OPLION A The detection and treatment of radbat bon related pathology in exposed and control populations ‘Note: Numbers under constraints refer lo common constraints, text p.g-¢/ 1. Eseablish the ideal objectives Screening: What pathologle findings are sought? (A) Thyroid + dypofunction and/or Til. Itt. Translation Reinstatement of refilaed Constrainca Freseatof Screening: (1)(7) (9) (LO) (11)" Treatment: (4) - BNL currently treats radiation induced problema at BNL and neoplasia - a4denuma or carcinoma {B} Breast CA (C} Skin CA (D) Hemarologic-leukesia, syelofibrosis, aplastic anemia, {E) Cleveland with good resules. Fullow-up: (2)(4)(8),(9) (10) (11) (12)4 malities (sumple size too small te establish a cause + effect relationship to genetic abnor- ExlutingPolicy GI tract CA (F) Cenetic abnor- malities) (per Dr. J. Mvel). 2.0 Treatment: (a) Shorc-cerm whatever treatment is indicated to stabilize che patienc until he can be safely transported to a designated tecthacy care center for definitive therapy. {8} Long-term therapy dJrected towards the pathologic condition(s} Found at screening or by tectlarcy care. 2. (A) Follow up: Short-term periodic re- evaluation of any detected abnormalities Co determine their status, €.%-, prugress!on vs remission. (3) Long-cerm: fixed protacal to follow tertiary/post operative cases for the rest of their lives. objectives in consideration of restraints. The relative constralnty would not materially change the basic objectives of Option A. An additional objective has been generated by the identification of a lack of coordination among the various agencies and labs tnvolved {n the tocai care of the Marshallese Our resident MD can easily follow up the treated cases bul not general primary care. (19 (49.05) (6) (7) (8) (9) (1094 A common point of contact does noc exist for all of the agencies effecting or effected by the BNL medical program. Existing needa and demands £4) (5) (6) (7) (8) (9) (103 (LV) * An additional objective would be to establish a single contacc point in DOE to coordinate all these programs and to establish close liaison No unique wich DOE & DOT. cunstraints for Option A, Projected needs and demands (2) C3) (43 (5) (6) (7 (8) 099 (10) (LL) + Option there should be ac leasctone annual users meeting with addittonal A offers the minimum needs and demands but will noe meer the Marshallese expectations. Plunuing at other levels 1) 2903) (5) (6) (7) (8) * - The dack of coor- dinacion/iiaison among the many Laboratories meetings tection), Treatmeit-shore-term, Follow-up,shert & long-term, Single contact point for efflcient coordination of above. and control populations whereever We can lucate then. When: Timing should be based upon the beset available know in the level of care provided wilk provoke lack of couperation by the Marshallese reauleing in poor cooperation, compliance » waste time, poor data, €2}(9)04)47)* - Marshallese clalo injury due to long-term exposure ta "low level" Recent U.S. “low levet” scuties and radiation. Bikinl episode - wedia. “srshallese positlon, fear of ong term effeces has strengthened Bowyruplic_ Pupulation Charactyrisrics ()(7)(B)() G0)* - The culture prohibles direcr PRs Awmedlator mast be used, ULS. efforts to clarify reduced ac this time. The following reasons: 1} Long lead rime (especially on the outer islands - we must always keep in mind the poor communications);2) Long lead time and a fixed schedule will do much to counter the charges chat BNL has planned its trips to the onter isiands to coincide wlth cle absence of many of the leaders; 3) Evenly spaced visits, about 2% months apart will assist che BNL fleld staff in the follow-up of the pathologic conditions, l.e., a relatively fixed time base Pine will remove snother variaube in data ailysrs, Flexibility This option offers us liccle flexibility. conditions related to radiation exposure The pathologic in the range deter— mined for the Marshal] Istandy Is rather bimbted. Ueno pro- Avoidance of untoward consequences With scrictly Limited goals the probabilicy of obtaining movement to “Free asfocla— tion” will probably compromise must be included co insure proper notification of the study group - out Cut-back in services and by inflation. How: The BNL medical team is wucy referral system is almost an absolute _ constraint. — Ilowever, a curback in the earliest deviation from “normal funceion" « TSH (ta document thyroid hypofunceion.) Each identified patholugic conditton (listed under objectives) will be sereened by che gram under this opiion would be construined to this limtted medical program was being is of greac importance for the itema the history, physical exam and laboratory profile co detect Jedge ccgarding the time f{nrerval for the detection of rudla- necessary to explain why che The timing of the BNL Cield surveys related pathologic conditions (e.x%, discase specific Wnere: Screening of exposed eational program would be Timing A detailed cesearch protocel wil) be developed to specify the medical ceitecia and algorichms for the detection of radiation Total coat(s) The togat cose will be very close to u 'd expenditures, The reduction in the patient popularion orfgoc by the cose of the educational program to ex,...6n che reason for Existing Facilities— However, Ve Selection Crirecta forth the eriteria tor the seleccion of an goprogcti opptopriate methodologies. Treatment and fullow-up will be assured by appropriace algorithms and check Jists. BNE medical team has 25 far screening, treatment and follow-up. DOE best suited to identify single contact poink, more than studying radiation related pathology. A wellplanned, high intensity cdu- (7) 8709) 10) (LL)* - The lack of a viable pri- Set Performance years of experfence inOprion A Whe: currently doing considerably offictaly, The resulting confusion has placed the U.S. dn a vulnerable position - 7? credibiliry. = (19090 65) (5907) QA1L)* - Gpedon A offers lowest requirements. croresstion of hustilicy toward another. Efievances ensuceesstul co dure, Analysis tion abnormalicics. ' the costs of Litigation brought by the Murshathese for compensatton could result ia significant increase in U.S. payments. ~~ necessary. cace of the Macshaltese has resulted in conflicting information from some coucerned U.S. Financial Taming ~ ag and governmental agencies involved in Che “CYS (6) (73 (8)* - option A will require the lowest operating budget, inicially. Minpower In addition, since Che logistics, e.g., transportation {8 oa common problem to all users, IV. Develop possible approaches to attaining che objectlves, with each approach being stated in terms of: What: Screening(primary de- the already tnadequate health care funding by the Truse Territory. area. valid data and early detection of disease is enhanced by concenteation of Funds on ltmited objectives - L.e., minimum dilution of effort. However, the public outery apainst the reduction in che proyram could have serious policical/suciolopic consequences, Risk The risks to DOE/BNL are: The public reaccion to reduced medical care. We are unable to quancify cin risks to the Program offered by this sprion but they would probably In¢lude: lack of patient couperacion (resuleting in ? duta), vigorous public protest (locally and internationally) and a viyorous Program for BOE/BNL to,at least, tetucn to the previous level of care, Risks to the Marshallese ure: 1) Failure to detect other than radiation related discases - with increased surBidity and mortality amuny the exposed & control geuups. 2) Possible ailenation of the Marshallese by DOE/GXL resulting in a breakdowns Jn vital communication. Cost/etiectiveness ~ No data format now exists te computy cours effectiveness or cost/benefit. The diffuse funding mechanisms muke it very diff€icule for the principal inveatiyacer ro ohtadia on accurate current accounting of montes expended ca the mdtcal propraum. [If such data were avallable and all screentag, Creatjeont wud follows up gouls clearly defined, some tough vstimacion uf cogt/par dent ceoadd be derived.