DISCUSSION
DR. HisLEP: Dr. Langmuir has laid out
very beautifully the case for epidemiology
with respect to communicable diseases, but
he said little about the importance of
epi-demiology in respect to chronic problems. I
think then it is logical to extend the
con-cepts that Dr. Langmuir outlined to a
con-sideration of such a chronic problem as
radiation effects.
We have here a phenomenon, at the dose
levels which have been most discussed, of a
long, latent period between exposure and
manifestation of effects and non-uniqueness of biological effects of radiation, making
causality virtually impossible to assign in
individual cases. Thus, good epidemiolog-ical principles must be followed in studying radiation effects in humans.
Permit me to use as examples some of the
presentations that have already been made.
The studies at Hiroshima, Nagasaki, and
Rongelap seem to me to have been
charac-terized by a high degree of epidemiological sophistication.
From the brief comments of Dr.
Chad-wick and Dr. Thompson I was prepared to
criticize the Utah study on the basis of why look at these 2,200 children without
knowl-edge such as where they were at the time of
the presumed risk. Dr. Thompson tells me
that they do indeed have this information
and that it will come out in due time. The
question remains as to whether it would
have been more effective and economical to
do the epidemiological studies first.
Dr. Hempelmann’s work clearly has a
strong epidemiological component. He
ad-mitted the limitations of the mail order
type investigation that he is having to use. This does not detract from the value of the information he is getting, but if better
epi-demiological techniques were available the
value of the study would be enhanced.
Let us turn now to the Eskimos. Dr.
Saenger made a critical point about this
study that must have been misunderstood,
judging from the testiness of the rebuttal to it. A great deal of time, effort, and money is
going into ecological studies of quantities and concentrations of cesium’37 in the envi-ronment and in the people. Yet, there is no indication of any effort to determine what
is happening or what will happen to these
Eskimos from a medical standpoint. This is
no criticism of Mr. Hanson’s work, he is
doing the project as he was requested. Per-haps it is a criticism of the officials who
have committed money and effort to this
project without taking the crucial step of
going on to determine what the basic
con-cern is with respect both to the welfare of the Eskimos and to the value of the scien-tific information that could be derived.
Dr. Haynie then made a plea for more
epidemiological follow-up on persons,
par-ticularly children, who receive clinical
ad-ministration of radionuclides. Surely this
appears to be fertile ground.
Dr. Rivera’s excellent work suffers
inter-pretation by his own admission from lack of
what is really good epidemiological data.
Dr. Charles showed a slide indicating
what was in effect the state of readiness of 50 states with respect to taking
counter-measures from fallout problems. The
infor-mation with respect to my own home state
of California was quite misleading, and I
had the same comment from representatives
of other states about the same thing. The
point here is not whether the right questions
were asked, or whether they were asked in
the right way, or whether the answers were
poor or not; the fact remains that this was in effect an epidemiological study in which the data leaves something to be desired.
My conclusion is that, although there are
outstanding examples of investigation into
radiation problems that have effectively
used the strengths of epidemiology, there
are too many examples of this not being the case.
DR. WEHRLE: Dr. Langmuir and Dr.
Heslep have led us along very beautifully
toward one direction we must go. One of
the problems that we have with regard to
deter-SUPPLEMENT 339 mining which are important. This is
partic-ularly true with the orphan type of agents that are potentially capable of causing
dis-ease that we are dealing with today.
Ran-dom case reports will continue to come in
to health agencies and some may require
attention. Dr. Langmuir alluded to this
very nicely as they exemplify the problems
inherent in focusing down in the one case
in five million that is important. However, if we reflect for just a moment on the
prob-lems presented by a drug that would
pro-duce a less dramatic defect than
thalido-mide-perhaps producing a patent ductus
rather than absence of extremities or
per-haps something that produced as dramatic
a defect with less frequency-could this drug be identified promptly? We realize we must
consider that radiation hazards are one of
many. There are hazards presented by
var-ious therapeutic agents, the various
immu-nizing agents, many food additives, many
pesticides, and additives that are going into
fuels. We have a whole battery of orphan
agents here for which we should be
think-ing of some kind of surveillance and this
must be in addition to specific radiation damage.
Is this a completely impractical kind of
surveillance? Actually, current
develop-ments may provide a workable approach
for this particular kind of surveillance. One of these is the greater use of automatic data methods. The second lies in the extension
of health insurance programs under Titles
XVIII and XIX of the Social Security
Leg-islation. For the first time we have not only the ability to provide rapid data recall but
also the necessity for reporting various
types of illnesses for compensation
pur-poses. This reporting could be designed to
provide a very sensitive method of detect-ing potentially hazardous agents by atten-tion to particular organ systems, diseases, or types of congenital defect observed. Dr.
Langmuir’s remarks and Dr. Heslep’s as
vell suggest that, if we are really to have
assurance that we can live with noxious
agents that are being added to the
environ-ment, we must develop a surveillance
sys-tem which will detect effects of these
addi-tional factors upon the morbidity of both
defect and disease.
DR. THOMPSON : I want to congratulate
Dr. Langmuir for his fine presentation and
comment on the commentor’s comments on
the Utah fallout study in terms of its epide-miological studies principles.
The question which Dr. Heslep asked is a
valid one. Unfortunately, this conference didn’t set up an agenda item to discuss the
Utah situation. Consequently, it has not
been adequately set forth here. Most of you don’t know the full scope of the Utah study.
You know of the thyroid nodules in
Wash-ington County because this is the point that got national publicity. The study in Utah is an epidemiological study. It is a very
com-prehensive study and there is a great deal
accomplished and a great deal more to be
done. None of it has been written about
any place.
