Fwd: JRC comments on the tenth anniversary of the Cs-137 accident in Goiania,...

[Ccja@aol.com]

John's summation is the best brief version I've seen.

chris alston
---------------------
Forwarded message:
From:	jrcamero@FACSTAFF.WISC.EDU (JOHN CAMERON)
Sender:	medphys@LISTS.WAYNE.EDU (Medical Physics Listserver)
Reply-to:	MEDPHYS@LISTS.WAYNE.EDU (Medical Physics Mailing List)
To:	MEDPHYS@LISTS.WAYNE.EDU (Multiple recipients of list MEDPHYS)
Date: 97-08-06 18:17:19 EDT

Dear Colleagues, It is probably appropriate to recall this sad accident.
For those who want a more factual account they should read the IAEA 1988
publication: The Radiological Accident in Goiania ISBN 92-0-129088-8
        If you read Portuguese you will find "GOIANIA, RUA 57 by Fernando
Gabeira interesting. It is more politically oriented. It quotes the experts
explaining that radiation is dangerous down to zero dose.
        Both books do a poor job at examining the cause of the accident. In
Appendix IV of the IAEA book  "Lessons learned by CNEN" (the nuclear energy
commission of Brazil) it lists 13 lessons. The last is the "programme of
inspection of radiological equipment and facilities is very important." It
seems to me it deserved to be listed first.
        The Italian made Cs-137 unit was installed about 1977 - that was
the last year it was inspected by the CNEN. About the end of 1985 the
private therapy group moved to new premises with their cobalt unit and left
the Cs-137 unit unsecured in the abandoned building. They did not notify
the CNEN authorities. However, the CNEN was aware that they had not
received a report on the unit for over three years but had failed to follow
up to see why not. At least one physicist of the CNEN was aware of the
abandoned Cs unit but it was not the responsibility of that physicist.  The
abandoned building had holes in the walls big enough to drive in a truck.
Some local scrap dealers became aware of that a heavy medical unit had been
abandoned. It weighed 600 kg - too heavy to move in their hand pulled cart.
They decided to remove the part that they could get at -the shielded source
holder. The source had a strength of 51 TBq (1375 Ci)  in Sept. 1987.  Over
the period Sept. 10-13, 1987 the two scrap dealers took the source out and
back to their shop. On 9/13 they were both vomiting and assumed it was
something they had eaten. On 9/18 the source was placed on the ground under
a mango tree where they worked on getting it apart. In the process they
punctured the 1 mm thick window and spilled the Cs powder. Thinking it may
be gun powder they tried to light it.  They sold their find to the scrap
dealer next door for about $20 U.S. who took it to his garage in a wheel
barrow. That night he noticed the blue glow from the source material and
called in family & friends to see it. On 9/21 several people took some of
the source home, a child ate some and others daubed it on their skin. The
child later died as did three others who had close contact with the source.
On 9/25 the remnants of the source were sold to a third junk yard! By 9/28
a number of people were physically ill. A woman from the home of the first
junk dealer went to the third junk dealer and had him put the remnants in a
bag which he carried on his shoulder on public transportation to the health
office where it was dumped on the desk of a doctor (DVM) . The woman told
him it was killing her family.
        The next day (9/29) they located a visiting medical physicist to
check it out. He borrowed a scintillation type monitor (range of 0.02 to 30
microGy/h) which was pegged when he turned it on a few blocks from the
source. He went back to get a monitor that worked, which he checked right
away. By 10:20 a.m. he was convinced that a large source was involved. and
convinced the fire brigade not to dump it in the river as they planned to
do! He also convinced the authorities to vacate people from the hot areas.
        Things moved along rapidly to detect contaminated people and areas.
Since it was over two weeks since the source had been ruptured the
radioactivity was spread through a large area. Interest in the blue glow
undoubtedly lead to a much larger number of contaminated people than would
have been the case if the source had not been ruptured.
        Who is at fault? The two MDs who abandoned the source deserve most
of the blame. The last I heard neither was serving time for their
negligence. Chances are they are still praciting radiation oncology.  The
four deaths were sad but they are a small fraction of the people who die in
a country of 150 million from various negligence causes each day. (The
highway death rate is about 50,000 - equal to that of the US with nearly
twice the population. The cost to clean up the mess was considerable.

        The following news story gives a more romantic and tragic view of
the accident. The "stone" was really a clump of Cs salt that was easily
powdered. Without knowing any specific details I believe that one or more
medical physicists might have prevented this accident if they had gone
outside their normal area responsibility to report the unsecured Cs
irradiator. The money spent for the clean up could have saved many more
than four lives if it had been used for health care.
        People from Goiania, a city with a population of about million,
who traveled to other cities often had a problem finding a hotel as they
were all assumed to be contaminated. The current news value of the tenth
anniversary will probably stir up more fears rather than educate the
readers.
        Speaking of education: The Aug. 2, 1997 issue of the New York Times
under National Report has the headline "THOUSANDS HAVE THYROID CANCER FROM
ATOMIC TESTS"  The lead paragraph states that NCI stated that fallout from
the bomb tests may have caused 10,000 to 75, 000 thyroid cancers, 70
percent of which have not yet been diagnosed. The materials released wre a
1,000 page "narrative report" to accompany " 100,000 pages of data that are
designed to give individuals a better basis for estimating their exposure."
NCI has placed much of the information on its WWWsite:
http://rex.nci.nih.gov in the "What's New" link.  You can download the
whole article from the NY times web page if you go to the 97/8/2 link or I
can send it to you.
        A separate story suggests that there were 2500 deaths from thyroid
cancer due to the fallout - more than five times the total cancer deaths
from radiation among the A-bomb survivors!!
        Sorry to use up so much space but you probably did note my name as
the sender. John

>.c The Associated Press
>      By HAROLD OLMOS
>      GOIANIA, Brazil (AP) - The moment his brother gave him the
>glowing blue stone, Ernesto Fabiano somehow sensed it would mark
>his life forever. And it did.

MOST OF THE NEWS STORY WAS DELETED. IT IS OF INTEREST THAT THE JUNK DEALER
WHO HAD THE HIGHEST ESTIMATED DOSE OF 7 Gy  SURVIVED TO DIE OF CIRRHOSIS OF
THE LIVER SEVEN YEARS LATER. I HEARD IT SUGGESTED THAT ALCOHOL CONSUMPTION
MAY PROTECT AGAINST LARGE RADIATION DOSES!

>      For 16 days, chunks of cesium had been carried around town.
>Everyone who had direct contact with it received a radiation dose
>of between 400 and 1,000 rems - as much as some victims of the
>Hiroshima and Nagasaki atomic blasts in World War II.
>      Over the years, three more people died from radiation-related
>cancer. Ferreira, the scrap dealer, died in 1994 of cirrhosis of
>the liver.

Check out ELECTRONIC MEDICAL PHYSICS WORLD - EMPW - which links to AAPM,
IOMP etc.at  http://www.medphysics.wisc.edu/~empw and the Bibliography of
books and journals in Medical Physics and related fields at
http://www.medphysics.wisc.edu/~cameron.

John R. Cameron, 2571 Porter Rd., P.O. Box 405, Lone Rock, WI 53556-0405
Phones: 608/583-2160;  Fax: 608/583-2269
 In the fall we return to our home at 2678 SW 14th Dr., Gainesville, FL 32608
 phones : 352/371-9865; Fax 352/371-9866

my  e-mail all year is: jrcamero@facstaff.wisc.edu