Child advocacy in the nuclear age

(1)

802 PEDIATRICS Vol. 61 No. 5 May 1978

Edie Jackson was a person totally devoid of

anger or self-consciousness or pretense, and this

delightful combination of unique personal

quali-ties with high degrees of psychiatric skills and

dedication to pediatrics made her one of the very

few individuals in American pediatrics and child

psychiatry who successfully bridged the gap in

the

two

fields by committing herself totally to a

department of pediatrics that cared about a

thorough integration of physical and emotional

factors in child and family health.

Edith Jackson enriched the lives of many, and I

sign this note on behalf of many thousand

physi-cians, nurses, and families whose lives she

touched. Precisely because she influenced so

many educators in nursing, pediatrics, and

psychiatry

and

social work, her contributions

are

being carried on, and she is therefore one of the

immortals-a gentle, serene, and creative life in

the service of man.

C. HENRY KEMPE,

M.D.

University of Colorado Medical Center

4200

East Ninth Avenue

Denver, CO 80220

Child

advocacy

in the nuclear

age

In 1943, amidst the nation’s mobilization for

the Second World War, there appeared an article

by Dr. William Schmidt of the Children’s Bureau

on the susceptibility of young people to the

hazards of radioactive materials.’ Reviewing the

literature, and invoking generally accepted

pedi-atric principles, Dr. Schmidt concluded that

young people possess special vulnerability to the

hazards of radiation, and that this warranted their

exclusion from employment in the gas mantle and

radium dial industries.

Now, more than 30 years later, there again

exists an urgent need to review the topic of

radiation and children. With the spread of

nuclear weapons technology to many countries,

the spectre of nuclear test fallout (not to mention

nuclear warfare!) is once again upon us. What is

at stake in the nuclear nonproliferation treaties

and the strategic arms limitation talks is obvious

to everyone. An issue of perhaps equal import is

the development and dissemination of nuclear

reactors for electric power. Predictions about

future energy needs; concerns about “energy

autonomy”; economic considerations;

uncertain-ties about technological performance; fears

concerning sabotage; the diversion of reactor fuel

for nuclear weapons; core meltdowns; problems

in the disposal of radioactive wastes; and the

possible restrictions on civil liberties engendered

by the “plutonium economy” have all entered the

debate.25 Where once the United States alone

possessed the means of enriching uranium and

extracting plutonium, there now exists an

interna-tional nuclear reactor industry whose members

compete for multi-billion dollar sales by

provid-ing technological advances as “sweeteners” to

attract foreign customers.6

It

is in

this

context that pediatricians, as

advocates for children, are prompted to add their

voice and perspective. The decisions to expand

nuclear power production and disseminate

advanced nuclear technology will affect not only

our children, but children of uncountable

genera-tions to come. More than 2,250 tonnes (2,500 tons)

of radioactive spent fuel are estimated to already

have been produced by the 64 commercial

reac-tons now in operation in the United States.7 In all,

some 200 radioactive fission products have been

identified.8

One

of them, plutonium, has a

half-life

of 24,000 years. While the disposal of

radio-active wastes-from spent fuel rods to

contami-nated work clothes-appears presently to be the

most worrisome source of environmental

expo-sure,9’1#{176}

in a greatly expanded nuclear power

industry emissions from mining operations, fuel

processing, transportation accidents, and minor

(

i.e., noncatastrophic) plant accidents must also

be considered.

That children have a unique vulnerability to

the hazards of environmental radiation is true on

two accounts: they have an increased risk of

harmful effects compared to adults given similar

exposures; and their risk of being exposed is also

increased. The most effective enhancer of

carcin-ogenesis is cell proliferation.” The cells of the

fetus are the most rapidly proliferating, and we

know that prenatal x-ray exposure is associated

with

a 40%

higher cancer mortality in

child-hood.’2 In infants

and

children, the thyroid, bone

(

including the hematopoietic marrow), and the

CNS might be suspected of being at increased risk

of radiation-induced effects, because children

have a higher metabolic rate than adults, their

epiphyses are open, and the brain continues to

grow markedly for several months postnatally.

That strontium, plutonium, and uranium are all

bone-seeking’3 and that radioisotopes of iodine

are common in reactor emissions14 strengthen

one’s concern. To the extent that the immune

system is involved in tumor surveillance and

rejection,” its immaturity in jnfants would also be

at Viet Nam:AAP Sponsored on September 8, 2020 www.aappublications.org/news

(2)

COMMENTARIES 803

to their detriment. The reports of

radiation-associated thyroid cancer and growth retardation

among children of the Marshall Islands who were

exposed to nuclear fallout from the Pacific

weapons tests’6 and of microcephaly, mental

retardation, and leukemia among the survivors of

the atomic bombs in Japan who were exposed in

utero’7 affirm the organ-specific vulnerability of

children.

