ATTACHMENT 9 Plans for 1959 Marshall Island Medical Survey Time of survey Exact time unsettled. Waiting for reply from Navy on request for use of ship (LST). Dates ship requested - middle of February to March 1, 1959, for one month period. If necessary to change time of survey, will this affect you participation? Examination schedule 1. Leave home in time to arrive at Honolulu on set date. 2. One to two days at Hawaii for staging. 3. MATS flight from Hickam Field to Eniwetok (about 12-13 hours). 4. Meet LST at Eniwetok and settle aboard. 5. Sail for Rongelap next day (estimated time 20 hours). 6. Remain at Rongelap 14-15 days for examinations. 7. Plans from Kwajalein or Eniwetok for those not needed for remainder of survey to be returned to Kawajalein and United States. 8. Leave for Utirik Atoll (estimated time, overnight). 9. Remain at Utirik for 2-4 days until examinations are completed. 10. Leave for Eniwetek or Kwajalein (estimated time 30-36 hours). 11. Majority of team leave Kwajalein or Eniwetok for United States. 12. Dr. Sutow and 2-3 team members to Majuro by plane (1 1/2 hours) for two day examinations. 13. Return to Kwajalein and United States. Examination facilities On LST Whole-body gamma spectroscopy. Decontamination station. A dressing room and shower facility will be prefabricated at Eniwetok to be unloaded on LST prior to survey. Wooden room (air conditioned) will be prefabricated at Eniwetok to house hundred channel analyzers and other electronics equipment and onloaded on LST prior to survey. Steel room (21 tons) will be onloaded also at Eniwetok where it is now in storage. Above facilities will be placed near middle of tank deck at LST REPOSITORY Washington National Records Center COLLECTION 32681-6 BOX No. Box 1 FOLDER 1 11314 X-ray facilities. The diagnostic x-ray machines (60 ms) will be set up in the forward part of the tank deck on arrival at Rongelap where the machine is stored. A 50 KH generator (to be supplied by AEC) will be onloaded an Eniwetek. Dental unit may be set up aboard ship either at Eniwetok or at Rongelap. Cdr. Lyon is arranging for loan of this unit from Pearl Harbor where it is hoped this unit may be onloaded on the LST. At Rongelap Village Three buildings are available for use. The dispensary, school house and council house. These buildings were wired for electricity last year. Two 5 KH generators will be furnished by AEC, Eniwetok. One generator should be ample for power and the other will act as a spare. Hematological examinations will take place in the laboratory of the dispensary, physical examinations in the school house, and administrative and possibly other examinations in the council house. Personnel Administrative: Examination arrangement with Rongelap people. Skin examinations, urine collections, urine analysis. Dr. Robert Conard (BML) Bill Scott (BML) Hematology: Dr. Lee Meyer, in charge (South "illegible" "illegible" "illegible" Emil "illegible" (BML) chief technician Irving Jones (South "illegible" Comm. Hosp.) technician James Greenough (BML) technician Pacifico Tenerie ("illegible") technician Physical examinations: Adults: Dr. William Lewis (Memorial Hospital) Dr. Barry Blumberg (NIH) Children: Dr. Nat Sutow (M.D. Anderson Hosp., Houston Texas) ("illegible") Opthamological examinations: Col. Austin Lowery (Walter Reed Army Hospital) ? technician Dental examinations: Cdr. Bill Lyon ("illegible") Kenneth Glassford ("illegible") dental technician -2- Gamma spectroscopy: Dr. Stan Cohn, in charge (BML) Maynard Richer ("illegible") Dave Potter (BML) ROG and audiometric examinations: James Gilmartin (BML) technician X-ray examinations: ? (BMRI) x-ray technician Photography: Robert Smith (BML) Marshallese assistants: 1 Practitioner 1 Technician (?) 2-3 Rongelap people to assist in interpreting, rounding up people, etc. In addition there will be 6-8 scientists from the University of Washington to study radiation ecology with our group. Personnel needs Passport Before a passport can be issued, a letter from Office of CNO authorizing entrance to Trust Territory is necessary. If you have an out-dated passport, send it in to be renewed (with $5). To get a new passport, go to the nearest court house with a friend of long standing, your birth certificate, two passport pictures and $10. International immunization card with necessary entry of inoculations - smallpox within one year, tetanus and typhoid within three years - are required. Travel All personnel, civilian and military, will travel under BML policies. First class round trip plane ticket to Honolulu will be furnished. (Let me later know your desired