Immediately after the April 26 Chernobyl accident, the Western press reported wild speculation about casualties. Later, the suffering and loss of life were obscured by the unfolding technical details of the accident and the widening fear of fallout in neighboring countries. Now the reactor is buried under thousands of tons of sand, clay, lead, and boron and is encased in concrete. Health effects outside the immediate area will not be apparent for some time. The hundreds of persons, however, who were exposed to intense radiation after the initial explosion and during the rescue effort have experienced devastating illness, beginning in the first hours and extending over weeks and months.

On Friday, June 6, or 39 days after the accident, seven other American physicians and I visited Moscow Hospital Six and talked with and examined several radiation victims from the Chernobyl site. We had come to the Soviet Union to lecture in a medical exchange program arranged by Physicians for Social Responsibility following the Sixth Congress of the International Physicians for the Prevention of Nuclear War (IPPNW) in Cologne, West Germany.

At the congress the Soviet delegates had given the first full reports heard in the West about the medical aspects of the accident. Dr. Leonid Ilyin, a member of the Soviet Academy of Medical Sciences and a leading radiobiologist, and Yevgeny Chazov, co-president of IPPNW and Soviet deputy minister of health, recounted that the accident produced an initial explosion which killed two operators and damaged the reactor’s core. Asked why there was a delay in releasing information about the accident, they responded that local officials had underestimated the magnitude of the damage and extent of radiation release. Local radiation readings, although initially very high, had fallen dramatically after the accident, they said.

We learned from physicians at Hospital 6—a designated Soviet center for acute nuclear accident injuries—that the hospital was notified within two hours of the Chernobyl explosion. Four hours later the first of what was to total 230 teams of doctors, nurses, and technicians were on their way to Chernobyl by plane, arriving the morning of Saturday, April 26.

According to Dr. Angelina K. Guskova, hospital director and a radiation researcher for more than 30 years, Ilyin, and other members of the medical staff, the medical teams examined between one and two thousand persons at the plant site, gave emergency treatment, and within 24 hours sent the first 129 patients to be hospitalized in Moscow. A total of 299 persons were admitted within 48 hours of the accident. We learned later that others, less severely injured, had been admitted to hospitals in Kiev.

The medical team also began the process of estimating the radiation doses that the victims had received. The estimates were based on observations of chromosome damage and lymphocyte counts, the history and time of onset of nausea and vomiting, and the extent of radiation burns. [See “How Radiation Victims Suffer” in this issue.] They estimated that several persons received doses of over 1,000 rads, that 50 persons received over 500 rads, and that 200 received doses of over 100 rads.

Many patients were still contaminated with radioactive dust when they arrived at the hospital. Decontamination of such patients, even by experienced personnel, is difficult. In the confusion of caring for burned and acutely injured persons, Guskova herself received a dose of two rads. Two physicians on the triage teams received doses that required their hospital admission, and one of them has since died.

Of the 299 patients who were admitted, most were men aged 25 to 35 and two were women. Ten percent were over 40 years old. With two exceptions all were technicians at the power station or rescue workers. Two Chernobyl residents who had been walking or bicycling nearby required hospital treatment. Eighty-nine persons, although significantly irradiated, were discharged as not acutely ill. By mid­-July, a total of 28 persons had died as a result of the Chernobyl accident, 26 from radiation and two in the initial explosion.

Many of the patients had combined injuries: smoke and radiation inhalation, and thermal and radiation burns, in addition to whole-body radiation. The acute radiation injuries were due to gamma and beta radiation. Biologically active radioisotopes in the environment included inhaled xenon and krypton and ingested iodine, cesium, and strontium. Inhalation or ingestion of radioactive materials was estimated by the Soviets to account for approximately 5 percent of each patient’s total dose. Several of the patients we saw had burns in their mouths and throats from radiation inhalation.

The medical staff presented us case reports of seven of the 210 patients still hospitalized on June 6. We then put on surgical gowns and masks for infection control and interviewed and examined a number of the patients.

The inescapable image was of Hiroshima and Nagasaki. My only experience of people with burned faces, no hair, and bruise marks from bleeding into their skin had been from medical textbook pictures of the Hiroshima bombing victims. I had a jumble of thoughts. “Now I have seen nuclear war. This could happen to us.” I immersed myself in the details of the injuries, which were complex: lung damage from breathing hot, toxic, and radioactive smoke, and skin burns from both heat and radiation. Beta-particle-emitting radio­ active material in dust on the skin produces a peculiar burn, which does not appear until 12-14 days after the exposure. It has a uniform thickness of a few millimeters and leaves the skin a mahogany color. The dead skin peels off over white flesh, leaving a morbid and motley appearance. Bruises, or petecchiae, result from bone marrow destruction and the subsequent failure of the production of platelets, the cell fragments needed for blood clotting.

The medical care given the Chernobyl victims at Hospital 6 appeared competent and humane. The patients we saw had received radiation doses varying from 100 to over 1,000 rads. Nineteen patients had received bone marrow transplants, and all had received very up-to-date treatment with antibiotics and blood products. Moscow’s five major blood banks were involved. One patient was in a “life island”—a plastic enclosed environment to protect him from infection. I was particularly struck with evidence that the psychological needs of these terribly injured people had been considered. Families were in attendance and the nurses were attentive. The patients were concerned to tell us the histories of their injuries. They had clearly been encouraged to “work through” their experiences.

Several of us asked the staff if we could photograph the patients. The reply, quite appropriately, was that we would need to get permission from the patients. We said that we would like their pictures for use in lectures and scientific journals. One refused for personal reasons, but the others agreed—especially, they said, if it would contribute to an understanding of their illness and of the accident.

