOR NAME CODE WP NUMBE? TASK NO. REV. NO. Associafd UnivwtitiOs, Inc. EJNL o 20. Detail Attachments. cont. Fiscal control will be exercised in the form of monthly comparisons, over the task term, of actual costs incurred against corresponding line items of the budget. Technical results shall be monitored through a periodic review, by the Contractor Task Manager, of accomplishments by measuring actual performance as compared to expected progress. All work shall be conducted in conformance with generally accepted standards for RhD and other investigative or analytic procedures, as observed by universities and large independent research facilities including Brookhaven National Laboratory. Technical Progress in FY 1980. In ‘FY’80 there were two surveys: a September-October 1979 and a May-June 1980. Y%e first survey was primarily pediatric with consideration of those adults not seen in last survey, parasitologic, and dental examinations. The May-June survey considered adult exposed and non-exposed persons with emphasis on hematology and endocrinology. Wring FY’80 6 patients werr transported to BNL for general workup and thence to Cleveland for thyroid surgery. One patient had adenopapi.llary carcinoma and the others benign lesions. Dental, ophthalmologic, and parasitologic studies were continued. The incidence of spontaneous thyroid tumors in the unexposed Marshallese is still not known with any degree of certainty and, until this is established, the significance of the thyroid tumors seen in the Utirik population remains uncerPediatric Sick Call Adult Sick Call Thyroid, Lab, X Ray

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Medical Studies of the People BUDGET AND REPORTING CODE DATE PREPARED of the Marshall Islands Accidentally ,. CONTRACTOR NAME CODE WP NUMBER TASK NO, Asxioted Univwsihef, inc. 20. Detail Attachments. Cent . f. Technical Progress. cont. Technical Progress in FY 1980. cent . c’ Anthilminthic therapy (Vermox) continues. Dr. Krotoski, USPHS, Nev Orleans supenises this and either he or an associate makes surveys annually. S&EP, BNL, continues to re-evaluate the thyroid dose from the iodine family The BNL technician in residence has been exceedingly valuable in assisting the resident physician to continue to deliver improved medical care to the exposed populations and to consult with the Marshall Island Fealth Services. The revision to Li.ktanur II improved the ship considerably, although it is still not large enough to really supply the needs of the medical program. ln addition, its sailing characteristics even in moderate seas induce a high incidence of severe seasickness in susceptible personnel. Expected Progress in n 1981. The Tabershaw contract for an epidemiological survey of Likiep was not implemented. The problem of disease on Likiep, asserted by others to be The educational activities of Dr. Naidu in 1979 were very helpful in bettering an understanding of the Xarshallese and improving their attitudes towards the medical team. No untoward encounters were experienced although the political and legal activities of the Marshall Island Atomic Testing Litigation Project are beginning to stir up further unrest. The survey of October-November 1?80 was completed. Four thyroid tumors were di94eovered. Three are in exposed persons (1 Aili.nginae, 2 Utirik, and 1 an

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nTLE Medical Studies of the People BUDGH AND REPORTING CODE DATE PREPARED of the Marshall Islands Accidentally CONTRACTOR NAME CODE WP NUMBER TASK NO. 20. Detail Attachments. cent . f. Technical Progress. cont. Expected Progress in ~ 1981. cent. unexposed person from Wotje). The three lxposed were brought to BNL on January 8, 1981 and were operated on in Cleveland the week of January 12th. ‘I%o tumors were benign, and one was an adenocarcincnna. To date, suusnaries of ~ertinent diagnoses of all exposed personnel have been cxspleted and will be forwarded to the resident physician and to Majuro after the exposure history and other pertinent data are microfiche. The examination of large numbers of Bikini people and extension of surveys to Wotje, Likiep, and other atolls cannot be undertaken without additional funding for BNL. It is probably unwise for BNL to undertake such epidemiologic surveys. The study of the Bikini people resident at Ejit and Ebeye is reasonable if planned ahead. The entire BNL program should be revised if and when the Burton Bill is implemented, to assure that there is no duplication and that the programs complement each other. Expected Progress in H 1982. 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 pericd of a number of significant carcinomas. Special examinations for the thyroid abnonualities, 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” radiation, the data from this study, even though the population is small, should serve as one of the longest prospective 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 with thyroid surgery in the United States on unexposed Rongelap and Utirik 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 at.alysis of the people and the ecosystem; d) studies with Dr. Rlymond 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; and e) studies of polymorphism and rare protein variance in the blood cells of children of exposed and unexposed parents—Dr. James V. Neel at the University of Xichigan has expanded his battery of tests for these variants and has agreed to continue these studies on Marshallese children. Expected Progress in Ff 1983. Continuation of the medical surveys and limited primary care of the ?iarshallese is anticipated on an indefinite basis. !bphasis will be placed on examinations for thyroid abnormalities, the previously-mentioned cancers,