reservations.) Per diem allowance include $6. a day for meals, plus taxi fares, official telephone calls, passport fees. Hotel bills, within reason, will be reimbursed upon presentation of receipted bill. Advance per diem may be made if desired. Clothing Travel light. Winter suit and coat (or uniform) will be stored at Hickam. (May be cleaned and pressed in your absence.) Other recommendations - a pair of summer slacks and sport shirt for Honolulu, 3 pairs khaki shorts, several short-sleeved shirts and T shirts, underwear, canvas shoes or sneakers, swim suit, toilet articles, camera, dark glasses, underwater goggles (snorkel and fins if desired). Total weight about 15 pounds. -3- The remainder of allowance (up to 60 pounds) may be used up on the return trip with personal purchases at Kwajalein, Eniwetok and Hawaii. Military personnel will need summer khaki uniform for Kwajalein. Examinations Identification pictures in color will be taken on all individuals. Interval histories: It is hoped a Marshallese practitioner will be made available to accompany the team for taking histories. Discuss history form. Physical examinations: 1. Complete physical examinations, including pelvic examinations on women and rectal examinations on all adults. 2. Special measurements for ageing will be recorded during the examination and, if possible, duplicated by another physician. Discuss various criteria. Two-step function test? 3. Pediatrics and growth and development studies: In addition to routine physical examinations on children (less than 20 years of age) anthropometric measurements will be recorded. A special grid measurement picture will be taken on each child. X- ray pictures of the left wrist and knee will be taken for bone maturation studies. (See the special growth and development forms used.) Special effort to get firmer birth dates on children will be attempted. Discuss means of accomplishing this. (This should also be done on adults.) 4. Ophthalmologic examinations: Complete examination of the eyes including slit-lamp observations and eyeground examinations. Note certain eye measurements used in ageing study. Special effort will be made to get good accommodation measurements (one of the best indices of ageing.). Retinal pictures? Discuss technician, photographic assistance. 5. Skin examinations: Residual beta burns will be carefully examined and photographed or biopsied for microscopic study if indicated. Note special skin measurements for ageing study. 6. Dental examination: Dental examination will be carried out as completely as possible under field conditions. Special study of status of dentition in children will be carried out with possibility of use a part of growth and development studies. 7. Audiometer test will be carried out on all subjects more than 10 years of age. Frequencies 256, 512, 1000, 2000, 3000, 4000, and 6000; also bone conduction tests. 8. Electrocardiograms on all adults? Discuss minimum number of leads. Discuss time element for one technician carrying out both audiometer and ECG tests. -4- Notification of hematology group of any clinical findings (elevated temperature, U.R.I., etc.) that would effect blood count of individual so that this can be recorded on blood data sheet. Physicians should especially be on the lookout for congenital anomalies and record them. Review criteria of ageing. Therapy One One of the best ways of maintaining rapport with the Marshallese is by medical and surgical therapy. In the past, particularly when the people were living at Majuro where hospital facilities were available, medical and surgical procedures carried out by our team were greatly appreciated by the people. Under the limited facilities at Rongelap, such procedures are necessarily limited in scope. However, every effort must be made to expand this aspect of our operation. Therefore, careful consideration must be given to therapeutic procedures that may be carried out such as medical, minor surgery, dental, etc. (Perhaps clinics should be held twice weekly, coordinated with Gab, the Health Aide.) Discuss list of drugs and equipment and suggest additions or deletions. Discuss inducement gifts. Laboratory examinations. Hematological. It is anticipated that two complete blood counts will be done on each individual about a week apart. The first count will be done by venipuncture with enough blood drawn (25-30 ml) for carrying out other procedures to be outlined below. The second counts will be from finger sticks. These routine counts will include WBC, Differential, Platelet count, RBC, and hemoglobin. At the time of the first count, the following