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Mortality and Morbidity of Members of the British Nuclear Tests Veterans Association and the New Zealand Nuclear Tests Veterans Association and their Families

SUE RABBITT ROFF
University of Dundee Centre for Medical Education

Published in Medicine, Conflict and Survival (Volume 15, Supplement 1, July-September 1999)

Part Two

Self-reported Morbidity and Mortality among Members of the British Nuclear Tests Veterans Association

The National Radiation Protection Board/Ministry of Defence cohort² of 21,358 men was constructed from various sources, including the membership rolls of the British Atomic Veterans Association, the British Nuclear Tests Veterans Association and the Royal British Legion (see Appendix 1). Its findings are compared with a questionnaire sent to a sample of the cohort.

For a descriptive (prevalence) analysis of self-reported morbidity in the sample,²⁰ a questionnaire was posted to 2,087 current (those who had joined prior to 28 October 1997)²¹ members of the British Nuclear Tests Veterans Association in early December 1997. More than 2,000 reports of self-reported, self-administered postal questionnaire studies concerning clinical conditions are cited in MEDLINE, most with sample sizes under 3,000 subjects. Clearance had been obtained for the questionnaire and protocol from the Multi-Centre Research Ethics Committee in November 1997. Parental reporting of children's conditions has been found to accord well with clinical findings in other studies of this type. A 90% clinical confirmation of self-reported diagnoses was found in a survey of the health of Australian nuclear test personnel.²²

By early January 1998, 1,041 questionnaires had been returned by respondents; 14 questionnaires were returned as undeliverable. The 1,041 respondents thus constituted 50% of the membership of the BNTVA. More than 50 telephone calls (the same number reported in Donovan and coworkers' study of 8,018 Australian nuclear test veterans) were received by the researcher from veterans and family members, most of whom expressed considerable anxiety, stress and/or depression regarding filling in the questionnaire, particularly where it related to deceased veterans or to children with whom these issues had not been discussed. It was therefore decided to analyse the first 1,041 questionnaires as a dataset before considering the possible need for a second mailing. Information provided on the questionnaires is essentially an update of information provided by the members when they joined the BNTVA, and supplementary data can be extracted from those files when funding permits. The Director of the Health and Safety Unit of the University of Birmingham reported²³ a response rate of just under 50% for a self-administered postal questionnaire on stress sent to all 5,000 members of the University staff, and considered this 'a good result for self administered questionnaires. There was a significantly high response from academics (58%) and administrators (84%); a reasonable response from clerical and technical (50%); and significantly lower from craft, catering and manual groups (23%).'

Bias in the sample

The degree to which the 1,041 respondents are comparable with the NRPB cohort² can be gauged from the fact that 14% of the present sample were born before 1930, compared with 28% of the NRPB cohort. Of the present sample, 82% were born in the 193Os, but only 66% of the NRPB cohort. Of the 1,041 BNTVA respondents, 143 (13.7%) had died before 31 December 1997. Of these, 76 (7.3%) died before December 1990. In the NRPB cohort, 2,847 (13.3%) died before December 1990. Of the 1,041 BNTVA sample, 67 (6.4%) died in the period from January 1991 to 31 December 1997. The NRPB has not released comparable data for this period. The present sample of 1,041 BNTVA members (who are also part. of the NRPB cohort) is therefore slightly younger than the full cohort, and had virtually half the death rate of the full cohort in the period to December 1990. Any bias, therefore, is more likely to be in the direction of a 'healthy volunteer' than an 'unhealthy volunteer' sub-sample for these 1,041 men.

The principal findings from the returned questionnaires are described here. A comprehensive list of the health problems reported can be obtained from the author.

Level of apprehension at the time of the tests

'After the 10th bomb I personally was developing a hatred of what was going on ... the bombs got bigger, louder and hotter.'

'It was sheer terror.'

'We were terrified of a chain reaction.'

'I was suicidal.'

'It was all in a day's work.'

Of the sample of 1,041 men, no information was supplied by the families of 138 of them (13%) on how they felt about the weapons tests at the time. 362 men (35%) reported themselves to have been relaxed, indifferent or pleased to be part of the weapons tests programme at the time, but 186 men (18%) reported themselves to have felt apprehensive, and 355 men (34%) were very apprehensive to terrified.

Smoking habits

'They were selling us cheap cigarettes seized as contraband.'

'We were issued 200 cigarettes a week.'

'There was nothing to do on the island so we smoked.'