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TITLE Medical Studies of the People BUDGET AND REPORTING COOE DATE PREPARED of the Marshall Islands Accidentally CONTRACTOR NAME CODE WP NUMBER TASK NO. REV, NO, f. Technical Progress. cont. Expected Progress in FY 1983. cent. hematologic disorders, and other possible effects of radiation exposure. Coordination with the patient and ecosystem nmnitoring teams from the Safety and Environmental Protection Division will continue. The scope of this program will be revised as the Burton Bill is implemented. Data obtained from this study will continue to provide baseline statistics for all studies of human health effects of acute high level and long-te~ low l~vel internal and lxternal radiation. h. Relationships to Other Projects. 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 fisherman exposed at the same time as the Marshallese to fallout. Acute and long-tenm, low-level radiation ranks as one of the most important hazards that ast be considered in the DOE 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 contaminated Marshall Islands and their inhabitants. These studies are closely coordinated with the medical Work done under this task proposal has either no environmental impact or has impacts similar to those described in and covered by BNL’s Environmental Impact Capital Equipment Requirements for FY 1983. A thyroid scanning system for combined x-ray fluorescence and radionuclide imaging studies is necessary to identify nodules of interest. The systsm smploys a large germanium detector (6 cm diameter, 2 cm thick) in a vertical mount; the du$ed and available at BXL in high purity and in large amounts. The system uses

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‘TLEMedical Studies of the People BUDGET AND REPORTING COOE DATE PREPAREO of the Marshall Islands Accidentally CONTRACTOR NAME CODE WP NUMBER TASK NO REV. NO 20. Detail Attachments. cont. Capital Equipment Requirements for FY 1983. cent. pulse-stepping motors driving a precision machine tool scanning table, under computer control, acquiring counts from characteristic x and gamma rays in CAMAC scalers and storing these in an LSI-11 in the CA.MAC controller. Data can be archived on floppy discs for analysis and image production. A monitor display will be included, buc final high quality images will be produced in the nuclear medicine general purpose This system will provide high quality dia~nostic i~ages that scale precisely, to the anatomical size of the neck. Xodules can then be marked on the image to compare precissly what is felt by the physician and what is detected by the imaging procedure. The x-ray fluorescence scan provides information on the iodine content of the thyroid that can be differentiated from findings on solid tumors by ultraThe x-ray fluorescence method yields data with low false negative rate; conveys very low radiation dose to the subject (< 100 mrem/study—rhyroid dose, essentially O whole body dose); and should be used in populations in which the risk of thyroid cancer is high and where there is reason to minimize radiation exposure. One-half the cost of the system ($20,000) is requested for studies of Marshallese patients. The balance of the cost will be requested in the Xuclear Medicine Program A portable x-ray unit ($7,000) is required to replace a device that is expected to be beyond economical repair. The unit currently in use by >Iedical Team surveyors is exposed to salt air and water. It is essential that the survey team have equipment that is reliable and as maintenance free as possible.