tests may also be done: reticulocyte counts, Price- Jones curves, coverslip smears for alkaline phosphatase determinations (by Dr. Malone in Boston) and extra smears for basophile counts of 4000 cells (to be done later at BML). (Bilobed lymphocytes?) With the second count, sedimentation rates may be done on those with high WBCs. A Coulter electronic counter will be used for WBC, RBC and, if the technique is worked out in time, for platelets. This device gives greater accuracy than visual counting and is quite a time saver. Pipettes and counting chambers will be taken should it be necessary to use the visual technique. Phase microscopy would then be used for platelet counts. The microhematocrit technique will be used for hematocrits. Hemoglobin - (Lumetron (?) Coleman (?) Other (?) Cresol blue staining for reticulocytes. The Health Aide has been requested to give about 34 people one 5 grain tablet of ferrous sulfate daily until our arrival. Comparison of RBCs and hemoglobins in this group with those not treated may indicate whether iron deficiency is a factor in their lowered hematocrits. 5 Other Tests Total plasma proteins by proteinometer Plasma volume - Cr51 tagging for plasma volume in about 10 exposed and 10 control people. Serum iron - serum will be drawn into specially cleaned glassware for serum iron determination to be done later at (?) Serum iron would have to be done on those not receiving iron tablets. Serum for iodine studies - Repeat PBIs on people run last time plus other studies. (Dr. Blumberg and Dr. Ball). (Special glassware) Thyroid uptake I131 - About 25-30 people being tested for serum iodine values will be given small amounts of I131 (1 uc?) and about 10 hours later counted in whole-body counter for thyroid uptake. Sesenguth-Kline flocculation slide test for trichinosis on some 25-30 people with high eosinophile counts. Skin test for trichinosis in some people as above. Are any kidney or living function tests indicated? (Higher Vitamin 12 levels.) Urinalysis - Routine urinalyses were carried out in 1957. Are they indicated on all or selected cases this year? Other tests? Whole-body gamma spectroscopy - Gamma spectra will be obtained on as many of the group being examined as is possible during the time there. Plant, soil, marine, and urine samples may also be analyzed in conjunction with the University of Washington group. Urine collections for radiochemical analyses will be carried out on a large sample of people. The radiochemical analyses will be done at BML. Efforts will be made to determine more accurately the 24 hour urine outputs. Gamma survey of the islands of Rongelap, Eniaetok, and Utirik will be carried out. Examinations at Rongelap About 100 adults and children in the exposed group and a slightly larger number of unexposed people will be examined at Rongelap as outlined above in the two week period. Examinations at Utirik These examinations will be concerned only with growth and development studies of the children there, gathering of vital statistics and determination of general health status. Whole- body gamma spectroscopy will be done on the maximum number of individuals that can be run in the 3-4 day period there. Urine collections for radiochemical analyses -6- on the subjects and perhaps a gamma spectroscopy of food, soil and urine sample will be done. A gamma survey of the island will be conducted in conjunction with the University of Washington group. Examinations at Kwajalein If the LST can spend a day or so at Kwajalein, it would be worthwhile to do gamma spectrographic analyses on some individuals and get urine samples for radiochemical analyses. Examinations at Majuro The two day period at Majuro will be spent doing growth and development studies on the 20 Rita Village children who have been followed in the past. 7 Protocol for 1959 Examination of the Marshallese In order that the various members of the medical team may be brought up to date on the various examinations which are planned for our next survey, the following rough protocol is outlined. Unless otherwise stated, the examinations referred to are those to be carried out at Rongelap. A routing slip, a copy of which is attached, will be used to keep track of each individual's examinations. A rough drawing is attached showing the examination facility setup on Rongelap (sketch 1). A second drawing (sketch 2) shows the proposed setup on the tank deck of the LST. History and Physical Examinations Interval History: (Hara Riklon, assisted by Jabue) Will be done in Room 1 of the schoolhouse. Vital Statistics: (Dr. Conard and Jabue) Review of Jabue's dispensary