One of the patients, a 55-year-old engineer, had received an estimated dose to his bone marrow of 490 rads as well as 7.39 microcuries to his thyroid gland (see photos). We spoke with him through an interpreter. He was in the plant at the time of the explosion and described a scene of noise and smoke and confusion. Workers were evacuated for a few minutes but returned to attempt to control the damaged reactor and fight the fire.

The engineer remained in the plant for four hours. He said he was aware that he was receiving large doses of radiation but that he felt responsible to stay at his work. Within a few hours he felt weak and nauseated and began to vomit. He had second-degree bums over 20 percent of his body, principally his legs and thighs, and first-degree bums of his face and neck. During his hospitalization he had suffered from bleeding, infection, and depression and had received antibiotics, transfusions, and burn therapy. He did not receive a bone marrow transplant. Although he was well enough to speak with us comfortably, he was still seriously ill.

Much public attention has focused on the bone marrow transplantations. In the Western press Chazov was accused of cynicism when he stated that the transplants had not been expected to save many lives. Several of us flew home from the Soviet Union on the same plane with Dr. Robert Gale, a University of California, Los Angeles, transplant expert, who confirmed that he and his Soviet colleagues had expected about a 25 percent survival for the transplant recipients. In early July, five of the 13 who received marrow transplants were still alive. Gale emphasized that transplantation is not a cure but rather a form of support until the patient’s marrow can resume making cells. Only very sick patients who had received high doses of radiation, over 500 rads, were selected for transplantation. Before Gale’s arrival, the Soviets had performed transplants of fetal liver cells in six patients who were so severely irradiated that they had no bone marrow cells left for matching with a donor. None of these patients survived. As Gale pointed out, the issue is not whether the transplant is a success but whether the patient survives.

The Soviets feel that the more than 100,000 persons who were evacuated from within a 30-kilometer radius of the plant and some areas beyond are at particular risk. A population registry has been created for them, and they have been issued special identification cards to assure reporting of all medical data. Eighteen thousand were examined in hospitals and clinics, and many were given screening tests including chromosome examination and thyroid scans. Ilyin said that a full report of all the medical activities to date would be made to the International Atomic Energy Agency at the end of the summer and subsequently to the World Health Organization.

The Soviets will establish a new national center for the long-term epidemiological and environmental followup to the accident, much like the Atomic Bomb Casualty Commission established after World War II. Properly controlled epidemiological studies of cancer incidence, genetic damage, and fetal abnormalities are being designed. Discussions are in progress regarding Soviet and American collaboration in the study of the biomedical consequences of the accident.

From this tragic situation medical scientists will learn much about acute radiation illness and its treatment. We must also closely examine the public health and medical aspects of such accidents—particularly emergency systems, communication, public information, decision making, and medical preparedness. The American Medical Association has already appointed an advisory committee on nonmilitary radiation emergencies and will hold an international conference on these issues, cosponsored by a large number of health agencies, in Washington, D.C., on November 19-20.

SIDEBAR: Glossary of radiation terms

Becquerel: radioactivity is measured in terms of disintegrations per unit of time. One becquerel equals one nuclear disintegration per second. (Disintegration is the transformation of a nucleus, either spontaneous or by interaction with radiation, in which particles or photons are emitted.)

Curie: one curie is the rate of disintegration of one gram of radium: 37 billion disintegrations per second.

Half-life: time required for a radioactive substance to lose 50 percent of its radioactivity by decay.

Isotopes: nuclides having the same number of protons in their nuclei, and hence the same atomic number, but differing in the number of neutrons, and therefore in atomic weight, for example, uranium 235 and uranium 238.

Nuclide: species of atom characterized by the number of protons, number of neutrons, and energy content of the nucleus, or, alternatively, by the atomic number, mass number, and atomic mass. To be regarded as a distinct nuclide, an atom must be capable of existing for a measurable lifetime.

Rad: “radiation absorbed dose.” One rad is the amount of ionizing radiation that deposits 100 ergs of energy in each gram of exposed biological tissue.

Radiation: the production and transmission of energy in the form of electromagnetic waves or particles. Electromagnetic radiation is generally classified as to frequency (infrared, visible light, ultraviolet, X-rays, and gamma rays). Alpha and beta radiation are particulate emissions from the nuclei of atoms.

Radioactivity: the property of the nuclei of certain atoms to emit radiation spontaneously in the form of gamma, alpha, or beta rays. Gamma rays are ionizing radiation with high energy and deep penetrance.

Rem: “roentgen equivalent, man.” This measurement takes into account the varying biological effects of different kinds of radiation and attempts to express them on a common scale. Rem and millirem (thousandth of a rem) are convenient units for measuring radiation exposure per unit volume of tissue. A rapid dose of 700 rem to a finger may do no appreciable damage, whereas exposure of the whole body to 700 rem over the course of a few hours or days would almost certainly lead to death from radiation sickness. Rate of exposure is important: spread evenly over a year, 700 rem would have no observable effect, although the chance of eventually developing a cancer would be significantly increased.

The exposure unit for considering health effects in a population is the person-rem. If 10 people are each exposed to 100 rem, or 10,000 people are each exposed to 100 millirem, the population exposure is the same: 1,000 person-rem.

The maximum permissible dose per year is 500 millirem; for those who work in radiation occupations, the maximum permissible dose is five rem per year, or 20 millirem per work day.

The following are typical doses:

• Average annual natural background radiation (from cosmic radiation, radioactivity in the earth and in foods): 90-100 milli­ rem.

• Average annual radiation from medical radiation or man­made radiation (diagnostic X-rays, weapons testing, building materials, and so forth): 90-100 millirem.

• Cosmic radiation received during a transcontinental U.S. flight: 2.5 millirem.

• Chest exam: 10 millirem.