Three per cent of the returns provided no information on the man's smoking habits, and 216 (21%) reported that they had never smoked. Nearly half the men, 478 (46%), reported that they had stopped smoking, usually within ten years of returning to the UK from the tests. 87 men (8%) reported themselves to be occasional smokers, and 230 (22%) men stated they were still smoking, mostly from 10 to 20 cigarettes a day.

Drinking habits

'I drink to stop the dreams coming back.'

'My medicine means I can't drink.'

As with smoking, no information was supplied by 3% of the 1041 men on their drinking habits. Sixty-nine men (7%) reported themselves to have never used alcohol; another 7% had stopped drinking; 813 men (78%) reported themselves to be 'social drinkers'; 56 men (5%) considered themselves 'heavy drinkers' or reported consuming more than 30 units of alcohol a week. While 36 men who reported themselves to have been terrified at the time of the tests also reported themselves to be heavy drinkers, 27 other men who were also highly apprehensive described themselves as lifetime teetotallers.

Emotional conditions

'Like being witness to the gates of hell opening up.'

'There was a panic on at Edinburgh Field.'

One hundred and fifty-two men (15%) reported themselves to be have suffered from mental or emotional problems, primarily depression and anxiety, since returning from the tests.

Health problems

Of the sample of 1,041 men, 877 (84%) reported health problems; 164 men (16%) reported none. The 877 men reported 3427 conditions.

Dental conditions

'I lost all my teeth within months of returning from the tests. I had good teeth and I was very proud of them.'

'My teeth all broke off at the gums. All of them.'

'My teeth started losing their enamel.'

One hundred and thirty-six men (13%) of the 1,041 men reported severe dental problems, many losing all their teeth within five years of returning from the tests.

Early hair loss

One hundred and thirteen men (11%) reported heavy hair loss in their twenties or thirties after returning from the tests.

Vision problems

Cataracts were reported in 65 men (6%), often before the age of 40 years; 93 men (9%) reported other eye problems including dry eyes, loss of tears, iritis and uveitis. Glaucoma was reported by 27 men (3%).

These three categories of conditions - dental, hair loss and vision - accounted for 434 (13%) of the 3,427 conditions reported by the 877 men. They are usually considered indicators of possible radiation exposure.

Hearing loss and tinnitus

'My ears felt as if someone had slapped them hard twice. We were excited all day and watched the cloud until darkness fell.'

'There was a feeling of sudden burning in my ears.'

'There was a deafening explosion. My ears felt as though they were going to burst.'

Hearing loss was reported by 255 men, often major and beginning within a decade of returning from the tests. Many of these men also reported tinnitus which has persisted. The hearing (255), dental (136), vision (185), emotional (152) and early hair loss (113) reports comprised 841 (25%) of the 3,427 conditions. This left 2,586 other conditions reported.

Musculo-skeletal conditions

'We were lined up on the beach with our backs to the blasts.'

'Every bomb felt like a blowtorch on the spine.'

'The heat on my back was shocking.'

'It felt as if someone was holding a blow torch against my back.'

Arthritis, ankylosing spondylitis, osteoarthritis, spondylitis, rheumatism, lumbar spondylosis, cervical spondylosis, hip degeneration, spine degeneration, scoliosis, generalized skeletal pain, gout and Raynaud's disease accounted for 702 items, or one-fifth of all the non-cancer conditions reported.

Skin conditions

'Within hours I was covered in watery blisters.'

'I was admitted to the hospital with severe sunburn the day after the blast.'

'Coral cuts that were healing before the bomb stopped healing. I ended up with coral poisoning.'

'White lumps came up on my skin on the island and never went away.'

'One air blast the upper atmosphere clouded and thickened to the horizon and the transport did not move for seemingly hours waiting for something to happen i.e. rain.'

Skin conditions were reported by 216 men (21%), including keratoses, blisters, warts, moles (often in scores), boils and rodent ulcers. One or more of dermatitis, eczema and psoriasis were mentioned by 96 men (9%); 51 (5%) men reported problems with their nails in the years following the tests, including loss, brittleness and suppuration. Skin conditions constituted 11% of the 3,427 total number of conditions reported.

Gastrointestinal conditions

'A few days after the first test everybody went down with flu-like symptoms, diarrhoea - nausea - high temperatures.'

'I have had persistent diarrhoea since I came home.'

