 Section 60 of Final Report of the Advisory Committee on Human Radiation Experiments. This is a LibriVox recording. All LibriVox recordings are in the public domain. For more information or to volunteer, please visit LibriVox.org. Recording by William Jones. Final Report of the Advisory Committee on Human Radiation Experiments. Case Studies Chapter 12, Part 2. The PHS Study. On August 25, 1949, the State of Colorado and U.S. Public Health Service officials met to explore radiation safety in the uranium mines and mills. Colorado was home to about half of the U.S. uranium mines. Because many of them were small mines, they employed less than 10% of the country's uranium miners. New Mexico, with much larger mines on average, had a fraction of mines, but nearly half the miners. The Colorado Department of Health established an advisory panel of federal, state, and uranium industry officials to oversee a comprehensive study. The panel advised the Health Department that more information was needed on the medical hazards of the uranium mines. In August 1949, the Health Department, along with the Colorado Bureau of Mines and the U.S. Binadium Company, formally requested a study of the mines and mills which the PHS agreed to do. The PHS initiated both environmental studies of the mines and epidemiologic studies of the miners. The environmental study ended in 1956, but the epidemiologic study is ongoing. In 1949, Henry Doyle, a sanitary engineer who was the chief PHS representative in Colorado, began environmental sampling in the mines. Doyle recruited Holiday to direct the study. The health departments of Utah, New Mexico, and Arizona also participated. The environmental part of the study began first in 1950. Between 1950 and 1954, medical examinations of uranium miners and millers were done on a hit or miss basis. But in 1954, a systematic epidemiological study of the miners was begun. Between 1949 and 1951, PHS investigators took environmental measurements of radon levels in the mines. Like Dr. Eisenbud, they detected high levels of radon. In a February 1950 memo to the PHS Salt Lake City Office, Holiday reported on a survey of four mines on the Navajo Reservation. He declared that while he anticipated that the samples would show high radon concentrations, the final results were beyond all expectations. The samples disclose a rather serious picture, leading Holiday to conclude, quote, that a control program must be instituted as soon as possible in order to prevent injury to the workers, close quote. On January 25, 1951, representatives of the AEC and the PHS Division of Industrial Hygiene and other branches of PHS convened to discuss in detail the radon concentrations discovered by the PHS study and what could be done about them. The PHS staff explained that the uranium study demonstrated, quote, radon concentrations in the mines high enough to probably cause injury to the miners, close quote. They also said the hazard could be abated by proper ventilation. The group concluded that the radon concentrations should be reduced to the lowest level possible consistent with good mine ventilation practices, but found it unrealistic to set a definite level that mine operators should meet. They recommended further research, especially on ventilation techniques. By this route, the radon concentrations in the mines would be materially reduced in all cases, and viable information would be yielded as to the effectiveness of standard ventilation practice in the control of radon. It was also noted at this meeting that the acceptable level of radon in manufacturing was only ten pico-curies per liter, one to three orders of magnitude lower than the observed levels in the mines. The PHS Progress Report for the second half of 1951 explained that because of the acuteness of the radon problem, it was felt that it was necessary to temporarily put aside our full-scale environmental investigation of this industry and concentrate on the control of this contaminant. The PHS met with the mining companies to discuss the hazards and urged them to undertake ventilation measures. In 1979, Duncan Holliday testified to Congress that by 1940 I do not believe there was any prominent scientist or industrial hygienist in the United States, except one, presumably Lawrence, who was not thoroughly convinced of the dangers, and it had been demonstrated that the radioactive elements could be removed from a closed area and be completely avoided. However, it appears the mining industry lacked the commitment to improve worker conditions. The PHS distributed its interim report on a restricted basis to state and federal government officials and mining companies in May 1952. On June 26, 1952, press release announcing the completion of the interim report began with the statement that, quote, no evidence of health damage from radioactivity had been found, close quote. Mining had been going on for only a few years and lung cancer has a 10 to 20 year latency period. The introduction to the report itself noted, however, that certain acute conditions are present in the industry, which, if not rectified, may seriously affect the health of the worker. Meanwhile, as evidence of hazard mountain, Dr. Huper, now at the National Cancer Institute, reported continued efforts to limit his speech on the risks involved. Dr. Huper reported that in 1952 he was invited to speak to the Colorado Medical Society, but declined to attend when ordered by the director of the NCI, at the request of the AEC's Shield Warren, to delete references to the observation of lung cancer in from 40 to 75% of the radioactive ore miners in Europe. Although these occupational hazards had been reported repeatedly since 1879, in a 1952 memo to the head of the Cancer Control Branch of NIH, Huper reported that an AEC representative had objected that references to occupational cancer hazards in the mines were not in the public interest and represented mere conjectures. After the Colorado episode, according to Huper, Warren wrote to the director of the NCI, asking for Dr. Huper's dismissal for bad judgment. Dr. Huper kept his job, but was, according to Victor Archer, one of the physicians who ran the uranium miner study, forbidden to travel west of the Mississippi for research purposes. U.S. officials, including those from the PHS, had no independent authority to enter the privately owned mines, as opposed to those owned by the AEC and leased to private operators, without permission of the mine orders. Dung and Holliday testified in court proceedings that in order to gain access to the mines, an oral agreement was made with mine owners not to directly inform those most affected by their findings, the miners. According to Holliday, this was a routine procedure that was followed in every business survey I was aware of. This went back for many decades. To gain entry to the mines, the researchers agreed that the PHS would not alarm the miners by warning them of hazardous conditions. In 1983, Holliday testified in Begay that you had to get the survey done and you knew perfectly well you were not doing the correct thing by not informing the workers. A medical consent from the PHS study dated May 1960 says nothing about the risk of lung cancer or any other health risk associated with working in uranium mines. There should be no over publicity. Holliday recalled in a 1985 deposition and when we reported the information that we found, it would be done in such a way that the facilities were a particular set of samples were taken, would not be identified, and that we would not inform the individual workers of what data we found. Holliday, toward Stuart Udall, a former secretary of the Interior, who represented the miners in the Begay case, that he did not try to go public because he didn't think that Washington would notice a little Utah tweet from him. Eisenbud has suggested that perhaps this was because in the Cold War environment, with nuclear weapons testing underway, no one would pay much attention to the long-term health risk of a small group of miners. Although the PHS and the AEC already knew the dangers of radon in the mines in 1951, and had pressed the states to take action with mixed results, PHS doctors nonetheless began to conduct basic health examinations to collect baseline data against which long-term health effects of radon could be gauged. These medical examinations did not initially find evidence of harm caused from working in the mines. However, one would not have expected to find such effects because few miners had been on the job more than five years, and lung cancer takes 10 to 15 years to appear. By 1953, the PHS had completed a series of ventilation studies. As early as 1951, federal and state officials meeting with mine owners in Colorado had told them that ventilation had been tried in other mines and found to be satisfactory. But while some large mines were ventilated during the 1950s and 60s, most of the small mines were not ventilated until the 1960s or later, and in those mines that had ventilating systems earlier, they were not always properly used. The uranium miners were discussed at a January 1956 meeting of the AEC's Advisory Committee for Biology and Medicine. The formally secret transcript records that in a status report on the Colorado Plateau, the Division of Biology and Medicines Dr. Roy Albert stated, there are no pressing, particularly pressing, problems associated with it now, but there has always been a rumbling of discontent with the status of the health conditions in the uranium mines of the Colorado Plateau because this is a mining industry which is essentially controlled by the federal government and by the AEC in terms of how much it can produce and how much it paid for its product. Albert explained that the tentative decision was to sit tight because it would be an unusual step for the federal government to enter the mining industry and the AEC could take a wait-and-see approach as the states took up the cudgel. Merrill Eisenberg responded to no evident effect that the federal government should pay to ventilate the mines. I think here is where our responsibility lies because I think this industry would not exist except for the fact that we need uranium. If the cost of operating these mines as determined by us does not permit adequate ventilation of those mines, we will have to change the price. It's as simple as that. In October 1958, the Roy Burney, the Surgeon General of the Public Health Service, wrote to Charles Dunham, Director of the AEC's Division of Biology and Medicine, that the numbers are too small to permit conclusions to be