A Doctor's Perspective on the Chernobyl Accident

Chris Keefer  0:00  

Welcome back to Decouple. Today I'm joined by Dr. Robert Gale. Dr. Gayle is regarded as a world expert on the medical response to nuclear and radiation accidents, and has been omnipresent at such events since the 1980s. In 1986, he was asked by the government of the Soviet Union to coordinate medical relief efforts for victims of the Chernobyl disaster. In 1987, he was asked by the government Brazil to coordinate such efforts at the going IEA accident, and in 1999, similarly, he was involved in the Takemura nuclear accident. And 2012. Gil was also in Japan discussing the medical consequences of the Fukushima nuclear power station and doing some very important knowledge translation there. Dr. Gail, I'm thrilled to have you on the podcast. It's been a long time coming. I saw some of your activity around the release of the HBO Chernobyl series and ever since then, I've been wanting to chat with you. So I'm glad this has finally come through. Welcome. Welcome to Decouple. Thank you. Now, you know, I've done a little bit of a job summarizing some of your activities, your bio is is far too long to adequately summarize, a few highlights 20 years as the chairman of the Scientific Advisory Committee on the international bone marrow transplant registry, think you have 22 medical books to your name over 800 scientific articles. But maybe I'll get you to self introduce yourself. Maybe on the more personal side, pretend you're trapped in the elevator with my guests for about 60 seconds and go ahead and introduce yourself.

Dr. Robert Gale  1:27  

Well, I feel sorry if they were trapped in an elevator with me, of course. So I'm, I'm in hematologist and oncologist. You know, I treat people with cancer, various cancers, especially blood cancers. I'm also a molecular biologist. And in my laboratory, we, we, we clone molecularly cloned genes that we think cause human cancers, especially leukemias, and then we try to develop treatments for all of these things. At pro of your audience, you know, one of the things we do is in treating people with leukemia and related cancers, we use very high doses of ionizing radiations.

Chris Keefer  2:26  

So again, one of the one of the big reasons I wanted to have you on was to get that sort of, in the trenches view of you know, what happened in Chernobyl, I've asked other guests, I think it's similar maybe to where were you at 911. But it took a few days for what had happened at Chernobyl to get out. And you were invited, I believe, by by Gorbachev to come in and assist. So I just want to sort of time travel and give you a chance to kind of recount that story. And then I want to get into the trenches with you in hospital six and talk about the management of some of these patients. And that'll lead into, I think, a discussion about the overall broader health impacts. But just take us back to 1986. And maybe where you were when you heard about the accident and the phone call that you received?

Dr. Robert Gale  3:11  

Sure. Well, to be precise. I first when Swedish authorities released information about the detection of radiation that they pinpointed to Ukraine. I happened to be jogging around the UCLA campus on my daily run. You know, I immediately, you know, realized, because I had been following Soviet nuclear activities. I also have many colleagues in in the Soviet Union. But I was also, you know, going to Russia or Soviet Union quite often. So. So I knew that that, you know, this was a large accident. I didn't know at that time exactly how big but I knew the limited resources that would be there in the Soviet Union. And I had contacts with Mr. Gorbachev. Over the years, I knew I was well known by the KGB. So after a day or two, when I realized, you know, further, what was going on. I contacted a colleague of mine, Armand Hammer, and who I knew, you know, he and I had met with Gorbachev previously and I, I told I asked him, you know, to offer the resources of our international transplant organization, and I didn't really fully expect that in the midst of the Cold War, that the Soviet government would be open to having foreign help, especially when you know these are, you know, highly sensitive issues? So I was a little bit taken aback. When about two o'clock in the morning, I got a call from Andre Durbin who was the Soviet ambassador to the United States. And he told me that Mr. Gorbachev, you know, wanted me to come to the Soviet Union. And he wanted me to come to Moscow. Of course, at that time, I didn't realize that the most seriously affected persons had been flown to Moscow. So I mean, I grew up my travel kit. And I was on a plane within a couple of hours, to Moscow.