Gastrointestinal problems, including persistent diarrhoea, Crohn' disease, irritable bowel syndrome, colitis and ulcerative colitis, diverticulitis, other bowel problems, duodenal ulcers, hernias and coeliac conditions, accounted for 486 of the conditions reported (14% of all non-cancer conditions). Most men reported the onset of these problems in their late twenties and early thirties.

Musculo-skeletal, skin and gastrointestinal conditions accounted for 45% of all non-cancer conditions reported by the 1,041 men.

Respiratory conditions

'There was a pungent smell within the cloud.'

Eighty-seven men (8%) complained of asthma after returning from the tests. In all, 171 non-cancerous lung conditions were reported (5% of all conditions).

Heart conditions

Two hundred and fifty-five men (25%) of the 1,041 men reported heart conditions ranging from angina to myocardial infarction, which accounted for 7% of all non-cancer conditions reported. Additional non-cancerous heart and respiratory conditions accounted for 273 (8%) of the total conditions.

Cancers

The self-reported incidence rate is not elevated above the general expected UK rate; 262 men (25% of the responders) reported 363 cancers. However, these results should be considered in relation to those of Part One relating to cancer mortality.

Haematological malignancies were reported in 52 men (14% of the cancers). There were 14 cases of multiple myeloma, seven of non-Hodgkin's lymphoma, 13 of leukaemia and 18 other lymphomas reported, together with four cases each of Hodgkin's disease and polycythaemia.

There were 70 gastrointestinal cancers (19% of cancers) and 56 skin cancers (15% of cancers), of which 27 were melanomas. There were 27 cancers of the head and neck (five larynx, four tongue, two pharyngeal, three mouth, five nasal, three salivary and five oesophageal), together with 22 lung cancers. There were 21 cancers of the bladder, two of the urinary tract, 19 of the liver (ten of them primary), two of the breast and six of the brain.

Psychological Problems

A well-documented syndrome of psychological distress among many atomic and nuclear veterans is also evident in this survey. A major reason for requiring more than a quarter of a million members of the armed forces to be present at the weapons tests which began in July 1946 was to examine the their emotional response to nuclear warfare.²⁴ Reports^25-42 on psychological stresses experienced by the 'indoctrinee forces' first appeared in the 1950s. Recent studies of veterans of these forces suggest that there is a syndrome with 'major thematic consistencies'³⁸ comprising:

1. a belief that they are dying of a disease caused by radiation;
2. a belief that they will die early;
3. a disrespect for the medical profession as a whole because they have been unable and sometimes unwilling to help; but
4. a longing to find that one doctor who will have all the answers;
5. a heightened concern for the future health of their children and grandchildren;
6. anger at the government, based on the belief that the government knowingly placed them in a dangerous situation and is now refusing to accept responsibility;
7. guilt over their own anger at the government;
8. the belief that they were used as guinea pigs;
9. a willingness to be in the service again; but
10. a refusal ever to be involved with nuclear weapons again;
11. the belief that others think the sufferers crazy for regarding ionizing radiation as dangerous and/or the cause of their illness.

This syndrome results in a preoccupation with health and radiation and a series of identity conflicts. It is exacerbated by the sense of 91invalidation 9142 many veterans experience in trying to have their Departments of Veterans Affairs to accept their ill health as service-related and therefore worthy of compensation.

Several cancers are more frequent in survivors of the Hiroshima and Nagasaki bombings. There is also evidence in the literature surveyed below of a link between a group of skeletal and connective tissue disorders, immune disorders, and the later occurrence of cancer. It appears that similar disorders may be more prevalent in the present groups of test veterans, and may be related to the development of multiple myeloma, and perhaps, other cancers, reported above. This possibility should be explored in the full clinical survey of the test veterans, which is the principal recommendation of this study.

A-bomb survivors

In Shigematsu and co-authors' book (ref 15:142) Ogawa and Ito report that:
The frequency of diabetes mellitus in Japan is known to be steadily Increasing; the rate in the atomic bomb survivor population is 10%, extremely high in comparison with populations in other areas of the country. An interesting problem concerning the mechanism by which diabetes mellitus develops is whether the high incidence among atomic bomb survivors is due to ageing of the population or whether it is somehow related to atomic bomb radiation.