drawn at this time about whether there were excess lung cancer deaths among the uranium miners. However, he added, if this proportion of mortality should increase or even continue in the future, it might be appropriate to conclude that our American experience is not inconsistent with that in Czech and German mine. Dr. Burney added, although we do not have complete environmental measurements in all mines, it appears that about 1,500 men in some 300 mines are working in uncontrolled or poorly controlled environments. The median level of alpha emitters in the mines of one state is five times the recommended working level, and in some mines the level is exceeded by more than 50 times. It is usually the older, smaller mines in which the workers are still exposed to these high levels. Burney concluded by suggesting that as the sole purchaser of ores produced in the mines, the federal government should require mine owners to conform to federal safety standards. Several months later, Dunham wrote a memo to AEC general manager A.R. Ludeck reporting it is doubtful if the commission's regulatory authority could be extended to cover the mines. The same day, March 11, 1959, AEC general counsel L.K. Olsen wrote to Dunham reporting that there is nothing in the legislative history of the 1954 Atomic Energy Act or the 1946 Atomic Energy Act which indicates that Congress may have intended to permit the AEC to regulate uranium mining practices. Later in 1959, the AEC asked the Bureau of Mines to inspect mines at least and then made follow-up inspections to see that the Bureau's recommendations were followed, closing sections of the mine temporarily until corrective measures were completed. In the ten months between July 1959 when the inspections began and May 1960, levels of radon in these mines improved dramatically. As the judge in the Begay decision found, the AEC concluded that it could enforce health and safety measures in leased mines as distinct from privately owned mines pursuant to the leasing provisions of the Atomic Energy Act and amended its mines leases to contain explicit enforcement language and procedures. The states began to enact standards in 1955 but inspection and enforcement came later and varied greatly. New Mexico began enforcement in 1958. Northern Utah did not begin serious enforcement until the 1960s and Arizona, according to Duncan Holiday, did nothing outside of take-air samples. In late 1959, the miners were provided with a PHS pamphlet that warned them about the hazards of radon exposure. The pamphlet mentioned the possibility of radon-causing lung cancer but said nothing about the experience of U.S. or European miners or the level of risk. It said that scientists are working hard to get the final answer on how much radon and its breakdown products known as daughters you can be exposed to safely. It did not tell the miner the suggested figures but suggested bringing enough clean fresh air to the face to sweep out the radon gas and dust. As well as several other measures to reduce exposures. All mining is dangerous and there is no reason to think that any miners went into the uranium mines unaware of this. Whether the uranium miners had an appreciation of the added cancer risk from radon is another matter. The 1959 pamphlet is the first document we could find that indicated that the federal government tried to reduce the miners of the radiation hazards. While the pamphlet mentioned the possibility of radon-causing lung cancer it gave no indication of the level of risk. Duncan Holliday told a congressional hearing in 1979, quote, we in the public health service made every effort to communicate with the men the situation that they were in. We put out pamphlets, conducted medical examinations and told them what the story was. Close quote. This statement is hard to reconcile with Holliday's other statements as quoted earlier that the researchers had agreed not to warn the miners as a condition for access to the mines. When Senator Orrin Hatch of Utah suggested to Mr. Holliday that some of the miners just were not capable of understanding or knowing the dangers to which they were subjected Mr. Holliday responded, I understand this perfectly well. In 1960, the PHS presented to the governors of the mining states what it believed to be conclusive evidence from the P.H. study of a correlation between uranium mining and lung cancer. The evidence showed that at least four and a half times more lung cancers were observed than would be normally be expected among white miners for whom the comparison data were available and that there was less than a 5% chance that such a difference had appeared by chance. The results of a study of 371 mines the number of miners surveyed was not stated. In 1959 showed that the number of mines with unacceptable levels of radon had increased from 1958. Yet the federal government continued to defer to the states on rule setting and enforcement in the case of the mines that were not AEC property and AEC, the PHS and the states continued studies and discussions. Finally, in 1967 Secretary of Labor Willard Wirtz announced the first federally enforceable standard for radon and its daughters in uranium mines that supplied the federal government. After 17 years of debate and discussions regarding the respective private, state and federal responsibilities for conditions in the uranium mines, Wirtz told Congress there are today, or were, when the hearings were called no adequate health and safety standards or inspection procedures for uranium mining. The standard was set at 0.3 working level W.L. Wirtz established this criterion under the 1936 Walsh Healy Act which provided for the regulation of health and safety conditions under government contracts. It is not clear why the authority granted Secretary of Labor under this 1936 law was not used earlier to control radon in the mines but it might have been because most of the mines were privately owned and did not operate under federal contracts, which made the applicability of the act questionable. The Beg A decision. Beg A versus United States was filed on behalf of a group of miners in Federal District Court in Arizona in 1979. The case came to trial in 1983. During the 1950s, according to the court, the PHS found radiation exposures in some mines higher than the level it recommended and even higher than the doses received as a result of the atomic bomb explosion in Japan. But on July 10th, 1984, the court decided that the United States was immune from suit although the judge wrote that the minor situation cries for redress. The decision in the Beg A case poses basic questions regarding the responsibility of the government and its researchers. The court found that the government's actions were aggravated by strong national security interests. The government in making its decision in this area was faced with the immediate need of a constant uninterrupted and reliable flow of great quantities of uranium for urgent national security purposes and as an energy source in the future for the growing peacetime nuclear energy industry. The decision makers had to be concerned that there was adequate data available to justify the standards to be set and that labor and management would have the tools to know when they were in violation. The court is not clear, however, on why or how a standard for radon in the mines would have interrupted the flow of uranium, damaged national security interests, or interfered with the development of peaceful uses of nuclear energy. Fintillating the mines would have been relatively inexpensive improved working conditions. This was demonstrated in PHS ventilation studies in 1951, making it more rather than less attractive to a potential workforce. In 1960, the Deputy Commissioner of Mines of Colorado is reported as having said that 98% of the mines would have to suspend work if forced to abide by a working level standard proposed in 1955, 100 pachyl curies of radium and equilibrium with 300 pachyl curies of radon daughters. In any event, the federal government did not invoke national security as a basis for its inaction. For example, in 1986 Duncan Holiday responded in the negative when asked in a deposition, in all your years from 1949 until your retirement did you ever receive directly or receive indirectly any document from the Public Health Service, from the Atomic Energy Commission, or from any other source indicating you or directing you that you are to pull punches or nothing was to be done because of national security considerations. As for the federal government's policy of not regulating the mines, this appears to have involved questions of the AEC's understanding of its authority and political questions relating to the traditional relationship between the states and the federal government. Was the failure to apply the same approach to the uranium miners as to the beryllium workers a matter of the absence of legal authority as claimed by the AEC or of recent difference to state regulators as the court suggested? The court's decision to not address the AEC's action to require its beryllium contractors to comply with hazard standards nor did it address the fact that radiation standards were enforced in industrial settings. Fragmentation of responsibility, both at the federal level and between the states and the federal government appears to have provided a convenient opportunity for the federal government to pass the buck among agencies and avoid decisive action until long after such an action should have been taken. Under what conditions should researchers enter into a long-term study where there is reason to suspect at the outset that the subjects are each day at continuing and largely unavoidable and unnecessary risk? The Beg a decision states clearly that if the bargain entered into by the government and its researchers on behalf of the epidemiological study it was necessary to obtain the consent and voluntary cooperation of all mine operators. To do this it was decided by PHS under the Surgeon General that the individual miners would not be told of possible potential hazards from radiation for fear that many miners would quit and others would be difficult to secure for cancer. This would seriously interrupt badly needed production of uranium. No individual mine or mines would be publicly identified in connection with that data. Consequently, the voluntary consent of mine operators was secured to conduct the PHS study. The Beg a decision does not address questions such as whether the researchers could have worked more effectively with the PHS agencies that had authority to