Chris Keefer  5:43  

And so you were taken to Moscow to help provide care for some of these patients. I don't want to do too much of a kind of spoiler here, but I understand that you brought along a very important medication that we use now for people who have suppressed bone marrow when they have infections, febrile neutropenia. But yeah, let it let us know, sort of, I mean, you said that there were some limitations to what the medical capabilities were in the Soviet Union. What did you bring along with you in terms of expertise and even equipment?

Dr. Robert Gale  6:15  

Well, initially, I just came myself, when I had a couple of days to assess the situation, I realized that, you know, we would try bone marrow transplants or he inadequate Excel transplants. And so I told my Soviet colleagues, you know, we need to bring someone who's with expertise in tissue matching tissue typing room that was portrayed in Sanki from UCLA, one of my deputies at UCLA champion, but then I thought I would test really test the system. Remember, this is the midst of the Cold War, and I told them that I wanted to bring an Israeli scientist, my colleague, Ilya Rhys Reisner from the Weitzman Institute. And you know them, I would say somewhat hesitatingly agreed. Soviet Union in Israel had no diplomatic relations. But they finally agreed now the treatment is you're referring to is the use of molecularly cloned Humana probiotic growth factors. So we had been working on these for years in mice and rats, eventually in monkeys. And it was sort of nearing production in Basel, Switzerland by Sandoz, one other pharmaceutical company, this was about 10 days or two weeks after I arrived. So I didn't bring this substance with me. But we, let's say smuggled it into the Soviet Union in the suitcase of a Swiss businessman. We had it put into his suitcase after he checked in at the airport. And we had to take a baby remove it from his suitcase, before it was returned to him. And then we brought it to the hospital. Now, this, this drug had never been given before to human being. We were pretty confident of the dose from monkeys and things like that. But when my colleague Andre, for OB have presented this to the Politburo that we wanted to use this drug. You know, they said, well, we don't want Soviet citizens to be guinea pigs. We don't want them to be the first people to receive this drug. So we were a bit discouraged, but then it occurred to me that I could give the drug to myself. And if that if I didn't drop over dead, the Soviet victims wouldn't be the first humans well, so Verone oven, I injected each other with this drug. He had a rocky time with it, but I was fine. We survived to the next morning, went back to the Polaroid Bureau and said, Okay, now they're not the guinea pigs. We were the guinea pigs. And we got permission to treat some of the victims with this molecularly cloned growth factor.

Chris Keefer  9:30  

So what was hospital six? Like? Again, this was I guess, where they brought the most severely ill patients. How many patients were there? What's What's the environment like in that hospital? And I guess what, what were the main issues that those patients faced?

Dr. Robert Gale  9:45  

Okay, well, the the hospital was attached to the Institute of biophysics. And so it was a high security hospital that treated radiation Shouldn't I mean it was a general hospital but treated members of the COVID Bureau and also treated the occasional radiation victims from atomic test nuclear testing. You know, we had battled several babushkas to get into the gate, that first day. But it would look like an American hospital 50 years ago. You know, very simple facilities, excellent physicians, my colleagues, you know, very highly trained, experienced in small radiation accidents. But nothing on this scale, we had several 100, more than 200 patients that were admitted to the, to the hospital, we had the army camped in the, in the on the grounds. And, you know, my, my team, my Soviet American Israeli team, you know, we concentrated on people who had the most severe bone marrow failure. There were other people with other injuries where, you know, burns or other things were predominant. But we tried to focus our attention on the most severely affected people.

Chris Keefer  11:20  

And, I mean, what kind of condition were they in? We working through translators? Do you speak Russian? I mean, what what was it like to interact with these patients?

