Mediation: Physicians' Role in Prevention of War

These are not my words. They are those of an eighty-eight year old physician who did what he could to prevent the violence in the Balkans in the 90's. He recruited physicians in the threatened areas to intervene for peace in what ever way they could. Ulrich doesn't travel long distances any more; his words are published here with his permission. It would be an enormous loss if his experience were not told.

Twenty Years “Bridges of Understanding“

Wuerzburg, IPPNW, August 28./29 2015.

Opening speech by Ulrich Gottstein

Dear friends,

Twenty years “Bridges of Understanding”, and today for the first time “Candles in the Night” in Wuerzburg. Twenty years filled with historical sad and hopeful events.

Walter Braun and Renate Geiser invited me to recall the beginning of the successful experiment of the Wuerzburg IPPNW group to bring together medical students from different regions of former Yugoslavia, to learn and work together, to remove enemy images and to build and enjoy friendship.

How did this start ? With great concern the world observed the political development in Yugoslavia after the first free elections in Slovenia and Croatia in April 1990. Our sorrows became true when the open war broke out, at first between Serbia and Slovenia followed by fighting between the Coalition of Croatia and Bosnia-Herzegovina with Serbia in June 1991. Many people in Yugoslavia, especially Medical Doctors were full of despair. Two of them decided to engage for dialogue, reconciliation and steps for a cease-fire, Dr. Vuk Stambolovic from Belgrade and Dr. Milan Kosuta from Zagreb. They founded the “ Peace initiative of Croatian and Serbian Physicians” and organized meetings in both cities. This was a “candle in the night” of chaos. Unfortunately nationalism remained stronger , war continued, the candle was blown out.

At that time I was IPPNW-Vice-President of Europe. IPPNW had received the Peace Nobel Prize about seven years before. I felt it my duty to support peace willing politicians and academicians and medical doctors in Croatia and Serbia and to prove our solidarity with them. In April 1992 I travelled to Zagreb and met with Dr.Milan Kosuta and professor of Cardiology Dzenana Rezakovic. At meetings with several members of the new Croatian government, e.g. the Minister of Foreign Affairs, the Minister for Refugees and the President of the Parliament I was informed about the difficult situation.. President Tudjman was not in the country, he sent me a letter. I urged for a cease-fire and steps for solving the problems without war. The President of the Croatian National Academy of Sciences and Arts invited me to explain the activities and philosophy of our international medical peace organisation “International Physicians for Peace and the Prevention of Nuclear War” .

Many of the people I met were afraid of a new large scale “Balkan War”, and especially the Medical Doctors showed willingness to support peace work. They gladly accepted our suggestion to found a doctors organisation cooperating with IPPNW, which they called “Physicians for Peace in Croatia”. They elected the professor of cardiology, Dzenana Rezakovic as the chair. With her we drove in a Red Cross car through destroyed villages and shelled cities and I spoke with Croatian soldiers at the front line. I was very sad and asked myself, why was this war necessary, could it not have been prevented by wisdom and dialogue? How can we help ? In Germany I reported to our government, to journalists and of course to our IPPNW.

In August 1992 I travelled to Belgrade and met with Dr. Vuk Stambolovic.He organized for me conversations with the leaders of the political parties in Belgrade. Very informative was a rather long talk with the leader of the Social Democratic Party Mr. Djinjic, who asked for diplomatic support from the German government.which so far he did not receive.

I had a two hour discussion with the President of Yugoslavia, Mr. Cosic. I urged him to use his influence to stop the bombardments of Sarajewo, but his power was reduced because the military responsibility was with the Serbian President Mr.Milosevic. I met with the Bishop of the Serbian Orthodox Church, and the Bishop of the Catholic Church and with different peace groups, as e.g. “the women in black”, or the “Belgrade Circle”, in which intellectuals who were opposed to the war and to Milosevic met and discussed. They all were grateful for my visit. I even got the opportunity to speak in a free channel of Radio Belgrade. I explained that Germany and the West was not against the Serbian people, but against the government´s policy to use military force against the other Yugoslav nations and Kosovo. Finally the group of medical doctors around Dr. Vuk Stambolovic founded the “Physicians for Peace in Serbia”. They elected Prof.Milan Popovic as their president. He was a well known Professor of Psychiatry and Psychology at the University of Belgrade. Dr. Vuk Stambolovic was a docent of Social Medicine. He was elected deputy and IPPNW- International Councillor.

Returned home I gave a detailed report to Foreign Minister Genscher and urged him to start dialogue with Mr. Djinjic and to support the peace movement in Serbia.

Again in December 1992 I visited the collegues of the Croatian Physicians for Peace in Zagreb and also Bosnian refugee camps near Zagreb, to which I brought medications and hygiene articles and blankets. The situation was very sad, war continued.