enter the mines or whether they could have conducted the study in mines on Federal or Navajo land to which they had access. In any case, there is no obvious national security or other ground on which to justify the continued exposure of miners to the radon hazard. As to medical examinations of the miners the court found that the physicians conducted them had the responsibility for dealing only with the examination and the results of that examination. Thus the court concluded it was neither necessary nor proper for those physicians to advise the miners voluntarily appearing for examinations of potential hazards in uranium mines. In the case of the epidemiological study the court explained an epidemiological study deals with group statistics and the conclusion of such a study appropriately cannot be applied to specific participants of a group. The government did not seek volunteers to work in the mines so that they could become part of the study group. At this point the advisory committee disagrees with the court. In epidemiological studies such as the one under discussion group conclusions are applicable to the members of the population of which the group is intended to be a representative sample. That is each individual can be told of the probability of developing disease based on his level and conditions of exposure. If the study was poorly designed then such applicability may not hold but to the committee's knowledge no one has argued this about the PHS study. Moreover the PHS researchers had opportunities to warn the miners face to face because they examined them periodically over more than 20 years. There is some disagreement about whether any miners were warned of the risk of lung cancer but even Duncan Holliday who in one instance indicated that some miners received warnings acknowledged that very likely these warnings were ineffective. End of Section 60 Case Studies Chapter 12 Part 2 Section 61 of final report of the advisory committee on human radiation experiments. This is a LibriVox recording all LibriVox recordings are in the public domain. For more information or to volunteer please visit LibriVox.org Recording by William Jones Final report of the advisory committee on Human Radiation Experiments Case Studies Chapter 12 Part 3 Radiation Exposure Compensation Act The Begay decision concluded that the plight of the uranium miners cries for redress. Because of the doctrine of sovereign immunity however the court declared that it could not provide the appropriate remedy. By 1990 410 lung cancer deaths had occurred among the 4100 miners in the Colorado Plateau Study Group about 75 lung cancer deaths would normally have been expected in a group of miners such as this. In the same year Congress responded with legislation the Radiation Exposure Compensation Act RECA which provided $100,000 compensation for miners with lung cancer or non-malignant respiratory disease subject to certain conditions. In the case of lung cancer the Act requires that the claimant demonstrate an occupational exposure to radon daughters from 200 WLM working level months to 500 WLM depending upon his age and his smoking history the higher figure applying to smokers and older miners. In the case of non-malignant respiratory disease the Act also requires documentation of disease by a panel of radiologists certified in assessing X-ray evidence of lung disease. In both cases records of occupational histories and civil records for next of kin claimants married certificates are also required. Records that are often non-existent or difficult to obtain particularly for Navajo miners. The most recent and authoritative analysis of risks of lung cancer from radon and uranium mining comes from a 1994 NIH publication that re-analyzed all 11 of the major occupational radon studies worldwide. This analysis considerably extends that undertaken by the National Academy of Sciences BEIR 4 Committee which was available in 1986 prior to the enactment of RECA. This report used similar methods of analysis but more recent and more detailed data on a larger set of studies. The most important conclusions of this report are that the risk rises approximately linearly with level of exposure with an average slope that is similar to that estimated by earlier committees including BEIR 4. One, that the risk per WLM varies strongly by age, latency, mining cohort and especially by dose rate or duration being a relatively recent observation but one that is now widely accepted. Two, that there is little evidence that the proportional increase in lung cancer risks is substantially different for smokers and non-smokers as a consequence the probability that a particular lung cancer was caused or contributed to by radon is not materially altered by smoking history. That on average more than half of the lung cancers among white miners in the Colorado Plateau cohort and the Navajo New Mexico cohort were caused by radon exposures and four that there were substantial uncertainties in the actual doses received by miners in different mines. Thus the 200 WLM figure that is used in RECA as the criterion for awarding compensation is not unreasonable as a balance of probabilities for the miners as an entire group but one is a much higher risk threshold than is required for either the downwinders of the Nevada test site or the atomic veterans covered in the same act and two, ignores substantial variation in age, latency and other factors and substantial uncertainties in dose estimates for individuals within the group of all miners so that many miners whose cancers are likely to have been caused by radon would not have attained this criterion. Furthermore the distinction between smokers and non-smokers established in the act is not well supported by currently available scientific evidence and tends to deny compensation to many miners, most of whom are smokers but suffered substantial increases in risk due to the synergistic effect of the two carcinogens. Clearly some miners have a stronger case for compensation than others and RECA makes an attempt to make such distinctions. In principle it would be possible to construct a formula for determining the probability of causation to better reflect the current state of scientific knowledge and a threshold on this scale of probabilities that would treat the miners more equitably vis-a-vis the other groups covered by the act. However the case of the uranium miners presents insurmountable obstacles in this regard, including the loss of records pertaining to occupational histories and exposures and variations in cultural practices and record keeping burdens on claimants especially onerous. When the difficulty of meeting such bureaucratic requirements is coupled with a strong link between lung cancer and uranium mining the scheme unjustly places too great a burden on the individual. The committee is strongly persuaded to propose an adjustment in the criteria so that the evidence of a minimum duration of employment underground would be sufficient to qualify for compensation. Any compensation scheme is necessarily imperfect but given the strength of causal connection and the severity of the energy the time spent in the mines is a rational and equitable basis for determining exposure levels. Conclusions about the uranium miners. The advisory committee concludes the insufficient effort was made by the federal government to mitigate the hazard to uranium miners through early ventilation of the mines and that as a result miners died. The committee further concludes that there were no credible barriers to federal action. While national security clearly provided the context for uranium mining our review of available records reveals no evidence that national security and economic considerations were relied on by officials as a basis for not taking action to ventilate the mines. Since most of the mines were not ventilated the federal government should at least have warned the miners of the risk of lung cancer they faced by working underground. We recognize that the miners had limited employment options and might have felt compelled to continue working in the mines but the information should have been available to them. Had they been better informed they could have sought help in publicizing the fact that working conditions in the mines were extremely hazardous which might have resulted in some mines being ventilated earlier than they were. The court in the Begay decision did not exaggerate when they called the abuse of these miners quote a tragedy of the nuclear age close quote. The committee believes that after 1951 when William Bale and John Harley's findings on radon daughters established that miners were getting a much larger dose to the lungs than previously suspected the mine owners, the state governments and the federal government each had a responsibility to take action leading to ventilation of all mines. There are basic ethical principles to not inflict harm without welfare of others as described in Chapter 4 under which all the relevant parties ought to have acted to prevent harm to the miners. The advisory committee has found no plausible justification for the failure of the federal government which is the focus of our inquiry to adhere to these principles. It is clear that officials of the federal government were convinced by the early 1950s that radon and radon daughter concentrations in the mines were high enough to cause lung cancer. The federal government's obligation flows from this knowledge and it's causal link to the mining activity. Without the federal government to buy uranium there would have been no uranium mining industry. Since the miners were put at risk by the federal government a minimal moral requirement would be that the government ensure that the risk was reduced to an acceptable level. Because the federal government did not take the necessary action the product it purchased was at the price of hundreds of deaths. The historical record is tangled and incomplete but legal responsibility for the health and safety of the miners appears to have rested largely but not exclusively with the states. At the same time the resources to implement remedial measures existed mainly within the federal government. The atomic energy commission which was the contracting agency of the federal government in its role as sole purchaser of uranium interpreted the atomic energy act as not providing it with authority over health and safety in the mines. It is not clear to the committee why the AEC as in the case of Beryllium could not have made ventilation a requirement of any contract to mine uranium or in any