Dr. Robert Gale  11:29  

Well, you know, we, of course, you know, that we had a large number of Soviet physicians with us, I speak some Russian so. But you know, as, as your listeners may know, when you're first exposed to high doses of ionizing radiations, you know, except for some nausea and vomiting, you feel pretty well. I mean, there's no apparent I mean, immediate, apparent adverse events. So, these are healthy young males, predominantly healthy young males that are firefighters or nuclear engineers. So when you first encounter them, you know, four or five days after their exposure? Well, you know, there's a couple of barriers, firstly, you know, most of them have no knowledge of ionizing radiations. And, you know, they, like most of the public, their firefighters, you know, the second thing is, you know, healthy young people that feel alone, you know, it's a little bit difficult to explain to them, what's coming, you know, that their blood counts are gonna fall, that they're gonna develop severe gastrointestinal tract symptoms, things like that. So there's a bit of suspended belief. But we function pretty well as a team. And as you can imagine, again, in the midst of the Cold War, the fact that a bunch of American veteran American physician had come to the Soviet Union was there to help them? No, they were, of course, you know, most appreciative of them, I don't think they, you know, fully understood the magnitude of their injuries or what was going to come.

Chris Keefer  13:19  

I mean, it sounds like the variety of different victims in this cohort. You know, the folks with thermal and radiation burns, probably had pretty horrific injuries. And I understand this, these compounded thermal radiation burns are particularly bad, because what really high doses of radiation do is shut down the rapidly dividing cells abilities to, to regenerate, and hence the the issues with the bone marrow in particular, but the the gastrointestinal tract as well. But it's really interesting hearing you discuss these patients that, you know, felt okay, for a few days, it must have been must have been pretty tragic to sort of watch the corpse, particularly of those who didn't make it. I understand the bone marrow transplant was was those those were done on on the most severe cases, is that correct?

Dr. Robert Gale  14:05  

Sure. I mean, we would, you know, the most, several issues, I mean, when issues of course, we were driven by our best estimate of the dose, you know, we, you know, if someone is exposed to five or six grades of radiation, we assume they can recover, we just have to keep them alive. When we start getting your eight rays and things like that, they can recover in theory, but we may not be able to keep them alive long enough for that to happen. So, either need to have a temporary or permanent bridge of a graft. At least that was our thinking at the time. Now, the other thing is you have to remember there was a explosion, there was a fire. So release of chemicals. So We're dealing with common injuries, overlapping injuries, I mean, we could, in theory and in practice, prevent death from bone marrow failure. But that person could go on to die from a chemical injury or thermal injury. The problem is that these things might not be apparent early on. For example, damage to the lungs might not appear for a number of weeks. So we've got to make a decision, we can't wait four weeks to do a transplant, we've got to decide to do a transplant in the first week. So we need to estimate the dose, which is imprecise. And we need to estimate that the bone marrow is going to be the thing that's going to kill this person and not their lungs. And, of course, that's error prone. You know, we we do the best we can, as we do in all of medicine. And we know that some of the people that we transplant will be rescued by their transplant, but they're gonna go on to die of pulmonary lung toxicity. But we have to accept that uncertainty.

Chris Keefer  16:19  

So stepping back a little bit, I've heard it say that radiation is perhaps the best scientifically understood toxin. But at the same time, it seems like there's the largest sort of perception gap between the general public and and expert knowledge in this field. How do we know what we know about radiation? Obviously, there's clinical experience, there's the I guess, the atomic bomb survivors, but can you walk us through a little bit about, you know, in terms of that knowledge translation, how we know what we know, maybe in how that informed, you know, your actions at Chernobyl and and the other nuclear accidents you were involved with?

