Chapter 12: The MarshalleseFollowing 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 Marshallese 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 Trusteeship 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 Atoll. In preparation for this operation, the Bikinians 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, delayed the return of the Bikinians, 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 imported 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 Bikinians and observed increases in plutonium, leading to their reevacuation in 1978. Today, the Bikinians remain scattered around the Marshall Islands, while a new radiological cleanup of their 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 Rongelap and other inhabited atolls downwind of it. The populations of the Rongelap and Utirik Atolls were evacuated, but not until after they had received serious radiation exposure (about 200 roentgens on Rongelap and about 20 on Utirik). 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 Rongelapese were resettled onto their atoll, but after an interval of only three years. Again, it was recognized at the time that some radioactivity remained, but U.S. officials concluded that appropriate dietary restrictions would minimize the danger. Unlike the case of the Bikinians, however, the medical follow-up 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 (BNL) medical team, wrote,
These and similar documents discussed below lay out clearly the purposes 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 Rongelapese on their atoll despite knowledge of residual contamination, the U.S. government was using the Marshallese as guinea pigs in a deliberate human radiation experiment.
The Committee heard extensive testimony about the difficulties the Marshallese 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 U.S. government activities conducted on their soil have for too long been shrouded in secrecy or made inaccessible to the Marshallese by bureaucratic obstacles. This inaccessibility of records, combined with a history of inadequate disclosure of hazards known to U.S. researchers, has contributed to a climate of distrust.
In our review of materials that are now becoming available, we found no evidence to support the claim that the exposures of the Marshallese, either initially or after resettlement, were motivated by research purposes. On the contrary, while there is ample evidence that research was done on the Marshallese, 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 Rongelap and Utirik populations that appear to have been nontherapeutic: 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, appears 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. Insensitivity 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 problems arose in explaining to the Marshallese the nature and purpose of the research activities that accompanied 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 1, 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 Rongelap, Ailinginae, and Rongerik, and still farther east, toward Utirik, Ailuk, and Likiep, instead of north into the Pacific as planned. It was soon clear to the task force command in charge of the shot that evacuations would be necessary and by the evening of March 2 a ship was steaming toward Rongelap to remove the population. Over the next three days, 236 Marshallese were transported by sea and 28 U.S. servicemen were airlifted from a weather station on Rongerik to Kwajelain Atoll, south of the fallout pattern, and then to a U.S. naval base with medical facilities.
Merril Eisenbud has observed:
The Marshallese and Americans were not the only ones exposed to fallout from Bravo. A 100-ton Japanese fishing vessel with a crew of twenty-three called the Fukuryu Maru (Lucky Dragon) was sailing some eighty 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, until May 1955. The event received international 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 Lewis 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, you have to remember 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 radiation due to high yield weapons." Thus, it appears to have been almost immediately apparent to the AEC and the Joint Task Force running the Castle series that research on radiation effects could be done in conjunction with the medical treatment of the exposed populations.
On March 8, Dr. Cronkite's mission was formally established in a letter to him that was classified Secret and Restricted Data and said, "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 fall-out from first detonation of Operation Castle." The project was given the designation 4.1 and titled, "Study of Response of Human Beings Exposed to Significant Beta and Gamma Radiation Due to Fallout from High Yield Weapons." The letter continued: "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.'"
As Dr. Cronkite understood it, his mission was to "examine and treat the Marshallese and the American servicemen that were exposed." Initial exposure estimates ranged from 15 rad for people on Utirik to 150 rad for those on Rongelap. 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, which 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 fallout particles. During the first few days after Bravo, several of the people from Rongelap 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 Ailinginae Atoll had these symptoms, and none from Utirik had them. The American servicemen on Rongerik 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. Conard, maintain the project never included nontherapeutic 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 Kwajalein the same day he received the memorandum establishing their mission. They set up examination and lab facilities in a building adjacent to the living quarters of the Marshallese and began their work. Team members took medical histories with the help of translators, inspected skin 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 Rongelap population, platelet levels fell to about 30 percent of normal by the fourth week, white blood cell counts fell to half of normal by the sixth week, but at the six-week point, when the initial examinations were completed, these blood elements 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 ten to fourteen days after exposure, radiation burns began appearing. These burns were much more pronounced among the Rongelap people than those from Ailinginae or the U.S. servicemen on Rongerik, and there were no burns noted in the Utirik group. Often the burns were accompanied by itching 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 percent of the children and 30 percent 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:
Dr. Cronkite noted that "there was nothing in the medical literature . . . to predict that one would have a relatively high incidence of thyroid disorders."