event why the AEC could not have sought clarification of its authority from Congress. The Labor Department appears to have had authority under the 1936 Walsh Healy Act to ensure safe working conditions in the mines but for reasons that are again to the committee it was not until 1967 that the Department of Labor applied the act. According to the Big A decision the United States did not recruit miners to work in the mines nor did it cause the miners to be exposed to hazard or withhold treatment from any individual. None of these considerations however detracts from what was for the advisory committee an overarching determinative consideration without the federal government's initiative and its role as a sole purchaser that would not have been an American uranium industry. Because the government played a pivotal role in putting the miners in harm's way it follows that the government had a moral obligation to ensure that the harm be controlled at least to a level of risk which is not excessive of those risks normally associated with underground mining an argument the government used to act in the case of beryllium. The uranium mines were not ventilated however adding particular significance to the second moral issue raised by this case. Why were the miners not warned about the risk to which they were being exposed particularly as the likely magnitude of the hazard became clear. All this question can be properly put to all the relevant parties including the mine owners the state governments and the various federal agencies. Most attention has focused on the public health service. Investigators of the PHS were the only federal officials in direct contact with miners as they recruited and then followed the miners in the course of their epidemiological studies. Also it was in the course of these studies that important evidence about the severity of the risk was accumulated. When the data collected by the PHS indicated the miners were working in an environment where the threat of lung cancer was significant which was clearly the case after the bail Harley findings and when the PHS observed in the early 1950s that the states and owners were not ventilating the mines to the PHS was obligated to warn the miners about the implications of its research. This research appears to have been conducted however under oral understandings with the mine owners that the PHS researchers would not directly warn the miners of the level of hazard. The question arises of course of whether the PHS should have entered into an agreement to study the miners that they were conditioned on not warning them of the hazard to which they were being exposed. The argument for accepting this condition is that it was the only way the PHS researchers could gain entry to the mines and that ultimately the study results would be available and likely save some lives. But the acceptance of the condition precluded the PHS from dealing in a straightforward manner with the people they were proposing providing a warning that had the potential in this case for saving at least some lives. The committee is divided on this issue. Some members concluded that the condition was morally objectionable and should have been rejected even if this meant that the research could not go forward or could go forward only in a limited way. Others argued that a morally acceptable course would have been to accept the condition and as the results emerged warn the miners anyway because in this case the duty of promisekeeping was justifiably overwritten by the duty to prevent harm. The PHS's decision to abide by the agreement not to warn the miners is particularly troubling in line of a regulation as noted by the court in the Begay Decision in force from 1951 to 1978 that govern the disclosure of information obtained and conclusion reached for PHS surveys, research projects and investigation. The regulation said in part that information obtained by the service under an assurance of confidentiality may be disclosed whenever the surgeon general specifically determines disclosure to be necessary to prevent an epidemic or other grave danger to the public health. Certainly at some point the potential and eventually realized lung cancer epidemic qualified under this regulation. The PHS's 1952 interim report is clear that certain acute conditions are present in the industry which if not rectified may seriously affect the health of the worker. So while the PHS had legal moral standing to breach its confidentiality agreement it did not do so although it appears to have made efforts to communicate its findings. The implications and abatement recommendations to the health authorities the AEC mine operators and owners and state agency. The agreement between the PHS and the mine owners no doubt also affected what PHS investigators were willing to tell the miners about the purpose of their investigations at the time the miners were recruited to participate. The PHS told the miners a little more than that they were studying miners health. In fact they were studying one the relationship between exposure to radon and other conditions in the mines and miners health and two engineering methods specifically ventilation techniques for controlling radiation hazards. Had miners been told the true purpose of the study then even in advance of any warnings connected with the progress of the research it is possible that miners could have used this information to advocate for their interests even if the miners were not well positioned to seek employment elsewhere or to advocate for improved working conditions the principle of respect for the self-determination of others would have required a more straight forward disclosure. Current guidelines for the ethics of epidemiological research as well as current practices would not counsel the original bargain with the mine owners the minimal disclosure made to workers about the purpose of the research or the failure to warn the workers as the hazard became clear. For example the current counsel for international organizations of medical sciences CIO-MS guidelines explain part of the benefit that communities groups and individuals may reasonably expect from participating in studies is that they will be told of findings that pertain to their health. CIO-MS guidelines also specify a duty not to withhold misrepresent or manipulate data. Today we are widely recognized among epidemiologic researchers that they have an obligation to report findings indicating potential or actual harm along with the uncertainties of those findings to the people being studied and to the public at large. Although the committee believes that the federal government should have acted to ensure that the mines were ventilated and that the PHS should have informed the miners about the difficulty of the risk it was investigating the committee did not have enough information to assess the moral responsibility of individual AEC and PHS employees and officials for these failures. Some effort was made by some investigators to get the states and mine orders to ventilate the mines and some warnings may have been given to individual miners but the ventilation effort was inadequate and the warnings ineffectual. We lack the information to evaluate whether officials such as Duncan Holiday, Henry Doyle and Meryl Eisenbud should have done more than they did to protect the miners granting that their superiors had ultimate responsibility for decisions not to press for ventilations and warnings. Whistle blowing to avert serious harm is an important moral responsibility but there are personal prudential considerations unknown to us that must be weighed before judging whether these people failed in their duty. While federal and state agencies may debate internally and with one another the limits of their authority from the advantage of those exposed to risk by the government the government should be reasonably expected to do what is needed to sort out responsibility to ensure that action is taken to address risk. This did not happen. Perhaps the most remarkable aspect of the uranium miners tragedy is that notwithstanding the national security context so much of it took place in the open. So many federal and state agencies were participants often with some formal degree of responsibility or authority in an unfolding disaster that appears to have been preventable from the outset. End of Section 61 Case Studies, Chapter 12 Part 3 Section 62 of Final Report of the Advisory Committee on Human Radiation Experiments. This is a LibriVox recording all LibriVox recordings are in the public domain. For more information or to volunteer please visit LibriVox.org by William Jones. Final Report of the Advisory Committee on Human Radiation Experiments. Case Studies, Chapter 12 Part 4 The Marshall Ease Following World War II the United States selected the Marshall Islands as the site of the Pacific Proving Grounds for testing nuclear weapons. The Marshall Islands are a widely scattered cluster of atolls located just above the equator north of New Zealand. They were designated a trust territory of the United States by the United Nations in 1947. The Marshall Ease were granted independence under a Treaty of Free Association that went into effect in 1986. The U.S. Department of the Interior oversees relations with the Marshall Islands with responsibility to ensure that the terms of the trustee-ship agreement are carried out. According to the 1947 agreement, the United States as trustee shall protect the health of the inhabitants. Testing of nuclear weapons began on July 1, 1946 with Operation Crossroads two tests at Bikini at all. In preparation for this operation the Bikiniians were evacuated in March of that year. Crossroads did not lead to any immediate exposure of the native population. However, the second shot in the series, Baker was a 21-kiloton underwater blast that contaminated the surviving test ships posing major decontamination problems for the military participants. It also contaminated the atoll itself which along with further testing returned of the Bikiniians who began returning to the island in 1969. Although some radioactive contamination was still known to linger, it was believed at the time that restrictions on the consumption of certain native foods and provision of important foods would make Bikini habitable. Unfortunately these assumptions proved wrong. After the resettlement the AEC and its successors monitored the internal contamination levels of the Bikiniians and observed increases in plutonium leading to the re-evacuation in 1978. Today, the Bikiniians remain scattered around the