In April 1993 I travelled for the second time to Belgrade.With Prof. Popovic I visited Serbian refugee camps, and with Dr. Vuk Stambolovic I travelled to Pristina in Kosovo. Prof. Popovic had organized for me to give a speech in the Lecture hall of the University hospital for Internal Medicine. I spoke about the responsibility of medical doctors to prevent hostility and war and cited the Hippocratic Oath and our medical ethics. I urged for cooperation and reconciliation with the doctors of Kosovo. They listened but after my speech they did not ask questions to the theme, but only about treatment of special diseases. Since Albanian speaking medical students and professors had been dismissed from the university by Milosevic, my audience consisted only of Serbs.

Thereafter I met with a group of 12 Kosovar professors and doctors who informed me about their absolutely intolerable situation. They built a group called “ Physicians for Peace in Kosovo” and started contacts with IPPNW-Germany and international.

In December 1993 I visited our Croatian colleagues for the third time and continued my mission to Bosnia-Herzegovina. With an UNHCR special passport I was allowed to take a car to West-Mostar. The town had received many destructions during fighting the Serbian and lateron the Croatian army. The coalition of Croatia and Bosnia-Herzegovina was broken. The Bosnian army was defeated and almost only Croats were now living here. Mostar was no longer the famous city in which people with three or more different religions had lived friendly together.The world famous bridge connecting West and East Mostar was destroyed. I visited the two hospitals.In the City Hospital the multi ethnic life was still vivid. The Chief Surgeon was still a Serbian, the Internist a Croatian, the Anesthetist a Jewish Croatian from Zagreb and the Head Nurse a Bosnian. This group was really a “candle in the night”. The other hospital , named “On the White Hill” was newly built before the war but not yet finished. Patients were lying in the front floor. Croatian and Bosnian people together.

I wanted to bring medications and food to the besieged and shelled East Mostar and to visit the doctors and see their situation..In an armoured car of UNHCR together with a British soldier and the local driver who knew which roads were free of mines, we reached after having passed military Croatian controles the city. We heard artillery and machine gun fire close to us. Fighting between Croatian and Bosnian soldiers was going on. East-Mostar and its infrastructure was almost totally destroyed. In two partially ruined private houses the Bosnian doctors had improvised a Surgical hospital, where they performed all the operations, during fightings up to 60 per day. The operation room was in a cellar kitchen, lighted by a diesel generator. The operated patients had their beds in a deep dark cellar without any light. Only if urgently needed they were allowed to light one or two candles. This really was “candles in the night” !

The Bosnian Doctors were very desperate. I will not forget the sentence of the surgeon “Until May we were friends and now we have to be enemies”. Nationalism had won about conscience and humanity. I asked myself, what can our Medical Peace Movement IPPNW do except humanitarian support and solidarity with the men and women who also long for peace? Solidarity was a “candle in the night” to them.They were so grateful for my visit, I was the first visitor from Germany since outbreak of the war. It had been a dangerous trip, therefore I had been asked by the UNHCR officer before starting, “ are you really willing to dare the trip to East-Mostar?”. My answer was a clear yes. I wanted to demonstrate that our Bosnian colleagues were not forgotten and that I wanted to dare what the doctors and people in East-.Mostar had to live through every day. When I said good buye they asked me to inform the world about their desperate situation. That I did in many lectures and papers and reports to our German people and government.

In July 1994 doctors from Sarajewo who had been informed about my visit to Mostar asked me to come to their encircled, besieged and continously shelled town.Together with a Bosnian Surgeon and an IPPNW-friend from Holland we drove in a car on small roads over the Mount Igmam to reach finally Sarajewo. The trip really had been dangerous as several people had been killed by snipers or artillery the days before. Over night we stayed in a Hotel with broken windows. The artillery and Machine gun fire was loudly heard. At first we visited the medical doctors of the partly destroyed University Hospital who welcomed us cordially. We saw that the former Olympia field was now a grave yard with more than 500 crosses or stones.The next day we spoke with the Chief Surgeon of the City Hospital.The bullet hole in the wall besides his desk was shown to us We were welcomed very gratefully. It meant so much to them that colleagues from Germany and Holland had come to see, how much the population suffered from the siege and artillery shelling from the surrounding mountains. Already 10.000 people of all ages and religions had been killed, among them 1.600 children. We visited also other professors of the Medical Faculty and the Peace Center of Sarajewo. Everybody blamed Europe for not helping Sarajewo since aleady more than three years.

Back in Germany I informed our government and IPPNW at national and international conferences, and helt many speeches, and interviews.