book. Ewajaiein hospital records for illness, treatment, pregnancies, miscarriages, births, and deaths. Age Determinations: (Dr. Sutow, Riklon, Jabue, John the Magistrate, parents, etc.) Establishment of more accurate birth dates will be attempted on adults and children, particularly the latter for growth and development studies, by studying sibling and other child relationships, events associated with birth, Jabue's records, John's records, and other records. This study might best be accomplished by first interviewing John and some of the elders as to important events which might be specifically dated and which would be known by most of the people. Next, family interviews will be held: later perhaps with whole clan groups. Information will be obtained on a) island of birth, b) who delivered the child, c) associated events, d) birth order with other siblings, e) birth order with other children or adults. Opthamological Examinations: (Col. Lowrey and a Marshallese assistant) These examinations will be carried out in Room 2 of the dispensary. Opthamological equipment will be found in boxes 17 and 18. Studies will include visual acuity, accommodation, external examinations of the eye, slit-lamp observations, and retinal examinations. Special photography of the external eye (Dr. Lyon). Ageing Study: Degree of arcus senilis, visual acuity, accommodation, retinal arteriosclerosis. (See aging studies below.) Pediatric Examinations and Growth & Development Studies: (Dr. Sutow and Dr. Hollingsworth) Examination equipment will be found in rooms 11, 12, 13. Studies will include grid photograph (Smith), pediatric examinations, anthropometric measurements, x-rays of hands and wrist (Snow), dental examinations (Dr. Lyon), dentition with photography, age determination. Growth and development studies will also be carried out on children at Utirik and Rita Village that Majuro. -2- Dental Examinations: (Dr. Lyon, Glassford) Dental equipment will be found in boxes 17 and 19. Dental chart will be completed showing caries, dentition, oral pathology, and photography. Attempts will be made to see if there is any correlation between people with oral pathology and high WBC by comparing the WBC before and after extraction of teeth or treatment of pathology. Extracted teeth will be saved for radiochemical analysis on return. Dental studies will also be carried out on children at Utirik and Majuro. Adult Examinations: (Dr. Lewis and Dr. Blumberg. An interpreter will be made available for help in pediatric and adult examinations). Examinations will be done in Room 3 of the school building. Equipment will be found in boxes 11, 12, 13. The past history will be reviewed. Complete physical examinations will be carried out as outlined on the examination sheets, starting with "illegible". Note special arthritis survey. EEGs will be done on all people over 19 years of age. Both the pediatric and adult examination groups will notify Dr. Meyer of any clinical finding that might affect the blood count. Aging Study: (Opthomological, Dental and Adult Examination Groups). Note an examination sheets the quantification of special observations on aging in plus values. Attempt to evaluate these criteria. For instance, in vital capacity and accommodation best the degree of cooperation of the subject is important. A special skin caliper will be used for skin looseness and retraction. It is hoped, if time permits, that the special criteria of skin aging and some others will be checked again (Dr. Conard). Missing teeth and possibly either dental criteria of aging should be recorded for evaluation (Dr. Lyon). Audiometer examinations (Gilmartin) will be carried out on all people over 20 years of age in a tent set up in a quiet area removed from the buildings. See the attached age score sheet. The exact age determination studies referred to above are an important aspect of this study. Further discussion will be necessary on these aging studies. X-ray Examinations: (Snow) The x-ray machine will be set up on the tank deck of the LST (see sketch 1). X-ray equipment will be found in houses stored in the Council House (see sketch 1). Additional equipment will be found in houses 1, 3, 15. X-ray of hands and wrist will be done on all children for growth and development studies and on all adults for the arthritis survey. Additional x-rays will be done upon request. Laboratory Examinations Hema"illegible" (Dr. Meyer, Adnik, Jones, Greenaugh, Tameric) These examinations will be done in the laboratory of the dispensary building (see sketch 1). Equipment will be found in boxes 3 through 9. -3- Two samples of blood