In May 1954 the AEC told the DOD that the "Utirik people" could return home following the completion of the current tests, "provided that specimens reveal absence of radioactive materials in quantity injurious to health." On Rongelap, however, radiation levels were considered to be too high. The Rongelapese were moved to Eijit, a small island in Majuro Atoll. The United States continues regularly to followup the exposed Rongelapese and Utirikese. The U.S. servicemen were sent to Honolulu for further examination by Army physicians. But according to Dr. Cronkite, "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. Cronkite went on to explain that if an induced cancer had been identified, early diagnosis and treatment might have benefited the exposed serviceman. The DOD reported to the Advisory Committee that twelve of the twenty-eight 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 twenty-eight had any other medical follow-up.
The Ailuk Exposure
According to a report by Lieutenant Colonel R. A. House, based on an aerial survey done within forty-eight hours of the Bravo blast, "The only other atoll which received fallout of any consequence at all was Ailuk [it is not clear to which atolls the word "other" applies]. . . . [I]t was calculated that a [lifetime] dose would reach approximately 20 roentgens," about the same as or slightly higher than the exposure of the Utirik population. Unlike the people of Utirik and Rongelap, however, the 401 people of Ailuk, south of Utirik in the eastern Marshalls, were not evacuated at all. The January 18, 1955, final off-site monitoring report of Operation Castle, however, gave the Ailuk exposure, based on several aerial and ground readings, as 6.14 roentgens. Readings from this report for other exposed atolls were as follows: Rongerik, 206; Rongelap, 202; Utirik, 24; Ailinginae, 6.7; Likiep, 2.19; and Wotje, 2.54. People living on these atolls would be exposed to additional radiation as a result of consuming contaminated food. Based on the initial reading of 20 roentgens, the U.S. task force should have evacuated the people of Ailuk. 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 Jaluit and Ebon.
By the afternoon of March 4, two ships, both destroyer escorts, seem to have been available to evacuate the 400 or so people on Ailuk. But according to Colonel House, "the effort required to move the 400 inhabitants," when weighed against potential health risks to the people of Ailuk, seemed too great, so "it was decided not to evacuate the atoll." However, evacuation would have reduced the lifetime exposures of the Ailuk population by a factor of three, according to an estimate provided by Thomas Kunkle of Los Alamos National Laboratory. In testimony before the Advisory Committee, Ambassador Wilfred Kendall of the Republic of the Marshall Islands noted that "the United States Government studied with interest the unexpected and dramatic incidence of thyroid disease on Utirik Atoll [but] no effort was made to reassess the health of the population on Ailuk, or Likiep, or other mid-range atolls."
Resettlement of Rongelap
Between March 1954 and mid-1956, the Rongelap population on Eijit was followed medically, with visits from a U.S. medical team at six months, one year, and every year thereafter. According to a preliminary report on the two-year medical resurvey, "There has been little illness among the people [and] none of the clinical entities noted in the Rongelap people appear to be related in any way to radiation effect."
By late 1956, about a dozen radiological surveys of Rongelap and neighboring atolls had been conducted to determine contamination levels. On February 27, 1957, the AEC 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 U.S. medical officers had recommended that the exposed Rongelapese "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." However, the displaced Rongelapese were eager to return to their home island. In March 1956, Dr. Conard wrote to Dr. Charles L. Dunham, director of the AEC's Division of Biology and Medicine, that "we are committed to return the people to their homes and that is their express wish."
In June 1957, a final resettlement radiosurvey was made from the air. Gordon Dunning, an AEC health physicist,wrote he would have preferred a full survey, but that "it appears we will have to settle for the external readings only." The exposed Rongelap people and 200 other Rongelapese, 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 Rongelap 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 recognized the importance of the opportunity that had been presented to gather 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 Rongelap. 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 Rongelap 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 recontamination of Rongelap from the 1956 series of weapons tests." The letter goes on to say, "The decay of the newly added radioactivity is such that it will soon be insignificant when compared with that from the 1954 series."
Atmospheric testing of nuclear weapons was ended in 1963 by international agreement.
Post-Resettlement Medical Follow-up
After the population returned to Rongelap in 1957, Dr. Conard visited annually with a medical team from Brookhaven National Laboratory. The team's primary mission, according to Dr. Conard, "was to treat the people. I don't think at any time the motivation . . . was anything other than treatment of the effects of radiation." He added, however, that "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" the effects of radiation exposure resulting from fallout from a nuclear explosion.