As you will remember, following the
Utah episode the question was raised in the Joint Committee Hearings in Washington, and also raised in the public press in Salt Lake City, has there been any detrimental
human effects from radiation fallout? The
answer has been that there has not been any identifiable disease in humans so far
report-ed. The next question is, have you looked
for it? How do you know it is not there,
and no one has found it or reported it?
Prior to the Congressional Hearing, the
people of Utah and the U.S. Public Health
Service, namely the Radiological Health
Division, had already set in motion a plan
to try and answer the question : Is there
detrimental effect which has not been
iden-tified? This is a complicated problem on
which we have little to work. It is obviously retrospective epidemiology.
In the 1963 Congressional Hearings the
Joint Committee formally requested the
U.S. Public Health Service and the Atomic
Energy Commission to undertake the Utah
study. Its title is something like, “The
Radi-ation Effect on the Human Population in
Utah and Nevada,” and it does include the
study to 1948, and from here on to the
fu-ture of how many years I don’t know, of
thyroid carcinoma, adenoma, or any other
thyroid disease that results in surgical
tis-sue from a patient under the age of 30. We
went back to 1948, in order to get a base
prior to the first testing at the Nevada test site. This also includes congenital
malfor-mations, leukemia, lung cancer, hepatic
cancer, and some other incidental items.
Obviously, there were some special points
of interest in Utah besides the total popula-tion. One of the special areas of interest
was the Washington County-St. George
area which had a very early experience.
There are other areas in Utah where we
may still have to do a St. George type of
study all over again with other populations
which have been exposed on a level which
may have been of importance.
In addition to this, there is the dosimetry
which Dr. Chadwick’s staff is working at
with a special task force. I understand that Dr. Mays is a task force of one, and maybe
some colleagues of his may come up with
some information on the dosimetry which
till now has to be developed without the
facts. We would like to have them back in
the 1950’s. From 1953 on there are some
measurements, but obviously they are
mad-equate. Now we have a question of how
best to carry this out.
Why was there publicity on the St.
George study? Obviously, all of the school children in St. George cannot be examined
without someone knowing about it.
Wheth-er we liked it or not the television cameras were there with the first team. This is
al-right. We don’t have any secrets. We call
this a fish bowl study in Utah. There are no
secrets in this and we have made it
com-pletely open to all parties concerned when there was something to talk about.
There are other aspects to tile St. George
study and the Safford, Arizona, study which
have not been mentioned, which may be
just as significant whether negative or
posi-tive-that is the eye and teeth survey. You
haven’t read about this because it did not
make the headlines. In fact, I don’t have the
data on the teeth or eye study because it is still on IBM cards and we have not gotten around to this. The reason the thyroid thing
got so much publicity was because this
was a clinical condition. We did not feel we could let it ride until all the
epidemiolog-ical studies were done. \Ve needed to
ad-vise the family and the family physicians of
the expert’s findings at that moment.
Con-sequently, this became public information
in a general way. We put the clamps on the
information from the standpoint of the pub-lie and the press when we reached the stage
of diagnosis and treatment and the
admis-sion of the children to the hospital; this be-came an area of privileged communication.
This was honored by the press in Utah and
nationally with one or two exceptions. This
was with the understanding that when the
clinical study was finished everybody
would be given a report of the clinical
studies and this is what you are reading in
the news release today. This is why Dr.
Chadwick and I can’t answer your
ques-lions, the epidemiological studies are not
completed. We are just as anxious to have
this information as you are.
I want to bring out that even in carrying
out a good epidemiological study you do
have the public information factor to
con-sider. It has to be presented honestly and
sincerely. We feel at this time that it would be no longer right not to give out the
infor-mation on the clinical findings. From here
on in, there just can’t be any more state-ments to the public until the epidemiolog-ical studies and probably the dosimetry as-pect are put into focus to give us a total an-swer. Every surgical thyroid in Utah under the age of 30 years is going to come under the special scrutiny of a group of
patholo-gists that really know the problem to
in-form us before any statements are made.
I wish I could say the data in Nevada is
as far along as the Utah data. Here again
we are trying to cope with the total
popula-tion who have had more than usual
expo-sure.
DrI. ROBINSON: One of the effects of
SUPPLEMENT 341
discussed is the effect on the nucleus and
particularly on the chromosomes. One of the effects on the chromosomes is
nondisjunc-tion. One epidemiological technique could
be used on a study of a large population exposed to radioactive fallout is a study of the status of abnormalities of the sex
chro-mosome body in these populations as an
index of nondisjunction. Perhaps this could be one of the answers to Dr. Langmuir’s or-phans looking for a disease.
DR. LANGMUIB: I don’t think I will take up the points seriatum, but there are one or two general points I would like to comment on.
I agree with Dr. Wehrle, we certainly
need to go after quite a battery of these or-phan agents. We are doing a little of this,
we have a cluster of meningomyoceles. It
got us quite steamed up because this
oc-curred just at the right time, about 7
months after the major fallout period of the
last episode. It also occurred with the
influenza B epidemic. It also occurred when
the Type II polio vaccine was being given
in large volume in Atlanta. We had a
clus-ter of 19 cases of meningomyocele rather
than the expected 3 or 4. We looked at the
other three causes very closely and we
could not tie up any one of these to the
epi-sode. We are confident that looking for
these and working them to the bone will
pay off in our time, but we must admit it is very frustrating.
I am very much interested in the uses of
new means of data processing that Dr.
Wehrle mentioned. I have great faith that
surveillance when properly interpreted and
properly evaluated can have a broader