Marshall Islands while a new radiological cleanup of the atoll is in progress. In 1954 the Bravo shot of the Operation Castle series was detonated at Bikini atoll. Bravo was the second test of a thermonuclear hydrogen bomb with a yield of 15 megatons a thousand times the strength of the Hiroshima bomb. A change in wind direction carried fallout from the test toward Rungalap and other inhabited atolls downwind of it. The populations of the Rungalap and Uteric atolls were evacuated but not until after they had received serious radiation exposure about 200 Rinkans on Rungalap and about 20 on Uteric. What followed was a program by the U.S. government initially the Navy and then the AEC and its successor agencies to provide medical care for the exposed population while at the same time trying to learn as much as possible about the long term biological effects of radiation exposure. The dual purpose of what is now a DOE medical program has led to a view by the Marshallese that they were being used as guinea pigs in a radiation experiment. As happened at Bikini the Rungalapis were resettled onto their atoll but after an interval of only three years again it was recognized at the time that some radioactivity remained. U.S. officials concluded that appropriate dietary restrictions would minimize the danger. Unlike the case of the Bikinians however the medical FAWA program has continued to the present reflecting the seriousness of the initial exposure and the added risk of continuing exposure at low levels. Five years after the Bravo shot Dr. Robert A. Conard then the director of the AEC's Brookhaven National Laboratory and the NL medical team wrote the people of Rungalap received a high sub-lethal dose of gamma radiation extensive beta burns of the skin and significant internal absorption of fission products. Very little is known of the late effects of radiation in human beings. The seriousness of their exposure cannot be minimized. Low levels of radioactive contamination persist on Rungalap at all levels are considered safe for habitation. However, the extent of contamination is greater than found elsewhere in the world and since there has been no previous experience with populations exposed to such levels continued careful checks of the body burdens of radionucleides in these people is indicated to ensure no unexpected increase. From these considerations it is apparent that we are obligated to carry out future examinations on the exposed people to the extent that they are deemed necessary as time goes on so that any untoward effects that may develop may be diagnosed as soon as possible and the best medical therapy instituted. Any action short of this would compromise our responsibility and lay us open to criticism. These and similar documents discussed below lay out clearly the purpose of the medical program. However, at the fourth meeting of the advisory committee representatives of the Republic of the Marshall Islands presented documents to support their contention that by ignoring forecasts about the weather patterns at the time of the Bravo shot and by resettling the Rungalap on their at all despite knowledge of residual contamination the US government is using the Marshall Ease as guinea pigs and a deliberate human radiation experiment. The committee heard extensive testimony about the difficulties the Marshall Ease have had in obtaining information relevant to their health. Their own medical records are only now being made readily available to them. Many other documents describing US government activities conducted on their soil have for too long been shrouded in secrecy and being inaccessible to the Marshall Ease by bureaucratic obstacles. This inaccessibility of records combined with a history of inadequate disclosure of hazards known to US researchers has contributed to a climate of distrust. In our review of materials that are not becoming available we found no evidence to support the claim that the exposures of the Marshall Ease either initially or after resettlement were motivated by research purposes. On the contrary while there is ample evidence that research was done on the Marshall Ease we find that most of it offered at least a plausible therapeutic rationale for the potential benefit of the subjects themselves. We have found only two examples of research in the rungalup and uteric populations that appear to have been non-therapeutic. This research was intended to learn about radiation effects in this population and offered little or no prospect of benefit to the individual subjects. There is, of necessity some tension between data gathering and patient care when the same physician is responsible for both. The advisory committee has found no clear cut instance in which this tension was likely to have caused harm to patients but some may have been subjected to biomedical tests for the primary purpose of learning more about radiation effects. This inherent tension coupled with the additional strains of language and cultural differences between the Marshall Islanders and the physicians appear to have compromised the process of informing the subjects of the purpose of the tests and of obtaining their consent which has doubtless contributed to their sense of being treated as guinea pigs. In sensitivity to cultural differences, failure to involve the Marshallese in the planning and implementation of the research and medical care program, divided responsibilities for general medical care and failure to be fully open about hazardous conditions have all contributed to unfortunate and probably avoidable distrust of the American medical program by the Marshallese. It is of concern to the advisory committee that the problems arose in explaining to the Marshallese the nature and purpose of the research activities that accompany their treatment and in obtaining their consent for both research related interventions such as bone marrow blood and urine tests and treatment. Both Brookhaven researchers and the Marshallese agree that general medical care provided by the trust territory government was inadequate but this question was outside the scope of the advisory committee's investigation. What follows as best we can piece it together is the story of how the United States handled its responsibility to provide medical care to citizens of a U.S. trust territory exposed to hazard by a U.S. nuclear bomb test that went awry. The Bravo Shot The Bravo Shot was detonated on Bikini at 6.45 a.m. on March 1st, 1954. Its yield was substantially greater than expected. The radioactive cloud rose to an altitude of about 100,000 feet before blowing east toward the inhabited atolls of Rongalap, Ailean Genai, and Rongarik and still further east toward Uttarak Ailuk and Likiyap instead of north into the Pacific as planned. It was soon cleared to the task force command in charge of the shot that evacuations would be necessary and by the evening of March 2nd a ship was steaming toward Rongalap to remove the population. Over the next three days 236 Marshallese were transported by sea and 28 U.S. servicemen were airlifted from a worth station on Rongarik to Quajolain Atoll south of the fallout pattern and then to a U.S. naval base with medical facilities. Merrill Eisenbud has observed there are many unanswered questions about the circumstances of the 1954 fallout. It is strange that no formal investigation was ever conducted. There have been reports that the device was exploded despite an adverse meteorological forecast. It has not been explained why an evacuation capability was not standing by as had been recommended or why there was not immediate action to evaluate the matter when the task force learned seven hours after the explosion that the AEC health and safety laboratory recording instrument on Rongarik was off scale. There was also an unexplained interval of many days before the fallout was announced to the public. Chapter 12 The Marshallese and Americans were not the only ones exposed to the fallout from Bravo. A 100 ton Japanese fishing vessel with a crew of 23 called the Fuku Uru Maru Lucky Dragon was sailing some 80 miles from Bikini when the bomb exploded. Within days crew members suffered from acute radiation sickness. Seven months after the test one of the crew members died. The others were hospitalized for more than a year in 1955. The event received the internal attention and contributed to a worldwide protest of atmospheric testing of nuclear weapons. Dr. Victor Bond a member of the medical team sent from the United States to treat the exposed population immediately after the accident said in an interview with advisory committee staff that initial statements by Washington officials underplayed the severity of the effects of the exposure. Dr. Eugene Cronkite who headed the medical team said he told Louis Strauss chairman of the Atomic Energy Commission in 1954 of his concern that the New York Times and others had reported a downright lie in reporting that the fallout hazard was minimal. Dr. Cronkite recalled Strauss's response young man that nobody reads yesterday's newspapers. On March 6 the Task Force Command approved a request by the Armed Forces Special Weapons Project to establish a joint study of the response of human beings exposed to significant gamma and beta irradiation due to high yield weapons. Thus it appeared to have been almost immediately apparent to the AEC and the Joint Task Force running the CASEL series that research on radiation effects could be done in conjunction with the medical treatment of the exposed populations. Medical follow-up On March 8 Dr. Cronkite's mission was formally established in a letter to him that was classified secret and restricted data and said quote, the objective of this project is to study the response of human beings in the Marshall Islands who have received significant doses due to the fallout of the first detonation of Operation CASEL close quote. The project was given the designation 4.1 entitled study of response of human beings exposed to significant beta and gamma radiation due to fallout from high yield weapons. The letter continued quote, due to possible adverse public reaction you will specifically instruct all personnel in this project to be particularly careful not to discuss the purpose of this project and its background or its findings with any except those who have a specific need to know close quote. As Dr. Cronkite understood it his mission was to examine and treat the Marshallese and the American servicemen who were exposed. Initial exposure estimates ranged from 15 red for people on uteric to 150 red for those on