In the same book (ref 15: 92) Akiba of the Kagoshima University School of Medicine states that:
A clear increase in colorectal cancer is observed among atomic bomb survivors, with the risk increasing as the age at the time of bombing decreases. Also, as with other solid tumours, the excess incidence due to exposure to atomic bomb radiation increases in an approximately proportional manner, as observed among non-exposed patients. It is anticipated that from now on the excess incidence will increase rapidly as all the atomic bomb survivors become older and those who were exposed while young reach the age at which the incidence of cancer usually increases. (emphasis added)

Ito (ref 15: 55, 56) of the Hiroshima Atomic Bomb Casualty Council notes that the relationship between radiation and gastric cancer attracted attention in 1965, after increased gastric cancer was reported in patients undergoing radiotherapy for ankylosing spondylitis.⁴³ Ito reports that in the Japanese survivors the rate of gastric cancer among people aged 34 years or less at the time of bombing tended to be higher than among those aged 35 or older.

Ito also points out (ref 15: 57) that prior to 1977 analyses based on death certificates showed a negative correlation between gastric cancer mortality and atomic bomb radiation in Hiroshima and Nagasaki. However, the study covering the period 1950-73 of approximately 80,000 individuals in a fixed population surveyed by the Atomic Bomb Casualty Commission (ABCC) found an increased gastric cancer mortality rate among the heavily exposed population in Hiroshima. He comments that 'The relationship with radioactivity first became apparent when gastric cancer incidence increased as the atomic bomb survivors reached the age at which cancer frequently occurs.'

Co-morbidity and radiation-induced autoimmunity

The co-morbidity pattern of musculo-skeletal, dermatological, and gastrointestinal conditions in this sample of UK nuclear weapon test veterans it is suggested, is consistent with sternocostoclavicular hyperostosis, acquired hyperostosis, pustulotic arthro-osteitis, psoriatic arthritis and the SAPHO syndrome - synovitis, acne, pustulosis, hyperostosis and osteitic syndrome. Many men report symptoms which may be pustulosis palmoplantaris. The typical age of onset was in the early thirties, about a decade after men had been required to expose their spines to nuclear detonations.

No significant increase in the incidence of lymphoma, leukaemia, or malignant melanoma was found in a US cohort of patients with psoriasis, but significant increases in the incidence of colonic cancer and primary neoplasms of the central nervous system were observed.⁴⁴ An excess of hematological malignancies was reported, particularly in males, in a study of 1,666 Finnish sufferers from rheumatoid arthritis.⁴⁵ The authors comment that 'One possible reason for the increased incidence of hematopoietic malignancies in RA patients is that RA and such tumours share common etiological agents.' Serious complications involving diverticulosis have been described.⁴⁶ An elevated incidence of infections, cardiovascular and renal diseases was found in a sample of 1,000 Finnish patients with rheumatoid arthritis.⁴⁷ An association between diffuse idiopathic skeletal hyperostosis (DISH) and multiple myeloma has been suggested.⁴⁸

A review of psoriatic arthropathy⁴⁹ notes that:
In our experience, there is no correlation between the severeness of the psoriasis and the frequency of onset of arthritis, just as there is no real evidence of a correlation between the gravity or type of cutaneous signs and the type of joint involved or the extent to which it is affected. Studies on the incidence of psoriatic arthritis among the general population give values ranging from 0.02% to 0.1%.

A subtype of psoriasis, palmoplantar pustulosis has been linked to a variety of skeletal abnormalities including sternocostoclavicular hyperostosis, chronic recurrent multifocal osteomyeliris and sero-negative spondyloarthritis, often with spinal involvement.⁵⁰ The authors consider that the 'relatively high percentage of skin disease in patients with sternocostoclavicular hyperostosis may even be an underestimation, because the skin lesions may be episodic or bone disease may precede the dermatologic manifestations of classic psoriasis'.

Sternocostoclavicular hyperostosis (SCCH) was first described in Japan, in the late 1960s. A report⁵¹ comments:
A noteworthy complication seen in ISCCO [inter-sterno-costoclavicular ossification] was pustulosis palmaris et plantaris. Although the etiology of this skin disease is not clear, bacteriological hypersensitivity is suggested to play an important role. We have found a strikingly high association of pustulosis palmaris et plantaris in ISCCO cases. This suggested common pathogenesis between these two conditions. In 1971 Enfors and Molin⁵² reported a ten-year follow-up study of pustulosis palmaris et plantaris. According to them, 13% of 82 patients had had articular complaints resembling rheumatoid arthritis, but details of the symptoms were not described. Ishibashi et al.⁵³ have reported that patients with this skin lesion were often found to have orthopedic symptoms in the upper chest region, but ossification as seen in ISCCO has not been reported yet. Although the precise mechanisms by which ISCCO accompanies pustulosis palmaris et planraris are unknown, we are suggesting the hypothesis that ISCCO might be one of the musculo-skeletal manifestations of pustulosis palmaris et plantaris.