Dr. Robert Gale  16:56  

Well, you know, we have, as you say, a very substantial data set. From, you know, starting with Drosophila, fruit flies, and we're working our way up to, you know, mammals to non human primates, and eventually to man. The data sources, you know, our most important source, of course, in my opinion, is the atomic bomb survivors, because we, we know exactly when they were exposed, we know, pretty well what their doses. And we have. Very importantly, we have a control cohort. So in the atomic bomb survivor studies, we have about 90,000, exposed persons with non doses. But we also have 20 or 30,000 people that were residents of Hiroshima and Nagasaki, but we're not in the city on that day. So if we want to know how many we can calculate how many excess cancers were caused by radiation, for example, we can calculate what dose the relationship between dose and cancer risk and so forth and so on. But our limitation, of course, is that this acute exposure happening in you know, seconds, at very, very high dose rates is act to a Japanese population, not to a Caucasian population. You know, trying to move from that, to what would happen to an American or European exposed to radiation under different circumstances. I mean, that's the challenge. So we have all these other data sets, we have people who are exposed to diagnostic radiations like a CT scan, we have people that get radiation therapy, or various cancers, or even non cancers, like ankylosing spondylitis. And we have people living in different geological areas where their background exposures are quite different. And so the challenge, which is, you know, incompletely resolved, we do the best we can, is to integrate all of these experimental and epidemiological data into some model, some model that would predict how radiation acts and what the consequences of exposures would be. And it's it's extremely important, you know, that we admit to uncertainties. You know, we are substantial uncertainties in our risk estimates And there are certain things we can't know, just emphasize one of them, which is the so called linear no threshold model. So, you know, I think most people, I in most regulatory agencies and scientific bodies, you know, we accept that any dose of radiation can increase your risk of getting cancer. But proving that, you know, it's pretty much impossible from an epidemiological point of view. But that is the most conservative position physician, that is the position that offers in theory, the greatest protection to the public. So that's where we are, you might say, flying by the seat of our pants, to some extent, but that's where we are.

Chris Keefer  20:56  

From my read of the literature. It's it sounds like we have a pretty decent sort of threshold at which we are able to measure increased cancer incidences, but as you said, below that it's it's impossible to find those signals just because the base rate of cancer is quite high. But what sort of signals would we see in the Chernobyl survivors? I know there's different sort of cohorts. There's the folks that you were treating in hospital six, the liquidators? You know, people that lived within a certain radius of the power plant? How do we study and understand the health impacts to those populations? And what have we seen in terms of the consequences? Because there's casualty rates that range from less than 100 to up to a million depending on the study that you look at?

Dr. Robert Gale  21:41  

Yeah, well, imperfectly, is the probably the best answer. So you know, we're dealing with a extraordinary number of challenges. For example, the dissolution of the Soviet Union. So now we have exposed persons in three different countries, in Russia, Belarus, and Ukraine. Plus, we have two of those countries in a war. So, you know, that doesn't help the situation at all. Now, in terms of, you know, what's happened, and in what is credible after the Chernobyl accident, now, the, you know, the subset of patients that we had the firefighters, and engineers that got these very, very high doses, you know, that, you know, with a 40%, background rate of cancer, in all of us. Four out of every 10 of us is going to develop cancer, one or more cancers in our lifetime. So in order to say anything meaningful, you need a control cohort. So we simply don't have that for the, let's say, the these fortune 200 immediate high dose victims. If we if we look at epidemiological data. mean, one thing is quite clear that there is a striking and crease in the incidence of thyroid cancer in young people. I mean, these are people children, I'd say that were approximately under the age of 16. At the time of their exposure, their route of exposure is via drinking radioiodine, contaminated milk. And, you know, thyroid cancer in children is extraordinary ly uncommon. So when you have several 1000 cases of thyroid cancer in young people, you don't need an epidemiologist or statistics to know that something is going on. So that's the easy thing.

Chris Keefer  24:01  

In terms of that the sickest cohort, those 200 or so victims of acute radiation syndrome. I mean, was there a cancer rate afterwards as they've been followed along much higher than 40%? Or what was seen in that really highly exposed group in terms of cancer?

