What Hiroshima and Nagasaki survivors taught us
Long-term monitoring of Japan's hibakusha documented the devastating long-term consequences of exposure to radioactive fallout.
This week marks the 79th anniversary of the U.S. dropping two atomic bombs on Japan, the world’s first and only use of nuclear weapons. With Russia’s Vladimir Putin threatening to use nukes in Ukraine and both countries embarked on massive nuclear weapons modernization programs, it’s as good a time as any to highlight two enduring health-related lessons from those horrific events:
The long-term consequences of radiation exposure; and
The extraordinary value derived from mining detailed medical records, especially if maintained over time for populations subjected to adverse events.
In 1995, I was living in Japan while serving as the Chicago Tribune’s chief Asia correspondent. That year marked the 50th anniversary of the U.S. dropping atomic bombs on Hiroshima and Nagasaki that ended the war in the Far East. The event held great interest for our aging readership, which included many WWII veterans then in their late 60s and early 70s.
As I pitched stories to commemorate the anniversary, my foreign editor, new to his job, pressured me to hew closely to the conventional wisdom about the two countries’ self-perceptions about The Bomb. Most Americans believed its use was responsible for bringing the war to a close without the million casualties that would result from an invasion of the Japanese islands. (Many historians dispute that that was the only alternative and that the casualty count would have been that high, but that’s another story). Veterans groups and members of Congress had already succeeded in pressuring the Smithsonian to eliminate from its planned exhibition any graphic images, melted objects or artifacts, which would put the spotlight on civilian suffering.
For the Japanese, the annual commemoration ceremony served as a touchstone for thinking of themselves as victims of the war, which conveniently ignored their imperial march through Asia that began the conflict. The exhibits in the Hiroshima Peace Memorial Museum dwelled on that victimhood. Western press accounts about commemoration activities invariably referred to the museum’s one-sided presentation, which excluded any mention of Japan’s own war-time atrocities.
A few months before the 50th anniversary, I headed west from my home in Tokyo to visit the Hiroshima peace museum and the Genbaku Dome, the only surviving structure within the one mile-radius bomb blast site, now a UNESCO World Heritage Site. In preparation for the trip, I read clips from the Japanese press (the English language versions; I’m not fluent) that mentioned the hibakusha (“explosion-affected people”) and the work of the Radiation Effects Research Foundation, which carried on the work of a commission formed by the U.S. and Japanese governments in 1947 to study the effects of radiation on human health.
This was several years before my career turned toward covering health-related topics. But I was familiar with worker exposure to radiation from my years in the late 1970s working on occupational health and safety issues for a public interest group in southwest Ohio. Learning more about the long-term health effects of radiation struck me as a good way to add the “anti-nuclear” angle into my coverage of the Japanese side of the story, even as I dutifully included the historical amnesia angle emphasized in every other western press account.
“What the hell do you want to write about that for?” the foreign editor yelled at me over the telephone from 10,000 miles away. I ignored him and reported that part of the story anyway.
Japan’s data miners
During an interview at RERF’s Hiroshima office, a top official explained that the organization had documented where every survivor — there were about a half million in the two cities in addition to the estimated 200,000 who died in the blasts — was standing, sitting or sleeping when the bombs went off. This enabled its researchers to estimate the radiation exposure that each survivor received in the immediate aftermath of the explosion.
The researchers also recorded their medical histories, which is ongoing activity for the 120,000 that are still alive. In addition to RERF maintaining a researchable registry containing those records, each individual was given a copy of their own record called the Atomic Bomb Survivor’s Health Handbook, a “cherished possession,” according to one of the few articles this year about the dropping of the A-bombs, because it gave them access to free annual checkups and treatments.
Studies using RERF's de-identified database quickly demonstrated the power of record-rich epidemiological research. They were used to create much of what medical science now knows about the short- and long-term effects of radiation exposure.
Over the decades, like clockwork, many hibakusha suffered premature mortality, mostly from various forms of cancer. Leukemia appeared in larger-than-expected numbers within five years of the blasts. Within a decade, excesses of solid tumors began appearing in the population, largely determined by the cell growth rates of exposed organs.
Excess rates of thyroid cancer began appearing in 1955; breast and lung cancer in 1965; stomach and colon cancer in 1975. The cancer rates soared to as much as six times higher than comparable groups in the general population. Later studies among workers who faced excessive doses of radiation at nuclear facilities and the civilian population near the 1986 Chernobyl nuclear power plant disaster confirmed those findings.
A learning health care system?
The research on the ill-effects of radiation exposure among the hibakusha powerfully reinforced popular consciousness about the horrors of nuclear war. It also helped change public policy. In 1963 the U.S., Soviet Union and United Kingdom signed the first nuclear arms control agreement. The Limited Test Ban Treaty banned above-ground or ocean nuclear-weapons testing out of fear of releasing radioactive isotopes into the environment.
Unfortunately, this extraordinary research initiative, partially funded by the U.S., didn’t lead to a deeper appreciation of the power of well-documented epidemiological research. It wasn’t until the 21st century that U.S. researchers and regulatory agencies began using registries or de-identified health records for medical research.
There were a few exceptions, of course, most notably the Pediatric Oncology Group funded by the National Cancer Institute. Over five decades starting in the 1960s, pediatric oncologists enrolled over 90% of children with cancer in clinical trials based on how they were treated (this is called a retrospective study as opposed to a prospective, randomized trial where one course of therapy is compared to either placebo or another course of therapy).
They weren’t interested in testing new therapies — the usual approach to cancer clinical trials. They wanted to determine which therapeutic approaches that were already being deployed had the best results and for which patients. The research results led pediatric oncologists to constantly update their treatment guidelines to reflect the treatments with superior outcomes. Over the course of five decades, the pediatric cancer survival rate went from 20% to over 80% through better use of existing therapeutic agents, not by looking for new drugs.
In 2009, shortly after the Obama administration took office and while the Affordable Care Act was still being debated, I wrote an article for Science Progress, published by the liberal Center for American Progress, that argued a similar approach should be taken for all cancers. Given that as much as 40% of cancer chemotherapies are used off-label (that is, they are not FDA-approved for the condition for which they’re prescribed), I concluded the nation’s oncologists were “engaged in what could be described as an unobserved and uncontrolled science experiment.”
Not much has changed. A decade-long effort to set up comprehensive cancer treatment registries by the American Society of Clinical Oncologists (CancerLinQ) has had limited success in signing up oncology practices. On its website, it boasts having records from over 100 cancer centers and community oncology practices in its database. The nation has over 3,750 such practices. The same can be said for most other disease states and the medical professionals that treat them.
The reality is that many researchers still balk at sharing data. Clinicians still hesitate enrolling their patients in registries given the extra time and expense it requires. Healthcare systems still fear that even though individual cases are de-identified, their overall record on outcomes will be compared to rivals and found wanting. Self-interest, not the quest for better health outcomes, rules.
A decade ago, at the dawn of the Obamacare era, health care think tanks, professional societies, academic medical centers, and forward-looking health care systems and medical practices talked a lot about using “big data” to create “a learning health care system.” Sadly, despite the ubiquity of electronic health records and the ease of transferring de-identified medical records to a centralized database, American patients still aren’t benefiting from the experiences of the hibakusha.
Such a great story. I very much appreciated your personal account of your experience and subsequent learnings. I wish we had been more successful in generalizing the learning as a nation, however.
Excellent and important piece! Thank you.