Children also have unique opportunities for

radiation exposure. Studies undertaken during the

nuclear weapons testing of the 1960s revealed

that cow’s milk was the principal route of iodine

131 exposure in man.18 Cow’s milk is the primary

nutrient for the majority of infants in America,

and is heavily consumed by children well beyond

the first year of life. Exposure to airborne

pollu-tants-such as radon, plutonium, and isotopes of

iodine-will be a function of ventilation. The

minute ventilation of infants and children, per

kilogram of body weight, is greater than that of

adults. In fact, the per kilogram basal oxygen

requirements at birth are 1#{189}times those of

adults.’9 Ground-borne contaminants also present

a unique risk for children because of the child’s

normal oral exploratory behaviors.20 Finally,

because children usually have a greater life

expec-tancy than adults, they will be exposed to

radio-active contaminants for a longer duration, and

therefore will be at increased risk for any and all

cumulative effects.

Given these concerns about the unique hazards

of environmental radiation, how can pediatricians

best serve the interests of children in the “nuclear

power controversy”? Further research is certainly

in order. Dr. Robert Miller, chief of the

Epidemi-ology Branch, National Cancer Institute, has

stated that “no federal health agency has the

responsibility for research into the special

expo-sure

and susceptibility of the fetus and child” to

environmental pollutants.2 Surveillance is also

indicated: geographic-specffic rates of leukemia

in children might prove to be a marker for undue

exposure to radioactive contaminants, since

“in-duction of leukemia by radiation is perhaps better

documented

and

correlated with dose than any

other form of malignancy.”22 The detection of an

increased incidence of other cancers might prove

frustrating: intervals of more than 35 years have

elapsed between irradiation of the head and neck

in childhood and the development of thyroid

cancer, for example.23

Perhaps the most effective avenue would be for

physicians to join with the scientists and

engi-neers who declared in a statement to Congress

and the President that

.. .the country must recognize that it now appears

impru-dent to move forward with a rapidly expanding nuclear power plant construction program. The risks of doing so are altogether too great. We, therefore, urge a drastic reduction in new nuclear power plant construction starts before major

progress is achieved in the required research and in resolving

present controversies about safety, waste disposal, and

plutonium safeguards.’4

LAWRENCE R. BERGER,

M.D.

Robert Wood Johnson Clinical

Scholar Program

Varsity Apartments HQ-18 3747 15th Avenue N.E.

Seattle, WA 98195

REFERENCES

1. Schmidt WM: Age as a factor in susceptibility of young

workers to toxic substances. I Pediatr 22:121, 1943.

2. Murphy AW: The Nuclear Power Controversy.

Engle-wood Cliffs, NJ, Prentice Hall, 1976.

3. Olson MC: Unacceptable Risk. New York, Bantam

Books, 1976.

4. Fuller JG: We Almost Lost Detroit. New York, Ballan-tine Books, 1975.

5. Patterson WC: Nuclear Power. Baltimore, Penguin

Books, 1976.

6. Gall N: Atoms for Brazil. Bull Atomic Scientist, June 1976, p 43.

7. Ackerman J: The lethal leftovers of nuclear power.

Boston Globe, Feb 27, 1977, p A4.

8. Routine Surveillance for Radionuclides in Air and

Water. Geneva, World Health Organization, 1968,

p 24.

9. Turner 5: The public issue that won’t go away: Nuclear

power and history’s deadliest trash. Boston Globe,

May 8, 1977, New England Magazine, p 10. 10. Meighan D: How safe is safe enough? New York Times

Magazine, June 20, 1976, p 8.

11. Ryser H: Chemical carcinogenesis. N Engl I Med

285:721, 1971.

12. MacMahon B: Prenatal x-ray exposure and childhood cancer. I Nati Cancer Inst 28:1 173, 1962.

13. Henry HF: Fundamentals of RadiatiOn Protection. New York, Wiley Interscience, 1969, p 119.

14. Report of the Advisory Committee on the Biological

Effects of Ionizing Radiation. Washington, DC,

National Academy of Science-National Research Council, 1972.

15. Law LW: Studies of the significance of tumor antigens

in induction and repression of neoplastic diseases. Cancer Res 29:1, 1969.

16. Conard BA, Dobyns BM, Sutow WN: Thyroid neoplasia as late effect of exposure to radioactive iodine in fallout. JAMA 214:316, 1970.