On January 11^th in 1994 I was invited to speak in the New University of Wuerzburg.The theme of my lecture was “Engagement of IPPNW in former Yugoslavia” . After the speech and discussion the Wuerzburg group and I sat down in Restaurant Dionysos, “in order to discuss what can be done regionally” as was printed on the flyer. The possibilities proposed were “medical support for hospitals, financial support for reconciliation work, partnerships with hospitals in Bosnia”. I proposed to invite medical students from different regions of former Yugoslavia in order to start with reconciliation. That was the beginning of “bridges of understanding” in Wuerzburg, with the generous help of the “Missionsaerztliche Klinik”.

When I recollect my experiences on my trips to war zones of former Yugoslavia I see in my inner eyes the operated patients in the dark cellar. They lightened 2 candles, and now we could see each other. These “candles in the night” and the sentence of the Surgeon, “until May we were friends and now we have to be enemies”, I will never forget. And I cannot forget the grateful faces of the doctors in the front hospitals near Tuzla on our way to Sarajewo and of the lady pediatric psychiatrist on the university campus, when we donated the necessary finances to restore the rooms and promised to remain in supportive contact. I believe, that our visits meant “candles in the night” to them. In the darkness of war, there was a light of hope for the future.

Our IPPNW and I personally are very grateful that you, dear friends from Wuerzburg, have built and kept strong the “bridges of understanding”. How wonderful that now the “Candles in the Night” give light and create happiness to friends from different nations of former Yugoslavia, who have promised to work for peace and reconciliation. For Peace and Reconciliation in West Balkan but also Peace and Reconciliation are urgently needed between Russia and the USA and on all spots, where war is being waged.

Yes, we are and want to be the “International Physicians for Peace and the Prevention of Nuclear War”. The commitment of the world wide civil society is absolutely necessary to reach that goal.

We shall not forget that war is being waged every year in 15 to 25 countries. From such wars a nuclear war can escalate. Therefore prevention of war is the precondition for prevention of nuclear war. So let us be “propagandists and pioneers” for a policy of early observing where risks of war start in order to immediately help and to prevent the outbreak of fighting.

In Germany we have a strong army and a Ministry of Defense but as in all other countries no Ministry of Peace. We can afford to buy the most expensive weapons but are told that we don´t have enough financial resources to treat causes of war. I ask again, why don´t we have a Ministry for Peace with specialised peace researchers, diplomats, economists, psychologist and historians.Why do the Western and Eastern wealthy countries not engage in early observing dangerous crises, why don´t they help immediately and see the causes of war. That would prevent death and wounds of hundred thousands of innocent women, men and children and thereby also prevent their need to escape from their suffering countries !

Dear friends, take these questions home and discuss them with your friends and co-students and politicians. We are not only doctors for single patients, we must feel our responsibility for humanity, for the “Respect for Life”, as Albert Schweitzer, medical doctor, theologist, great humanist, receiver of the Peace Nobel Prize, our great example lectured and published. We must carry our candle for peace further !

Real Security - Real Change

Harper’s idea of security is more jails, tougher sentences, more surveillance, more fighter jets and more assistance to warring parties. How did we get to a place in history where our security is an election issue? Where our leader sees a “terrorist” in every – almost ever crazy person who wields a gun? (“Almost” – a man who gunned down four policemen in New Brunswick was not considered a terrorist, perhaps because he was not Islamic.)

When the World Trade Towers went down on September 11^th, 2001, the United States invaded Afghanistan – which had no responsibility for the attacks. (Osama Bin Ladin was rumoured to be hiding in Afghanistan.) Canadians went along. Hundreds of thousands of Afghanis lost their lives, faceless, nameless civilians from a culture steeped in “honour” with a justice defined by revenge. Hence one Canadian soldier commented, “you kill one Talaban and five take his place”.

Al Qaeda gains recruits big time.

Dissatisfied, the USA then leads the “coalition of the willing” into Iraq and decimates infrastructure – universities, museums, schools, roads, bridges, sewage and water systems. What is not to like? As atrocities like Abu Ghraib and the deaths of more than half a million children become public, radical Islam gains more recruits. (We were leaving Iraq when Abu Ghraib became public and experienced first hand the fury of native Iraqis.)

Then, in Libya the West actually armed the rebels – a ragtag badly organized bunch of hooligans. Whatever the goal in that invasion, weapons flowed south to assist radical fundamentalists in raping and kidnapping in Nigeria and overthrowing an elected government in Mali.

Most recently, in the Syria, the armaments sent to the oppose the Assad regime fueled the rise of ISIS. While the USA has armed the Kurdish guerrillas for years to operate in the mountains to de-stable Iran, it now is openly arming them against ISIS. (Ironically producing a situation that is the delight of weapons manufacturers! Western arms against Western arms.)

None of these acts of aggression against foreign countries are designed to win friends and influence progressive change. None of these behaviours are designed to make us more secure. They accomplish exact the opposite. Continuing in this manner will produce more angry disenfranchised people and an increasingly insecure world.