The term 'hyperostosis syndrome' is now used to describe patients with SCCH, pustulotic osteitis and SAPHO syndrome. A discussion of 'Arthroosteitis - A clinical spectrum' concludes that 'Arthro-osteitis is an infrequently recognised condition in Caucasians. In many cases there is a history of a co-existent or previous dermatosis in particular palmoplantar pustulosis.'⁵⁴ SCCH can be often combined with a spondylarthropathy, particularly ankylosing spondylitis.⁵⁵

Osteoporotic bone necrosis can be associated with the direct skeletal effects of radiation:⁵⁶
The highest risk ratios were found among persons receiving internal doses of alpha-emitters ... In this group, which consists primarily of dial painters and patients who received Thorotrast, the effect of a small total dose of radiation may be magnified considerably, since the radionuclides involved are in fact deposited in bone tissue, so that high-linear-energy-transfer alpha-emission effectively irradiates the marrow. This means of exposure may also be an important factor among workers in the nuclear industry, especially in plutonium-reprocessing plants, for whom the risk ratio ... was higher than one might predict from the recorded exposures to external gamma-rays.

It has been reported that pemphigus can be induced by X-irradiation.⁵⁷ The authors propose that X-irradiation may play an important role in the aeriology and pathogenesis of what are considered autoimmune disorders of the skin.

A case has recently been described of basalomarosis caused by cobalt-60 irradiation.⁵⁸ A 55-year-old farmer developed 43 basal cell carcinomas 20 years after treatment of an immunoblastoma with cobalt-60 irradiation. All the tumours were located within the radiation fields. They conclude that 'The patient's multiple superficial basal cell carcinomas probably represent a late adverse effect of the 60-Co irradiation'. The relative immunosuppressive effects of UVB and PUVA irradiation, used as treatments for psoriasis, has been discussed.⁵⁹ A case of 'Unusual telangiectasia in a nuclear veteran', who is also a subject in this sample, has been described.⁶⁰

A further report⁶¹ states that:
Associations with certain skin diseases are known in about one half to two thirds of cases with SCCH ... The disease designation pustulotic arthro-osteitis is intended to indicate that certain skin diseases accompanied by pustulation induce inflammatory hyperostoses or that they may arise after such hyperostoses. These include palmoplantar pustulosis, pustular psoriasis, acne conglobata, acne fulminans and hidradenitis suppurativa. The severe forms of acne specified here are to be expected in about 15% of cases of AHS. In addition, SCCH or AHS has also been observed in psoriasis vulgaris, i.e. in a nonpustulous skin disease. There are also reports on combinations of pustulosis palmoplantaris and psoriasis vulgaris in AHS. In addition, about one third of AHS cases do not manifest skin disease, so that the attribute 'pustulotic' is superfluous in these cases.

In a report he submitted to the Australian Nuclear Veterans Association in 1985, Dr W.G. Wilson described the findings of his full examination of 18 members of the association. These were discussed with a specialist psychiatrist and a specialist physician. He stated that:
The subjects of the Survey were aged between 48 and 75 years and most of them had significant health problems. These health problems included arterial hypertension, ischaemic heart disease, varicose veins, chronic obstructive lung diseases, bronchial asthma, peptic ulceration, pancreatitis, cholelithiasis, hiatus hernia, diverticulitis coli, haemorrhoids, epilepsy, tinnitus and hearing disorders, depression and/or anxiety state, testicular cancer, thrombocytopenia, gout, osteoarthrosis, skin cancer, dermatitis and psorlasis.

He concluded that 'there is a lot of morbidity and the possibility exists that exposure to radiation may have been an aetiological factor in some instances'

The present researcher has read the full case histories of more than 20 men from the present survey who participated in the nuclear weapons tests and whose symptoms are consistent with those of the full cohort. Skin conditions, early onset cataracts and early hair loss (together with impaired fertility) are commonly used as indicators of possible exposure to ionizing radiation. It is therefore suggested that the members of the overall sample of 1,041 men are susceptible to the SAPHO syndrome and its variants. It is proposed that this susceptibility may have been induced by their exposure to ionizing radiation in their twenties, triggering autoimmune responses in the following decades. The susceptibility is associated with a range of cancers known to be linked to these conditions.