will be drawn on each individual at Rongelap, about a week apart. The first sample will be from venipuncture and about 30 ml of blood will be obtained so that, in addition to the routine studies. about 15 ml of serum will be obtained for studies on return. The second sample will be from finger stick for routine studies only. Routine Studies: a) Done 2%. WBC, differential, RBC, platelet count, hemoglobin, hematocrit. b) Done only first time. Alkaline phosphatase smears, hemophil smears, reticulocyte counts, plasma proteins. c) Done on second count. Sed. rate on people with high WDC indicated in first count. Special samples to be taken at Rongelap, Utirik, and possibly Majuro: a) Serum iron (15 Rongelap, 5 Rongelap). b) Serum iodine studies (15 Rongelap, 5 Utirik). c) Blood for grouping studies (those Rongelap people not studied last year. Other samples to be drawn at Utirik and possibly at Majuro). d) Blood for hemoglobin electrophoresis (those Rongelap people not studied last year. Other samples to be drawn at Utirik and possibly at Majuro). Special study at Utirik: a) Red cell volume at chromium tagging (about 5 people along with routine blood studies on these people, serum iron and PHI). The possible effect on Rongelap people who have been receiving iron for the past few months will be evaluated. Special Serological Studies to be Done on Return: a) Genetically determined traits: (Dr. Blumberg) (1) Serum proteins -- hemoglobins, (2) serum proteins, (3) gamma globulins (On groups), (4) serum proteins -- gamma globulin levels, (5) serum cholinesterase inhibition studies, (6) primaquine sensitive red blood cells (7) urinary SAIB excretion. b) Thyroid function: (Dr. Ball) (1) Protein bound iodine and butanol extractable iodine. (In addition thyroid uptake studies in Utirik people, iodine content of diet, Urinary iodine, iodine in sea water.) c) Antibodies to virus and "illegible" borne disease and parasitic diseases: (Dr. Blumberg) (1) Echo virus, (poliomyelitis, (3) visceral larval "illegible", (4) amoeba, (5) filaria, hookworm, (6) trichinosis, etc. d) Cholesterol levels: (West Coast, Stanford) Urinalyses: (Dr. Canard, Scott) Routine analyses will be carried out on all people on examination list at Rongelap. -4- Sample Collections Using Samples for Radiochemical Analyses: (Dr. Conard, Dr. Cohn, Scott, 24-hour samples - 40 on Rongelap, 20 on Utirik, and 10 on Ebeya. Feeled samples - 20 on Rongelap. Food sample Collections at Rongelap, Utirik, and Ebeya: (Dr. Conard, Scott) Prepared Meals. S-10 on Rongelap, 2-3 on Utirik, and 203 on Ebeye, primarily for radiochemical analyses but small samples to be studied for iodine, sodium and potassium, and iron. Raw food and other samples to be collected on Rongelap and Utirik for spot check in steel room and returned for radiochemical analyses (Dr. Held's group, Dr. Cohn, Dr. Conard, Scott). Whole-Body Gamma Spectroscopy Routine: At Rongelap all subjects on examination schedules. At Utirik as many as can be measured in 3-4 days. At Ebeye as many subjects as can be measured in about 2 days. Special Studies: Raw foods, marine life, animal life, soil samples at Rongelap and Utirik Iodine101 thyroid uptake studies in 10-20 people at Utirik. Sketch #1 "GIF" Lagoon FOR REFERENCE SEE (14bb01.gif) 5 FOR REFERENCE SEE (14bb02.gif) 6 ROUTINE SHEET 1959 Name ______________________ Age _____ Sex ____ No ____ Section Date Initials 1st Blood Count ________ _________ 2nd Blood Count ________ _________ History Photography ________ _________ Physical Examination ________ _________ Skin and Urine ________ _________ Audiometer ________ _________ Dental X-ray ________ _________ Whole-Body Counts ________ _________ 7 AGE SCORE - 1959 Date _________________ Name ______________________ Age _____ Sex ____ No ____ Estimate ages _____, _____, ______ SCORES Skin Looseness (mm) Actual Corrected Weighted Neck _________________________________ Retraction (secs) _________________________________ Senile changes (1, 2+, 3+) _________________________________ Hair Greyness (1+, 2+, 3+, 4+) _________________________________ Baldness (1+, 2+, 3+, 4+ _________________________________ Eyes Accommodation (diopters) _________________________________ Arcus senilis (1+, 2+, 3+, 4+)_________________________________ Arteriosclerosis retina (1+, 2+, 3+) _________________________________ Cataracts _________________________________ Physical vigor Vital capacity _________________________________ Hand grip (avg. 3 tries) _________________________________ Neuromuscular (hand tally count no. in 1 minute) _________________________________ Total _________________ 8