One definition of insanity is “doing the same thing over and over and hoping for a different result”. It is time to do something different. It is time to develop an international policy that makes friends, influences progressive change AND makes us more secure. To really get rid of an enemy, turn them into your friend.

How do we do that? First of all, get away from the warring bodies. Second, undermine the ability of ISIS and their ilk by going behind the lines and responding to the needs of the people. What do ordinary Syrians in refugee camps need? What do Iraqis need? Food, water and safety. Remember the nonsense of being in Afghanistan for women’s rights? Fund schools, fund teacher education, protect women with “safe houses” and education of both genders. What about Iraq in the South, now plagued with diseases and deformities believed to be the result of the wastes left behind by war? Support and fund medical research. The list could go on and on but all of these are much less expensive (and more environmentally friendly) than fighter jets and army personnel.

And far more likely to increase the security of Canadians.

Causes of Cancer: Mourning the Loss of Glyphosate

Yes, I believe that nuclear bomb testing in the 1950’s and 1960’s plays a role in the “cancer epidemic” that we are experiencing (radioactive fallout maps from testing in the US). I also believe that today’s cancers are the mere tip of an iceberg in so far as cancer is concerned, largely due to the human influence on the environment.

A few environmental toxins and cancers have a clear connection. Examples include: chimney sweepers and testicular cancer, uranium miners and lung cancer, sun worshippers and skin cancer, benzidine workers and bladder cancer, cigarette smokers and stomach cancer (as well as lung). However, not cigarette smoker or uranium miner (etc) gets lung or stomach cancer and for most cancers the connection between toxin and cancer is much less clear. Genes play a role in both protection and cause but even in this case, not everyone with a gene for prostate or breast cancer will get the disease.

With all this uncertainty about a potentially fatal disease, you would think that an intelligent human race would be cautious about new substances to which they could be exposed. However, from DDT in the 1950’s to dioxins in the 1980’s, from fire retardants to skin lotions, we constantly add chemicals to our environment. We are generally in denial – we like our chemicals and what they do for us. We apply them liberally to do what they are advertised to do (eg. keep away mosquitoes) without considering the possible consequences of our body absorbing the active ingredient. (In the case of mosquito lotion, what short circuit in our brains lets us believe that we can wear an insect poison without affecting ourselves?) Even non-chemicals can be harmful as we have seen the effect of microbeads from cosmetics entering the water system to adversely affect fish populations. 

One of the more recent additions to the growing list of carcinogenic (cancer-causing) substances is glyphosate. Countries have banned it: the Netherlands, El Salvador and France and Brazil has a ban pending. I’m dismayed to discover that it doesn’t breakdown in the environment as I was lead to believe when it first came onto the market and that once it is leached into water, it barely breaks down at all! (Fortunately, most of it binds to the soil.) How could we have thought that something that kills almost all weeds would have no effect on other biological systems?

Once a connection between a substance and the existence of an environmental and health hazard, the challenge to change is enormous. Besides industrial dependence and political denial, questions abound. How do we make lotions and scrubs without microbeads – or parabens (another addition to the list of no-no’s)? How do we shift from Round-Up® dependence into the next phase of modern farming? And, even harder, how do we prevent ourselves from investing in another dead-end technology or by being duped by the next industrial innovation?

At the market level, prevention depends upon the ability of entirely independent scientific panels to do independent studies of new chemicals before they are released to the market. I don’t believe that companies like Monsanto deliberately try to poison the public; they are focussed on making money. Their preliminary work made the chemical look very safe – and they wanted to rush it to market. Where Monsanto and other companies err both ethically and morally is when infiltration or other interference with clear and independent research occurs - as Monsanto did recently in Germany when it "bought" the German Risk Assessment Panel. While this makes it difficult to decide whom to believe, it also creates suspicion of the original research and raises the questions, "Why would Monsanto worry about independent assessment? Do they already know something they don't want us to know?"

It is up for us to apply the “Precautionary Principle” and refuse to approve the release until confirmation of safety can be assured. That should be the role of government. Consumers should be able to trust that substances released for use are safe for us and the environment whether food, water or flame retardants. 

Prevention probably also depends upon a healthy dose of scepticism. “If it seems too good to be true” – gets rid of all our weeds or kills all insect pests without side effects – “it probably IS too good to be true.”

Small Modular Reactors?

If you were buying a new car, wouldn't you check it out against its competitors, ask others about their experiences and review accident records of the model? Would you buy something that has never been built before, has no track record and is made by an industry that has never delivered either on time or within budget?

Small Modular Reactors (SMR) are an idea, not a reality. The idea is to create a small nuclear reactor than can be built centrally and transported to the location where it is needed. They could be “popped” down beside rural communities across the countryside. The World Nuclear Association's web site seems to imply that the science is sound and that there are hundreds of them either being built or in service – but also, in fact, “in January 2014, Westinghouse announced that it was suspending work....it could not justify the economics of its SMR without government subsidies.”