Rungalab. Dr. Bond, who accompanied Dr. Cronkite on the mission, told advisory committee staff that we were given estimates of dose but they were poor and we still don't know very well the effects. The Marshallese were exposed to highly penetrating gamma radiation resulted in whole body exposure external radiation from deposition of fission products on the skin internal radiation from consumption of contaminated food and water and to a lesser extent from inhalation of fall out particles. During the first few days after Bravo several of the people from Rungalab were suffering from nausea and vomiting the first signs of radiation sickness depressed white blood cell counts and slight hair loss. Only one of the Marshallese exposed on alien agonies at all had these symptoms and none from uteric had them. The American servicemen on Rungalab were asymptomatic as well. Although the medical program for the exposed Marshallese was designated a study both Dr. Cronkite and his successor Dr. Robert A. Canard maintained the project never included non-therapeutic research. Both men assert that the primary goal has always been the treatment of the exposed population and that the data that were collected were always intended first and foremost to benefit the Marshallese. There is no conclusive evidence available to the advisory committee to contradict their statements in examining various studies of the Marshallese that could have been driven by pure research goals The advisory committee has found treatment-related goals that are at least plausible. It appears that in the medical follow-up to the Bravo shot treatment and research objectives were essentially congruent. Dr. Cronkite and his team arrived on Quagelain the same day he received the memorandum establishing their mission. They set up examination and lab facilities in the building adjacent quarters of the Marshallese and began their work. Team members took medical histories with the help of translators, inspected scan to monitor for radiation burns, took body temperatures drew blood regularly to check white cell counts, platelet levels, leukocytes and red cells, took urine samples, checked for eye injuries and monitored pregnancies. In the Rungalab population platelet levels fell to about 30% of normal by the fourth week. White blood cells counts fell to half of the normal by the sixth week but at the sixth week point when the initial examinations were completed these blood ailments began moving back up toward normal levels. There was substantially less depression of platelet and white cell counts in the other groups which received significantly lower doses of radiation. Despite the low platelet and white cell counts, there appears to have been little unusual bleeding or increased susceptibility to infection. Dr. Bond said there was some excessive menstruation and blood in the urine but nothing that merited strenuous therapy. About 10 to 14 days after exposure, radiation burns began appearing. These burns were much more pronounced among the Rungalab people than those from alien agonies and the U.S. servicemen on Rungarik and there were no burns noted in the Uttarik group. Often the burns are accompanied by etching and some of the lesions on the top of the feet were described as painful. In two to three weeks the burns began healing. There was some weight loss in the exposed population and about 90% of the children and 30% of the adults lost hair. Dr. Bond told advisory committee staff that the exposed Marshallese seemed to be perfectly healthy people but we were well aware of the latent period and that they might well become ill later. He went on to say and quite frankly I'm still a little embarrassed about the thyroid. The dogma at the time was that the thyroid was a radio-resistant organ. It turned out they had very large doses of iodine to the thyroid. Dr. Ron Kite noted that there was nothing in the medical literature to predict that one would have a relatively high incidence thyroid disorders. In May 1954 the AEC told the DoD that the Uttarik people could return home following the completion of current tests provided that specimens reveal absence of radioactive materials in quantity injurious to health. On Rongalap however radiation levels were considered to be too high. The Rongalapese people were moved to Ajit a small island in Mayuro at all. The United States continues regularly to follow up the exposed Rongalapese and the Uttarikese. The U.S. servicemen were sent to Honolulu for further examination by army physicians. But according to Dr. Ron Kite, somebody at a higher level within DoD decided that they did not want to study the American servicemen and cast them to the wind. Sort of forget them. I think that's a terrible thing to do but it was done. Medically it was unacceptable. Dr. Kronkite went on to explain that if an induced cancer had been identified early diagnosis and treatment it would not have been possible to expose servicemen. The DoD reported to the advisory committee that 12 of the 28 servicemen were examined in 1979 by the Veterans Administration as part of a notification and medical examination program for military personnel exposed to radiation. We have not been able to determine whether any of the 28 had any other medical follow up. According to a report by Lieutenant Colonel R. A. House based on an aerial survey done within 48 hours of the Bravo Blast quote, the only other atoll which received fallout of any consequence at all was eye look. It is not clear to which atoll the word other applies. It was calculated that a lifetime dose would reach approximately 20 rinkins about the same as or slightly higher than the exposure of the uteric population. Unlike the people of Uttarak and Rangalap, however the people of eye look south of Uttarak and eastern marshals were not evacuated at all. The January 18th 1955 final offsite monitoring report of Operation Castle, however gave the eye look exposure based on several aerial and ground readings as 6.14 rinkins. Readings from this report for other exposed atolls were as follows Rangarik 206 Rangalap 202 Uttarak 24 Alienganai 6.7 Vikiap 2.19 and Votya 2.54 People living on these atolls would be exposed to additional radiation as a result of consuming contaminated food. Based on the initial readings of 20 rinkins the U.S. Task Force should have evacuated the people of eye look. A 1987 epidemiological study reported in the Journal of the American Medical Association, however shows higher rates of thyroid abnormalities on other atolls to the south and east of the blast site including Jelluit and Eben. By the afternoon of March 4th two ships, both destroyer escorts, seemed to have been available to evacuate the 400 or so people on eye look. But according to Colonel House, the effort required to move the 400 inhabitants when weighed against potential health risks to the people of eye look seemed too great so it was decided not to evacuate the atoll. However, evacuation would have reduced the lifetime exposures of the eye look population by a factor of 3 according to an estimate provided by Thomas Kunkel of Los Alamos National Laboratory. In testimony before the advisory committee, Ambassador Wilfred Kindle of the Republic of the Marshall Islands noted that the United States Government studied with interest the unexpected and dramatic incidents of thyroid disease on uteric atoll, but no effort was made to reassess the health of the population on eye look or licky up or other mid-range atolls. End of Section 62 Section 63 of the final report of the advisory committee on human radiation experiments. This is a LibriVox recording. All LibriVox recordings are in the public domain. For further information or to volunteer please visit LibriVox.org. Recording by William Jones. Final report of the advisory committee on human radiation experiments. Case studies Chapter 12 Part 5 Resettlement of Rungalap. Between March 1954 and mid-1956 the Rungalap population on IJIT was followed medically with visits from a specialist medical team at six months one year and every year thereafter. According to a preliminary report on the two-year medical survey there has been little illness among the people and none of the clinical entities noted in the Rungalap people appear to be related in any way to radiation effect. By late 1956 about a dozen radiological surveys of Rungalap and neighboring etals had been conducted to determine contamination levels. On February 27, 1957 the Atomic Energy Commission informed the commander of the Pacific Fleet that resettlement was approved despite lingering residual radiation most pertinently in the food supply. This decision which was consistent with international pressure for resettlement was made even though in 1954 US medical officers had recommended that the exposed Rungalap peas quote should be exposed to no further radiation external or internal with the exception of essential diagnostic and therapeutic x-rays for at least 12 years. If allowance is made for unknown effects of surface dose and internal deposition there probably should be no exposure for rest of natural lives close quote. However the displaced Rungalap peas were eager to return to their homeland. In March 1956 Dr. Conard wrote to Dr. Charles Eldunham director of the AEC's division of biology and medicine that quote we are committed to return the people to their homes and that is their express wish close quote. In June 1957 a final resettlement radio survey was made from the air. Gordon Dunning an AEC health physicist wrote that he would have preferred a full survey but that quote it appears we will have to settle for the external readings only close quote. The exposed Rungalap people and 200 other Rungalap peas who were not on the atoll at the time of the Bravo shot were returned to their home islands at the end of June. The advisory committee has not been able to learn why Dunning's advice to carry out a more thorough land based survey was not heeded. A 1957 project report notes that while the radioactive contamination of Rungalap island is considered perfectly safe for human habitation the habitation of these people on this island will afford most valuable ecological radiation data on human beings. Nevertheless the advisory committee does not conclude that the resettlement decision was motivated by AEC research goals. From 1954 on the U.S. researchers recognize the importance of the opportunity that have been presented together data on radiation effects. However we have seen no evidence including this report that convincingly demonstrates that research goals took priority over treatment in a