Dr. Robert Gale  24:16  

Yeah, I mean, I don't think it's possible to say very much about that, because we have to account for other lifestyle changes. So for example, many of these people had the I would say misimpression, that they were fated to die from cancer is a common misimpression. And so they increase their smoking. They increase their drinking. And again, you know, these something like cigarette smoking, of course, is a usually important risk factor for camp for a variety of cancers, not just lung cancer, but a variety of cancers. So I don't think you can make any sense out Have the 200 or so heavily exposed people. What we can say is there's a striking increase in thyroid cancer in the in children that were exposed. Now there are two other reports that I think are dicey to analyze. One is a report done by some very good people have an increased risk of chronic lymphocytic leukemia. In these liquidators so called people who were recruited to clean up or mitigate the accident. The studies are reasonably good. The problem is that, generally speaking, and based on the atomic bomb survivors and other data, this is the one form of leukemia that we don't think, is caused by radiation. It's also a form of leukemia that we usually just pick up by doing routine blood tests. You know, people don't have signs or symptoms. So if you have a population where you suddenly start doing a lot of blood tests, you're going to find more cases of chronic lymphocytic leukemia. The leukemias that were increased after the a mom's the acute Mei Li myeloid leukemia, chronic myeloid leukemia, those leukemias are not reported to be increased. So, we have this one report of an increased risk of this chronic lymphocytic leukemia, but it's statistically sound, but it is biologically a less plausible, and there is a recent report of an increased risk of breast cancer. Again, you know, without a proper control group, and with the myriad risk factors for breast cancer, such as age of onset of menses, age of onset as menopause, breastfeeding, you know, we have to, I mean, we know that breast cancer risk is increased in women exposed to radiation. I mean, that's clear. But whether it's increased in women who were exposed to ionizing radiations, from the Chernobyl accident, I would say is less certain. But I think the big message here is, you know, there have been estimates, you know, if you take a very small increase risk, and multiply it by four 400 million people, then you wind up with, you know, 10,000 70,000, extra cancers. All we can say, and all I can say is that there hasn't been a striking increase in cancer. And if we think about the atomic bomb survivors, I think this gives us a way to look at this, as you think of the atomic bomb survivors that have been father now for 70 years, only 10% of the cancers in the atomic bomb survivors can be attributed to radiate their radiation exposure, it is 90% of all the cancers in the a bomb survivors, would have occurred anyway. So that's, that's the extreme situation. And that's under ideal circumstances. So it's natural for anyone who was living in Ukraine or living in below rose or living in Russia. I mean, it's natural for them, and even for their doctors, if they get cancer to ascribe it to the Chernobyl accident. But this is very, very likely to be incorrect. But we'll never really know, we would never know.

Chris Keefer  29:19  

We had a really interesting episode with Geraldine Thomas on the phenomenon of the Chernobyl children and the Chernobyl children's charity. And one of the reflections that we kind of mutually had as the you know, when something strikes like cancer, there's always the desire as a human being to know why, and to have something to blame. And the kind of cruel reality that so many of these diseases are spontaneous or birth defects or spontaneous, that it gives them comfort, I think, to parents to be able to say it was that you know, in terms of our stages of change of forgetting them now, but you know, rejection, denial, anger, you know, getting to acceptance, that's the kind of vital vital part of it, and so it's it's very human and I think a very human reaction to it. responded that way. Of course

Dr. Robert Gale  30:02  

it is. This is human nature to do that, but you know, we neglect the randomness of cancer. Cancer is fundamentally a random event. And you can make your chances worse, I mean, you can smoke cigarettes, or drink excessive alcohol. So you can, you can increase your risk of getting cancer. But most cancers are random or stochastic events. When we look at twins, genetically identical twins, for example, both of them smoke cigarettes, usually only one of the twins gets lung cancer. We don't see it in the other twin. So this is not environmental. And this is not genetic. This is randomness. Now human beings don't like randomness is Chernobyl children with heart defects and so forth and so on. You know, we have, I think, a huge amount of data that we could say with confidence that these birth defects and cancers are not related to the Chernobyl accident. But I'm always reluctant to say that publicly. Because, you know, these children are getting better care. You know, people are contributing money. If we think of the medical care they would have gotten in the old Soviet Union. Yeah, they're their health problems are not related to radiations, from Chernobyl, but I wouldn't like to discourage people from giving money and helping these children because, you know, our, our job is to help children not to worry about what's the cause of their problems.