The nuclear power industry is the ultimate scam; the government subsidizes the building and commissioning of the power plant and cost of insurance while the industry walks away with the money. Jobs? There are more jobs in almost any other method of producing energy.

Problems are multitude. First of all, “small” is relative and in the realm of nuclear reactors hardly at all. Second: they still need water for coolant, lots of it and so need to be situated near water. Third: they must have a minimum base load electricity demand to work – they are very clumsy at powering up or down in response to needs. Fourth: with an accident record of five meltdowns in thirty years wasting thousands of square miles of farmland for hundreds of years, does it make sense to even enter the field? A “small nuclear” meltdown will still be a meltdown.

The issue of security with all these "little" nuclear power plants planted all over the place is never mentioned.

Is nuclear power green? When all of the input (construction, mining, milling, transporting), after-put (decommissioning) and waste management is taken into account, nuclear power is decidedly “ungreen”. Does it have less impact upon the environment than dirty coal? The people around Fukushima, Chernobyl and Three Mile Island don't think so.

Premier Brad Wall in Saskatchewan has been sold a bill of goods - 

PS.  From the Nuclear Monitor, April 23, 2015: "The term small is used to indicate that the power level is much lower than the average power delivered by currently operating reactors. Modular means that the reactor is assembled from factory-fabricated parts or “modules”. Each module represents a portion of the finished plant built in a factory and shipped to the

reactor site. Modularity is also used to indicate the idea that rather than constructing one large reactor, the equivalent power output will be generated using multiple smaller reactors that allow for greater tailoring of generation capacity to demand.

SMRs such as the SMART are likely to be even more expensive ways of generating electricity than the large nuclear reactors being built today. Small nuclear reactors

are cheaper in absolute terms, but they also generate less electricity. When the two factors − smaller overall cost and smaller generation capacity − are taken together, the cost per unit of electricity for small reactors generated turns out to be higher that for large reactors.

This is why reactors became larger and larger over the 1960s to the 1980s/1990s. Thus, it seems likely that SMRs will lose out on the economies of scale that standard sized (roughly 1000 MW) reactors benefit from.

"Because we are always exposed to background radiation....."

We have heard nuclear industry pundits including Jeremy Whitlock, an extraordinarily well-spoken man, repeat the mantra that natural terrestrial background radiation is not harmful to human health. Furthermore, the presence of background radiation is used as an excuse to add more radiation to it!

Medical experts disagree about the safety of background radiation.

Just one example: According to the Canadian Cancer Society radon-222, a natural decay product of uranium-238 found in the soil, is the leading cause of lung cancer in Canada after tobacco smoking. Lung cancer is the cause of approximately 3,200 deaths in Canada annually.

Another natural background radionuclide, polonium-210, a decay product of radon-222 is believed now to be the main cancer-causing agent in tobacco. It gets into the tobacco leaves via the phosphate fertilizer which is used. The action is somewhat synergistic - polonium binds onto the sticky tar particles which have attached themselves to lung tissue -  the body cannot then expel the polonium, so over time it continues to irradiate the tissue, often ultimately causing a tumour to develop. The polonium is an alpha emitter so it would require internalization by breathing, eating or wound contamination to exhibit the alpha effect - which has 5000 times more energy than the alpha particles from radon. Polonium is also a gamma emitter; in fact, polonium has so much energy that it can aerosolize itself.

"Natural" uranium, U-238, is also known to be highly carcinogenic and to cause other deadly respiratory and other diseases. Uranium's radioactivity is combined with its actions, much like lead or mercury, as a heavy metal. 

The sun's rays are considered to be in the radioactive energy range - sources disagree about whether these are cosmic rays or not - but, in any case, we know that excessive exposure of especially light-skinned people results in increased wrinkling and an increased incidence of skin cancers.

We also receive internal radiation from potassium and carbon in our foods and nitrogen and carbon in the air we breath. Radioactive carbon-14 exists as one-trillionith of the carbon in the world; radioactive potassium-40 is 0.012% of the potassium in our food and water. We cannot avoid them but that does not mean that they may not be responsible for a very small proportion of the cancers people experience.

What we do know is that whenever we increase background radiation, we increase the incidences of leukaemia in offspring (Alice Stewart, 1958 and Rosalie Bertell, 1965), the increases in Down's syndrome and other genetic abnormalities. Research has shown non-statistical increases in heart disease, athersclerosis and auto-immune diseases like rheumatoid arthritis and lupus.

There is enough evidence. Enough that Biological Effects of Ionizing Radiation VII (BEIR VII), a publication of the US National Academies' National Research Council, confirmed a linear relationship of health effects all the way down to zero. Ionizing radiation is not good for ordinary human beings.