After their return to their native island in 1957, the Rongelapese continued to be monitored annually by the Brookhaven teams. On Utirik, exams were carried out every three years, then annually with the appearance of thyroid abnormalities. The examinations included complete physicals; blood tests; examinations of reproductive effects including fertility, miscarriages, stillbirths, observable birth defects, and genetic studies; growth and development studies of children; thyroid function tests 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 or to other hospitals. One eighteen-year-old male was treated in 1972 at NIH 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 "chelating" agent (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 exposures 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 51) was used to tag red blood cells in ten unexposed Rongelapese 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 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 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." Often, Dr. Cronkite noted, the members of the Brookhaven team did take care of nonradiation-related health problems. "Physicians being what they are," he said, "you see disease and there's something you can do about, 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, chicken pox, and pertussis, all of which, according to Dr. Conard, 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, "The Marshall Islands medical 'system' under the Trust Territory is underfinanced. The professional staff is undertrained and overworked. Critical supplies are usually not available."
By 1958, Dr. Conard was aware of Marshallese dissatisfaction with the annual exams and wrote to Dr. Dunham:
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." Held added that Amata agreed this was true.
The annual exams given to the people of Rongelap were described by Konrad Kotrady, a Brookhaven physician resident in the islands from 1975 to 1976, from the Marshallese point of view:
Eventually, Dr. Conard tentatively arranged for the AEC to pay the Utirik 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 2 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 Utirik, was the fact that he predicted that there would be no cases of thyroid carcinoma in this population and one occurred. Dr. Kotrady 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 . . . [i]t has been found that there is as much thyroid cancer at Utirik as at Rongelap--3 cases each. . . . The official explanation for the high incidence of thyroid cancer at Utirik 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 Rongelap 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 Rongelap population)." This is the only instance we found in which a U.S. 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." This letter was rescinded before it was sent, however. Although it was read once over the radio, the "broadcast probably did not reach the Rongelap people since there are only three radios on the island." Courts Oulahan, the AEC's deputy general counsel, apparently 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 relevant 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 Rongelap and Utirik 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 effect of radiation among the Marshallese. These endpoints appear to have received both extensive study and appropriate treatment. As thyroid abnormalities began to appear in the Utirik population, the Brookhaven team felt a need to establish a baseline in an unexposed Marshallese population. Over the years, members of the Ailuk "control" population--at best an imperfect control population because of their exposure--had emigrated 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 Likiep and Wotje Atolls in 1973 and 1976. They also examined more than 900 Rongelap and Utirik people who were not on their home islands during Bravo. It is likely that many if not most of the controls selected had some radiation exposure resulting 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 Utirik population. There were also growing numbers of people from Rongelap and Utirik 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 Marshalls 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 Marshalls. "His principal responsibilities included (a) monitoring the thyroid treatment program, (b) visiting Rongelap, Utirik, and Bikini Atolls for health care purposes every 3 to 4 months, and (c) assisting the TT [Trust Territory] medical services with the care of Rongelap and Utirik patients at the hospitals at Ebeye and Majuro."
In 1974, the researchers conducted extensive screening for diabetes, a nonradiation-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 percent of the population. In 1976, a new agreement provided for Brookhaven to provide examinations and health care for all Marshallese living on Rongelap and Utirik when they made their visits and for the resident Brookhaven physician to assist in the care of Rongelap and Utirik patients at the hospitals at Ebeye Island in Kwajelein Atoll and Majuro, the capital of the Marshall Islands in the Majuro 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 Trusteeship 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 Rongelap and Utirik. During this period the Brookhaven medical team often treated nonradiogenic as well as radiogenic medical conditions.
In 1985, expressing concern that radioactivity in the food chain represented a significant health hazard, the people of Rongelap 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 Majetto Island in Kwajelein 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,
However, the report recommended that no categorical assurances be given the people of Rongelap that their annual exposure upon returning would be less than the 100-mrem 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 nonnative sources and that no food be gathered from the northern islands of Rongelap and Rongerik 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 Marshallese for damage done by the U.S. nuclear testing program. The United States accepted "responsibility for compensation owing to citizens of the Marshall Islands . . . for loss or damage to property and 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 Marshallese government is solely responsible; there is a Four Atoll Program, which is run by the Marshallese, but funded by the United States at about $2 million a year (the atolls that benefit from this program are Bikini, Enewetak, Rongelap, and Utirik), 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 Marshallese
The United States has a special responsibility to care for the radiation-related illnesses of the exposed Marshallese 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 nontherapeutic research have been identified. The Committee found no evidence that the initial exposure of the Rongelapese 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 clearer separation of the two activities and clearer disclosure to the subjects. For the most part, consent for tests 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 atypical for the time (see chapter 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 teams 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 commends the expansion of the BNL program in the 1970s to include general health care, and the U.S.-supported Four Atoll 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 midrange atolls such as Ailuk and Likiep also merit inclusion.