Chris Keefer  32:07  

What about the many of the reports like the WHO turnable forum, talk about the main health consequence being the consequence, the consequence of radio phobia of people being being afraid? What What were some of those? What are some examples of of those harms?

Dr. Robert Gale  32:23  

Well, I mean, one striking example was shortly after the accident, there was a, I would say, a mob scene in Kyiv. People, you know, Kyiv, was not really in the direction of the radioactive plume, it's in the exact opposite direction of the radioactive plume. I mean, it's true that the Dnepr River, which flows by the Chernobyl nuclear power station flows through kin, but, you know, radiation gets diluted out in order very, very quickly. But there was a mob scene of people trying to evacuate from Kyiv. And I considered how, how could we stop that? And my decision was to bring my family to tf. So I had my wife and my two children, meet me and Tiff. And we visited a bunch of hospitals, we did a bunch of television interviews, and I felt that bringing my family there, and my especially my children, would be the most effective way to stop this mass exodus from Kyiv, where there wasn't really any radiological danger. But I think we, you know, to fast forward to today, you know, we're facing an extraordinary potential catastrophe with climate change. And these accidents, Chernobyl, Fukushima, have so soured the public on nuclear energy as a non polluting source, that we're in a bind, and I don't see any way that we can meet reasonable climate goals, absent the use of nuclear energy. And so maybe that is the most serious consequence of these accidents is, for example, Germany, you know, stopped its use of nuclear energy. Meanwhile, they're importing electricity from France. It's made mostly by nuclear energy, and now they are really We'd say up the creek, having become reliant on Russia, for gas and oil. Japan markedly increased its carbon footprint after the Fukushima accident. So these kind of, you know, ignorance is our worst enemy. And educating the public to the appropriate risks and benefits of nuclear energy and other radiation sources. I mean, that's our only hope for the future is education.

Chris Keefer  35:43  

I know, we just have probably less than a minute left. But, you know, I guess from a population level, given what you've just said, Do you think that adherence to the linear no threshold hypothesis, you know, as conservative and well intentioned as it is, is actually causing a net harm in terms of exaggerating what the potential impacts of these accidents can be? And that leading us to revert to coal burning, for instance, or delay the phase out of fossil fuels?

Dr. Robert Gale  36:11  

I don't think so. Because, you know, the concept of a linear no threshold model is way beyond what the public can grasp. I mean, that it's radio phobia. That is, because, you know, the issue is, I think, a pretty fundamental one, most of the dangers in our life, we can see, I mean, if there's a hurricane coming, if there's a fire, if you're standing on the edge of a cliff, and then we, as human beings, we can perceive the danger. And in theory, we could try to mitigate the danger. But the problem with radiation is that you and I could be receiving a lethal dose of radiation while we're having this interview. Right? And you wouldn't know you wouldn't know. So it's beyond our perception as human beings. And you know, it's only human nature to fear, these kinds of things that you can't perceive. So again, I have to go back to the notion of education that all of us are being exposed to ionizing radiations all of the time. You know, this is not a yes, no, it's not a binary. And I think we save more lives. With radiation in the context of radiation therapy, we save more lives than we lose. So, but the challenge is to inform the public and inform political leaders, because political leaders play to their audience. You know, anyone who favors nuclear energy is immediately going to lose the forthcoming election. So you know, it's a long term challenge for all of us involved in radiation and Radiation Biology, and education and medicine. It's a steep, steep climb. But I remain optimistic that if we could introduce this into high schools in the long term, we could succeed. But perhaps I mean, naive.

Chris Keefer  38:46  

I do find it fascinating that that experts like yourself and Dr. Geraldine Thomas, who, you know, were drawn towards studying Chernobyl tend to be some of the most some people with very positive attitudes towards nuclear energy as as a source, particularly in our fight against climate change. But listen, I know you have many other engagements. Thank you so much for making the time. Dr. Gayle. A real honor and pleasure to chat with you.

Dr. Robert Gale  39:09  

Well, thank you for the opportunity to speak to your audience. Absolutely. Take care