 

Health Care and Ionizing Radiation

Definitions:

Radiation: is “the transfer of energy as electromagnetic waves or as moving particles” (Oxford English Dictionary). Examples of non-ionizing radiation include light, radio waves, microwaves, heat, electromagnetic  waves of cell phones and Wi-Fi networks.

Ionizing Radiation: radiation that has enough energy to dislodge electrons from atoms and molecules to form ions and free radicals.

Isotopes are different kinds of atoms of the same element – just as German shepherds and collies are different breeds of the same thing, dogs. They will possess the same number of protons but differ in the number of neutrons in the nucleus.

Radioisotopes are isotopes that emit radioactivity as gamma rays, beta particles or alpha particles.

Radioactive Decay:  the process whereby a radioisotope gives off energy and/or particles and becomes a different element  If the new element is also radioactive, it, too, will change into a third element. A series of these changes is called a decay chain. A commonly used radioisotope, technetium-99m, has a two step decay chain from Tc-99m to Tc-99 and then to stable ruthenium-99.  Uranium-238 (“depleted uranium” – called so only because it has no value in nuclear power plants or nuclear weapons, unlike its fissionable isotope, uranium-235) undergoes a 14 step decay chain before reaching stable lead-206.

Half-life: The length of time taken for one half of the radioactivity in a sample of an element to dissipate.  In effect, this could mean that half of the sample has become another element. For example, the half-life of caesium-131, used in radiopharmaceuticals, is 10 days so after ten days one half of the caesium has become xenon-131. Ten half-lives, 100 days, results in only 1/1024 of the original caesium-131.

Radiopharmaceuticals: this term covers a range of drugs, chemicals or elements that are chemically bound to radioisotopes.  When used for a medical examination, a radiopharmaceutical may be referred to as a tracer. As the ultimate “designer drugs”, they are designed to be absorbed by specific cells or organs in the body and may be introduced by injection, inhalation, or ingestion. The optimum radioisotope is short-lived, delivers high energy to a specific target and decays to a stable product. For example: Used for treatment of hyperthyroidism or thyroid cancer, iodine-131 delivers high energy beta radiation to the thyroid and decays with a half-life of eight days to stable xenon-131.

X-rays are short high-energy waves that are released in the form of excess energy when an electrically produced electron collides with, or has its path altered by a tungsten target. The process of production is highly controlled. Modern machines are very focussed with little scatter.

Gamma rays are very similar to x-rays in that they are also short high-energy waves but they are given off by radioisotopes during the process of radioactive decay. Radiopharmaceuticals make use of gamma radiation because they will concentrate in organs or blood which can be picked up on photographic film.

Beta particles are electrons emitted from the nucleus of an atom during decay – as a neutron changes to a proton, it emits an electron. They have poor penetrating energy but are more dangerous when inhaled or ingested. Tritium, the radioactive form of hydrogen found naturally in extremely small amounts but a common gaseous release from nuclear power plants, decays by beta emission.

Alpha particles are equivalent to the nucleus of a helium atom – two protons and two neutron. They are slow-moving and easily stopped by skin. They are considered 20x more biologically damaging than either gamma rays or beta particles when taken internally. Uranium-238 and radium-226 decay by alpha particle emission to thorium-234 and radon-222 respectively.

Electron capture: an electron from an atom’s circulating electrons is pulled into the nucleus. Gamma rays are released as a proton in the nucleus becomes a neutron; the atom becomes the next lower element in the periodic table.  Palladium-103 is one such radioisotope sometimes used for prostate cancer. Its decay product is stable rhodium-103.

Radiotherapy: the use of ionizing radiation for treatment usually of tumours.

History:

In 1895, x-rays were discovered by Wilhelm Roentgen, a professor of physics in Bavaria, when he was experimenting with electrons. He made the first x-ray immortalizing his wife’s hand and her wedding ring. Physicians were quick to jump on the bandwagon of a technology that would differentiate bones from soft tissue. The first x-ray department was opened in 1896 in Glascow, Scotland. Side effects were not far behind when, in the same year, an Austrian doctor reported that he had severely burned a patient’s back.  

Although by 1905, reddened skin was a known side-effect of x-rays, it was believed that cancer was merely a progression of the radiation dermatitis. The first regulations governing exposure were established as “tolerance levels” – if reddening of the skin didn’t occur, exposure was below the tolerance level.  While physicians experimented with their new tool, its unregulated use left such damage in its wake that, in 1936, a monument was built in Hamburg, Germany, to mark the end of this era and to commemorate the thousands of people and hundreds of medical staff who had perished as a result of x-ray exposure.