way that would expose the populations to greater than minimal risk. Apart from the radiation deposited by the Bravo shot there is evidence that later bomb tests also contributed to the overall radiation level on Rungalap. For example, a January 1957 letter from Dr. Edward Held the director of a University of Washington group conducting ecological studies for the joint task force said that activity levels in the water at Rungalap were higher in July 1956 than the levels obtained at earlier visits and the best evidence seems to indicate that the increase is due to the re-contamination of Rungalap from the 1956 series of weapon tests. The letter goes on to say quote, the decay of the newly added radioactivity is such that it will soon be insignificant when compared with that from the 1954 series close quote. Atmospheric testing of nuclear weapons was ended in 1963 by international agreement. Post-resettlement medical follow up. After the population returned to Rungalap in 1957 Dr. Conard visited annually with the medical team from Brookhaven National Laboratory. The team's primary mission according to Dr. Conard quote, was to treat the people I don't think at any time the motivation was anything other than the treatment of the effects of radiation close quote. He added however that quote, we also were trying to get as much information as we could into the medical literature. We knew that we were dealing with an area that was unexplored in human beings and we wanted to find out as much as we could about close quote, the effects of radiation exposure resulting from fallout from a nuclear explosion. Part 2 After their return to their native island in 1957 the Rungalapies continued to be monitored annually by the Brookhaven teams. On Utarik, exams were carried out every three years then annually with the appearance of normalities. The examinations included complete physicals, blood tests examinations of reproductive effects including fertility miscarriages, stillbirths observable birth effects and genetic studies growth and development studies of children thyroid function test and palpation and studies of absorption, metabolism and excretion of radioisotopes. In addition to the annual exams conducted in the Marshalls in 1957 some Marshallese were flown from their islands to Argonne National Laboratory in Chicago where a whole body counter and other advanced equipment was available. When Marshallese developed medical problems that required treatment in the United States such as thyroid nodules requiring surgery they were sent to Metropolitan General Hospital in Cleveland for hospitals. One 18-year-old male was treated in 1972 at the National Institute of Health and at a Western Reserve University teaching hospital for leukemia which proved fatal. In our search of documents related to the Brookhaven medical program the advisory committee has found only two examples of studies that were not primarily intended to benefit the individual participants. In one a cheerleading effect EDTA normally administered shortly after internal radiation contamination to remove radioactive material was administered seven weeks after exposure. The stated rationale was that the agent would mobilize and make detection of isotopes easier even though it was realized that the procedure would have limited value at this time because there was virtually no therapeutic benefit envisioned it appears the primary goal of the study was to measure radiation exposure for research purposes although the knowledge may have been helpful in the clinical care of the patient. In the second experiment a radioactive tracer chromium-5-1 was used to tag red blood cells in ten unexposed wrangled uppies to measure their red blood cell mass the purpose was to determine whether the anemia that had been observed among Marshallese was an ethnic characteristic or due to their radiation exposures. The tracer dose used would have posed a very minimal risk but it was clearly not for the benefit of the ten subjects themselves the data could however have benefited Marshallese exposed as a result of the Bravo explosion. No documentation addressing whether the consent was sought is available for either experiment. The AEC was responsible only for continuing studies of the Marshallese to detect radiation effects and for medical care required for radiation related effects while the trust territory government under the department of the interior was responsible for general medical care. But this appears to have been a meaningless distinction to the Marshallese all they knew Dr. Cronkite told advisory committee staff is that something had happened to them and they wanted to be taken care of very logically close quote. Often Dr. Cronkite noted the members of the Brookhaven team did take care of non-radiation related health problems physicians being what they are he said you see disease and there's something you can do about it you like to take care and help people the Brookhaven team sometimes included a dentist because severe dental problems had been observed the dentist mostly did extractions and a little restoration according to Dr. Cronkite the Marshallese appreciated getting dental care because they were getting something they had never had before in their lives and they liked it although the extractions appear to have been done for therapeutic or prophylactic purposes the extracted teeth were analyzed for radioactive content primary care however remained inadequate there were serious epidemics of poliomyelitis, influenza, chickenpox and pertussis all of which according to Dr. Cronkite were imported into the Marshalls by the U.S. medical teams the epidemics were severe with high mortality rates and could have been prevented by the use of available vaccines the AEC insisted that primary care be left to the trust territory which had neither the personnel nor the equipment to provide adequate services Dr. Hugh Pratt who succeeded Dr. Conard in 1977 wrote as late as December 1978 quote the Marshall Islands medical system under the trust territory is under financed the professional staff is under trained and overworked critical supplies are usually not available close quote by 1958 Dr. Conard was aware of Marshall's dissatisfaction with the annual exams and wrote to Dr. Dunham I found that there was a certain feeling among the Rungalab people that we were doing too many examinations, blood tests, etc which they do not feel necessary particularly since we did not treat many of them Dr. Hicking and I got the people together and explained that we had to carry out all the examinations to be certain they were healthy and only treated those we found something wrong with I told them they should be happy so little treatment was necessary since so few needed it, etc, etc perhaps the next trip we should consider giving more treatment or even placebos also in 1958 Edward held the University of Washington Professor involved in environmental surveys of the islands wrote to Dr. Conard about a meeting he had with Amata son of a paramount chief of the Marshalls in which Amata said the Marshallese were apprehensive about being stuck with needles Amata, who is now president of the Republic of the Marshall Islands asked about the need for continued medical examinations and Dr. Held told him that he should talk to Dr. Conard but Held also wrote that there have been medical benefits not connected with radiation which have resulted from the medical surveys he added that Amata agreed this was true the annual exams given to the people of Rongelab were described by Conrad Kutrade a Brookhaven physician resident in the islands from 1975 to 1976 from the Marshallese point of view each march a large white ship arrives at your island doctors step ashore lists in hands of things to do and people to see each day a jeep goes out to collect people for examinations totally interrupting the normal daily activities each person is given a routing slip which is checked off when things are done they are interviewed by a Marshallese then examined by a white doctor they speak their language and usually without the benefit of a Marshallese man or woman interpreter their blood is taken, they are measured and at times subjected to body scans eventually Dr. Conard tentatively arranged for the AEC to pay the uteric participants $100 each for their inconvenience a Marshallese who acted as a translator for the Brookhaven team said that people didn't believe Dr. Conard according to this man they began to say you people coming back every two years to just do the experiments on us like guinea pigs according to Dr. Pratt some of the distrust of Dr. Conard at least among the people of uteric was the fact that he predicted that there would be no cases of thyroid carcinoma in this population and one occurred Dr. Coltrady wrote that for 22 years the people have heard Dr. Conard and other doctors tell them not to worry that the dose of radiation received at the island was too low to cause any harmful effects however it has been found that there is as much thyroid cancer in uteric as at Rungalab three cases each the official explanation for the high incidence of thyroid cancer at uteric is unknown at present yet in the people's mind the explanation is that it is a radiation effect despite what the doctors have said for 20 years in 1961 Dr. Dunham wrote an open letter to the exposed people of Rungalab in which he explained the need for medical follow-up Dr. Dunham specified that one reason was the health care of the exposed population but that the other was of no direct value to you the Rungalab population this is the only instance we found in which a US official explicitly says research is being conducted that has no direct benefit to the Marshallese population under the care of the Brookhaven doctors the letter continued the health studies help us to understand better the kinds of sickness caused by radiation the United Nations has a special scientific committee to study these things and the information we get from our work here is made available to that committee and to the whole world close book this letter was rescinded before it was sent however although it was read once over the radio the broadcast probably did not reach the Rungalab people since there are only three radios on the island courts Ulahan the AEC's deputy general council they requested the letter be rescinded although the reason for the request is unclear the district administrator of the Marshall Islands William Finale complied with the request and the letter was never published many complaints resulted from the fact that the U.S. researchers