17. Miller RW: Delayed radiation effects in atomic-bomb survivors. Science 166:569, 1969.

18. Terry LL, Chadwick DR: Current concepts in radiation protection: II. Radioiodine intake, 1961-1962. JAMA 188:343, 1964.

19. Smith RM: Anesthesia for infants arid Children. St Louis, CV Mosby, 1968, p 14.

20. Barltrop D: Chemical and physical hazards for children, in Baltrop D (ed): Paediatrics and the Environment. London, Fellowship of Postgraduate Medicine,

(3)

804 PEDIATRICS Vol. 61 No. 5 May 1978 1975, p 11.

21. Miller RW, in discussion, The susceptibility of the fetus and child to chemical pollutants. Pediatrics

53(suppl):777, 1974.

22. Warren S: Radiation carcinogenesis. Bull NY Aced Med 46:131, 1970.

23. Favus MJ, Schneider AB, Stachura ME, et al: Thyroid

cancer occurring as a late consequence of head and neck irradiation: Evaluation of 1,056 patients. N Engl I Med 294:1019, 1976.

24. Scientists’ Declaration on Nuclear Power. Cambridge,

Mass, Union of Concerned Scientists, 1975.

Fit for the Future:

Lessons for the

United

States

The United States has its tradition of White

House Conferences; the United Kingdom has its

Royal Commissions or Special Committees. The

report of the Committee on Child Health

Services,’ which took three years for a “far

reaching inquiry” on how to improve child health

services in the United Kingdom, is in this tradition

of both countries. It is a report well worth the

waiting and worth careful thought by

pediatri-cians and policymakers in the United States.

Volume 1, 448 pages long, is the body of the

report. Volume 2 is a statistical appendix.

At the outset, any reviewer of this extensive

work must limit his comments to only a few areas

that seem most pertinent to our own scene.

Others will see more importance in other points.

Recommendations that seem most important to

me include the following.

An Integrated Child Health Service

The most important theme of the report is that

child health services cannot exist in a vacuum and

that as a result there must be an integrated child

health service-integrated with the rest of

medi-cine, with education, and social work. The social,

economic, and educational setting and the state

and organization of medicine in general all have

powerful effects on the ability of the child to

“grow to live a full adult, living, breathing life.”

The limitation of medical care and the

impor-tance of other factors on health are now familiar

strains in writings from both of our countries. This

limitation means that child health services are

only one of several approaches that must be taken

to improve children’s health. The question is,

How can physicians work most effectively in

these boundary areas? How can they integrate

services?

Boundary problems will always be difficult. If

one becomes too great a “lumper” without

boundaries, there is danger of getting nothing

done

and

slipping into banal generalities. On the

other hand,

too

narrow espousal of child health

services to the exclusion of the other needs of the

family

and

society will limit programs to ones of

minor benefit to the child. I believe, as do the

authors of this report, that the time is past for

narrow advocacy, at any cost, of child health

services to the exclusion of the needs of others of

our society. But, I admit to frequent anxiety about

how far beyond these narrow boundaries anyone

can function with effectiveness. One of the

force-Ilil conclusions of this report is “that, in the long

run, only a combined approach from housing,

health, education,

and

social services can even

begin to eradicate the causes of the initial

disad-vantage.” How to achieve this combined

approach without sacrificing focused competence

is the major agenda for both of our countries and

is not fully addressed in this report.

Primary Care: Combining Preventive

and Curative Services

The report recommends special training of

general physicians to provide primary care for

children-a move toward the pattern of primary

care

pediatrics as practiced in the United States.

The dilemma emerges again. Narrowness is

some-times

limiting in effectiveness, especially in

deal-ing with problems whose origin lies in the family

or community; but breadth is sometimes limiting

in quality, as those who wrote the report believe

now exists among many general practitioners in

the United Kingdom.

At a time when many pediatricians in this

country are broadening their skills into ability to

deal with adolescence, youth, family-focused

services, education, emotional problems, and

handicapped services, some family physicians in

the United Kingdom are urged to narrow their

focus by concentrating on children, while

main-taming a family focus. But the report also

recom-mends joining of curative

with

preventive

services for children, a pattern characteristic of

U.S. pediatrics but not traditional in the United

Kingdom. As is often the case, somewhere

between the traditional pattern of the United

States and the United Kingdom lies a better

balance. The report rejects a separate child health

service (neat as that might appear), and instead

opts for integration of child health within general

family-centered health services, with upgrading

(4)

1978;61;802

Pediatrics

Lawrence R. Berger