Radiotherapy was used as early as 1896 when a medical student in Chicago reported using x-rays to reduce the size of a cancerous nodule of the breast. Fifteen years of trial and error – many seriously injured patients and use of radiotherapy for everything from hair removal to plantar’s warts and cancerous tumours – passed before an Austrian physician suggested that using fractionated doses over several days would result in less tissue damage. By 1922, this was common practice. In 1930, its use for hair removal was forbidden. Exposing tumours to radium-226 or badly focussed x-rays was supplanted by cobalt-60 when its production in cyclotrons made it widely available in the 1950’s. Even so, while the patients were often cured, the side effects were lifelong scarring and erosive dermatitis.

Effects of ionizing radiation on a cell:[i]

This diagrams a simple triage of possible outcomes when ionizing radiation passes through a biological cell: no effect, death or mutation, the latter having two outcomes - if the cellular function is otherwise controlled by the body, there may be no effect but if the cell is altered enough, it may spawn a chronic disease, affect the reproduction of the cells to produce a cancer or affect the germ cells for the next generation so that there is a inherited defect.

Medical uses of radioactivity:

1)     External:

a)     X-rays – machine generated ionizing radiation.

b)     CT (CAT) scans – Computerized (or “computed”) axial tomography is a series of x-rays taken at different levels through a body part like slices of bread and computer-manipulated to form a three dimensional image.

c)     External radiotherapy – radiotherapy is generated by linear accelerators that focus high-energy x-rays at tumours preferentially destroying cancer cells. Older units targeted tumours with gamma rays from cobalt-60 but were limited by the energy that could be generated. They continue to be used in low-resource settings.

2)     Internal:

a)     Scanning materials and devices:

i)      Gallium scans – The earliest and most widely applied radiopharmaceutical was a gallium-67 salt (citrate or nitrate) making use of a short half-life of 3.26 days and ease of production in  a cyclotron. As it decays to zinc-67, it emits gamma rays which were picked up by photographic film before the advent of gamma cameras and computers. Gallium behaves like ferric iron and concentrates in areas of inflammation. It has mostly been supplanted by other tracers but the fact that it can be absorbed by both dead and alive white blood cells gives it special value in identifying places where they accumulate such as lymphomas, osteomyelitis and abscesses.

ii)     PET scans – Positron emission tomography scans show how the body works. A simple gamma camera detects gamma rays and a computer generates a three-dimensional image in contrasted colours. The most commonly used radioisotope is fluorine-18 with a half-life of 1.83 hours produced in cyclotrons close to the hospitals. It decays to stable oxygen-18.  The ease with which fluorine can be bound to sugar molecules makes it useful to examine places where rapid metabolism occurs.

iii)   SPECT scans – Single photon emission computed tomography scans use moving gamma cameras in order to provide the three-dimensional image. The image is less specific but cheaper to produce. For intracranial examination, technetium-99m is attached to exametazime, a molecule that crosses the blood-brain barrier.

iv)    MIBI scans using the radioisotope technetium-99m have special use in parathyroid and heart scans. MIBI is short for methoxyisobutylisonitrile which is picked up by actively metabolizing mitochondria. Two scans are usually performed, an early scan and one after a “wash-out” period.

v)     MUGA scans: Multi-gated acquisition scans also involve the use of technetium-99m in this case attached to a pertechnetate ion which binds to red blood cells. Typically sixteen images are taken using the contractions of the heart to trigger (gate) the pictures.

b)     Brachytherapy – (from Greek “brachys” meaning “short distance”) the radioactive source is implanted directly into or close to the tumour itself. Ideal elements for brachytherapy deliver a high dose in a short period of time minimizing the effect upon healthy cells. The first implantable radiotherapeutic materials were alpha particle emitters like radium-226.    

i)      Permanent brachytherapy: small “seeds” of the radioactive element are placed into the tumour - Iridium-192 which decays by strong gamma and beta emission is commonly used for prostate cancer but other elements, caesium-131, iodine-125 and palladium-46 have also been used.

ii)     Temporary brachytherapy: The radiopharmaceutical is delivered by catheter, needle or applicator inserted into the body cavity or interstitially. Doseages may be high, low or delivered intermittently. Iridium-192 (which decays by electron capture to platinum-192) is a radioisotope frequently used.