had difficulty communicating with the Marshallese most of whom did not speak English information about risk countermeasures and radiation was not easily explained to the Marshallese and cultural differences made it difficult for the researchers to appreciate Marshallese practices and customs according to Dr. Bond an early member of the medical team the Brookhaven doctors did not believe that they needed to obtain consent for treatment or to conduct studies related to treatment the Brookhaven team offered needed medical care therefore despite complaints the Marshallese requested extension of the medical program provided to the Rongalep and Uttarak people to include more general medical care and to include other islands and atolls thyroid abnormalities in addition to the one fatal case of leukemia have been the most significant late effective radiation among the Marshallese these endpoints appear to have received both extensive study and appropriate treatment as thyroid abnormalities began to appear in the Uttarak population the Brookhaven team felt they need to establish a baseline in an unexposed Marshallese population over the years members of the I look control population at best an imperfect control population because of their exposure had immigrated or died and had been lost to follow up this population was too small to provide an adequate baseline so the Brookhaven team conducted surveys of 354 people at the Kiev and Wachia atolls in 1973 and 76 they also examined more than 900 Rongalep and Uttarak people who were not on their home islands during Bravo it is likely that many if not most of the control selected had some radiation exposure from the bomb tests during the early 1970s there were increasing complaints about and resistance to participation in the medical surveys coupled with the continuing appearance of thyroid abnormalities including their development in the less exposed Uttarak population there were also growing numbers of people from Rongalap and Uttarak who as a result of thyroid surgery or reduced thyroid function needed thyroid medication and indications that those on medication were not adequately complying with their therapeutic regimen as a consequence of all these events Brookhaven expanded its staff and medical care programs in the marshals in the mid 1970s including for the first time primary care for a number of conditions not thought to be radiation related full time resident staff was increased. In 1973 Brookhaven stationed a full time physician in the marshals quote his primary responsibilities included a. monitoring the thyroid treatment program b. visiting Rongalap, Uttarak and Bikini atolls for health care purposes every three or four months and c. assisting the trust territory medical services with the care of Rongalap and Uttarak patients at the hospitals at Abeya and Mayuro in 1974 the researchers conducted extensive screening for diabetes a non-radiation related condition in order to determine the impact of diabetes on the population and form the basis for development of a program for treatment and management of this significant problem which affects 17% of the population in 1976 a new agreement provided for Brookhaven to provide examinations and health care for all Marshallese living on Rongalap and Uttarak when they made their visit and for the resident Brookhaven physician to assist in the care of Rongalap and Uttarak patients at the hospitals in Abeya Island in Kwajalein atoll and Mayuro the capital of the Marshall Islands in the Mayuro atoll in 1977 an extensive program to diagnose and treat intestinal parasites was carried out by 1978 administrative responsibility in the trust territory government shifted to the individual island groups the Marshallese at this point took responsibility for general health care while the 1947 trust T-SHEP agreement provided for health care for the Marshall Islanders the department of the interior carried out this responsibility mainly in an oversight capacity the department of energy carried on the programs of its predecessor agencies for treating radiation related illnesses in the people of Rongalap and Uttarak during this period the Brookhaven medical team often treated non-radiogenic as well as radiogenic medical conditions in 1985 expressing concern that radio activity in the food chain represented a significant health hazard the people of Rongalap rejected the department of energy's advice that they stay on their island at their own request they were evacuated on the Greenpeace Ship Rainbow Warrior to Mayetto Island in Kwajalein atoll where they remain today in 1994 the national research council published a report that among other things reviewed food chain data collected and analyzed by Lawrence Livermore National Laboratory according to this report on the basis of current radiation dose estimates there is no expectation that any medical illness due to exposure to ionizing radiation will occur in any members of the resettlement population of the island of Rongalap from either intake of native food or environmental contact however the report recommended that no categorical assurance be given to the people of Rongalap that their annual exposure upon returning would be less than the 100 millirem limit agreed to in a 1992 memorandum of understanding between the Republic of the Marshall Islands and the United States moreover the report recommended an initial diet in which half the food consumed would be from non-native sources and that no food be gathered from the northern islands of Rongalap and Rongarik atolls in 1986 a compact of free association went into effect between the United States and the Republic of the Marshall Islands the compact established a $150 million fund to compensate the Marshall ease for damage done by the US nuclear testing program the United States accepted responsibility for compensation owing to the citizens of the Marshall Islands for loss or damage to property in person of the citizens of the Marshall Islands at present there are three separate health care programs for citizens of the Republic of the Marshall Islands there is a program of general health care for all citizens for which the Marshall ease is solely responsible there is a for atoll program which is run by the Marshall ease but funded by the United States at about $2 million a year the atolls that benefit from this program are Bikini in a Weetalk, Rongalap and Uttarak and there is the continuation of the Brookhaven program which is responsible for medical monitoring and care related to radiation exposure the Lawrence Livermore National Laboratory conducts environmental surveys as part of the Brookhaven program whose total cost is about $6 million a year the funding for this entire program is discretionary and can be reduced or eliminated by Congress conclusions about the Marshall ease the United States has a special responsibility to care for the radiation related illnesses of the exposed Marshall ease because of its role as trustee and because it caused the exposures as best the advisory committee can determine it is carrying out this responsibility well treatment has been provided as needed for acute effects monitoring continues to this day and latent radiation effects have been identified early and treated the research conducted between 1954 and today consisted mainly of blood and urine tests and procedures to measure radiation with little or no additional risk to the subjects overall these tests seem to have been related to patient care although two instances of minimal risk non-therapeutic research have been identified the committee found no evidence that the initial exposure of the rungal appease or their later relocation constituted a deliberate human experiment on the contrary the committee believes that the AEC had an ethical imperative to take advantage of the unique opportunity posed by the fallout from Bravo to learn as much as possible about radiation effects in humans nevertheless the inherent conflicts posed by combining research with patient care could perhaps have been reduced by clear separation of the two activities and clear disclosure to the subjects for the most part consent for test and treatment appears to have been neither sought nor obtained although lack of consent for minimal risk procedures performed on a patient population was not a typical for the time, c. 2 the committee believes efforts should have been made to ensure that the people being monitored and treated understood what was being done to them and why and their permission should have been sought while cultural and linguistic differences made communication with the Marshallese difficult at first the advisory committee believes the situation continued for much too long as a consequence dietary differences and other eating habits were not recognized and may have led to higher exposures among some members of the population cultural differences may also have resulted in an inadequate accounting of adverse reproductive outcomes certainly differences in pace and lifestyle contributed to a perception by the Marshallese that they were being told what to do rather than asked the advisory committee was unable to determine whether the early medical team should have been more aware of such cultural differences but they do appear to have been slow to learn the BNL medical team was constrained by instructions from the U.S. government to restrict its activities to treatment and research related to radiation related illnesses general medical care was held to be the responsibility of the trust territory government however there was no adequate medical service available to refer other complaints to so the BNL physicians were put in an awkward situation where as doctors they felt obliged to treat conditions that were presented to them the lack of clear lines for general medical care in the early years of the program seriously compromised relations with the Marshallese since the Marshall Islands were a trust territory both general medical care and care for radiation injuries were ultimately the responsibility of the United States and the care of individuals should not have suffered as a result of bureaucratic confusion thus the committee recommends the expansion of the BNL program in the 1970s to include general health care and the U.S. supported four at all program that went into effect after the compact of free association was approved in 1986 it may be depending on factors such as food chain and other environmental exposure levels that certain mid range at all such as eye look and liquefaction also merit inclusion End of section 63