Putting Ionizing Radiation Exposure in Perspective[ii]:

Source of Radiation:                                      Radiation dose in mSv:             

Airport passenger scan                                  0.0001

Hand or foot x-ray (one view)                         0.005

Watching tv (4 hrs/day)                                   0.01/yr

Bitewing dental x-ray                                      0.03

Air travel: Toronto-Vancouver return               0.05

Chest x-ray (one view)                                    0.10

Nuclear medicine thyroid scan                        0.14

Dental panoramic                                            0.15

Pelvic x-ray                                                      0.7

Screening mammogram (four views)               0.7

Thoracic spine x-ray                                        1.0

Lumbar spine x-ray                                          1.5

Nuclear medicine lung scan                             2.0

Background radiation (average Cndn)             2.5

Nuclear medicine bone scan                            4.2

Nuclear cardiac diagnostic test (MIBI)            10

Abdominal CT scan                                         10

Smoking (20 cigs/day)                                     53

Hazards: 

When the ionizing radiation of x-rays or gamma rays pass through a body, no radioactivity remains in the body. A trail of damaged structural proteins, enzymes and nucleic acids marks their passage. The damage done is cumulative, the probability of genetic defects, cancers, and life-shortening effects increases over a person’s lifetime. By and large, the greatest body burden of ionizing radiation for North Americans is the result of medical diagnostic or therapeutic uses.

The medical profession is so enamoured with diagnostic and treatment using ionizing radiation that even though two researchers, Dr. Alice Stewart in the UK in the 1950’s and Dr. Rosalie Bertell in the USA in the 1960’s, established the link between a single chest x-ray on a woman in pregnancy and an increased risk of leukemia in the offspring, it was not until the 1970’s that patient shielding became standard practice and performing x-rays during pregnancy severely limited. An entirely new phase of medical excitement over technology occurred over CT scans[iv]. Given that these scans deliver in order of magnitude at least 75 times the radiation of a chest x-ray, it should be no surprise that the incidence of cancer increases with the number of CT scans.[v]

Radiotherapy using radioisotopes also has its risks.  Although the intention is to avoid irradiation of healthy cells, some will inevitably be exposed to radiation. The possibility exists that one of these cells will mutate and lead to a secondary cancer. One study estimated that 8% of secondary cancers are caused by radiotherapy.[vi] This is very difficult to calculate because the same risks present for the first cancer may still exist (for example, smoking). The risk will also vary with amounts of radiation exposure, parts of the body exposed and the age of the patient. In 2011, researchers at McGill reviewed more than eighty thousand patient charts and concluded that the risk of cancer from low-dose imaging techniques increased 3% for every 10 mSv of radiation received.[vii]

Finally, concern exists over the variety of decay products from radioisotopes used in radiopharmaceuticals. Although the tracers may decay rapidly to a stable element, their progeny may not. While fluorine-18 decays to oxygen-18 which is stable, technetium-99m decays to technetium-99 which is also radioactive with a half-life of 211,000 years.

In conclusion, ionizing radiation has literally opened the living human body to knifeless dissection but carries its own risks. It is challenging to “first do no harm”[viii] and curb our ever-increasing desire to know more about our patient’s body or disease – whether or not we can treat it.

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[i] Adapted by F. Oelck from Grenier, Gilles W. (2006). Lignes Directrices Pour Le Depistage De La Contamination Et La Decontamination Des Personnes Lors D’une Urgence Nucleaire. As posted online at: www.urgencenucleaire.qc.ca/documentation/decontamination_perspdf, [May 10th, 2011].

[ii] Modified based on Society of Nuclear Medicine, “Beneficial Medical Uses of Radiation,” www.molecularimagingcentre.org/index.cfm?PageID=7083>; American Dental Association, “Oral Health Topics,” www.ada.org/2760.aspx., Neil Savage, “X-ray Body Scanners Arriving at Airports,” spectrum.ieee.org/biomedical/imaging/xray-body-scanners-arriving-at-airports.

[iii] For example, varies with elevation, surroundings (mountains of granite or flat prairies), wind and other geographic factors – such as mines, nuclear power emissions, basements (radon). 

[iv] James C. Worrall, Sadia Jama, Ian G. Stiell, “Radiation doses to emergency department patients undergoing computed tomography” Canadian Journal of Emergency Medicine, 2104;16(6):477-484 cjem-online.ca/v16/n06/p477

[v] Carina Storrs, “How Much Do CT Scans Increase the Risk of Cancer? Scientific American, 309, Issue 1, Jun 18, 2013 scientificamerican.com/article/how-much-ct-scans-increase-risk-cancer/

[vi] “Benefits of Radiotherapy Outweigh Small Increased Risk of Second cancer,” Ecancernews, 2011 ecancermedicalscience.com/news-insider-news.asp?itemid=1660

[vii] Mark J. Eisenberg, Johathan Afilalo, Patrick R. Lawler, Michal Abramhamowicz, Hugues Richard, and Louise Pilote, “Cancer Risk Related to Low-Dose Ionizing radiation from cardiac Imaging in Patients after Acute Myocardial Infarction,” Canadian Medical Association Journal 183 (March 8, 2011): 430-436.

[viii] Erroneously thought to be from the Hippocratic oath but attributed to Dr. Thomas Inman according to Wikipedia, en.wikipedia.org/wiki/Thomas_Inman