Chernobyl Liquidators' Health
as a Psycho-Social Trauma
3.3. Analytical studies of the liquidators' health as an effect of radiation,
psychological and social factors
of the Chernobyl Disaster
In order to get deeper insight into the possible causes of the liquidators' health, in this subchapter I will discuss medical research that examines both the health state and various relevant factors in detail, and is of analytical rather then merely descriptive nature, as the research referred to above.
1. Medical research of the immediate impact of participation in the mitigation of the Chernobyl accident upon the liquidators was done in 1986—1987 (Komissarenko and Zak 1994). The research appears to be unique. Thirty-two military liquidators drafted from reserve, of age within 20—38 years (the average 30±1 years), reported to have voluntarily participated in the study, were the objects of the research in question. They participated in reconstruction and decontamination work in the 30-km zone from August 21 to September 16, 1986, where they received the dose of 0,25 Gy (25 R), at an approximate rate 1.5 R/day; the special efforts to accurately control the dose were undertaken (Komissarenko and Zak 1994: 13—14). Members of the group underwent medical examinations (which included all set of haematological and immunological indices) 3 times:
— 1st — in their local military commissariats 1 day before being sent to the zone; all were considered to be healthy;
— 2nd — immediately after their return from the zone (usually the 2nd test was about 1 month after the 1st); absolute majority of the liquidators had no complaints about their health and no observable somatic deviations. Almost all of them were in high spirits looking forward to the forthcoming return home;
— 3rd — one year after return from the zone, in Kiev: the majority complained on increased fatigue, susceptibility to colds and virus diseases. Most of them had “husky voice”, tracheitis, soreness of nasopharynx, and frequent quinsy. Almost all liquidators complained, especially first half-year after the zone, about heavy headache. Four men (12.5%) suffered heavy apathy, suppressed mood, lack of interest in their work and family (Komissarenko and Zak 1994:11—12).
In particular, immediately after the zone, an absolute number of large granular lymphocytes — the morphological homologue of natural killer cells (NK-cells) — in blood noticeably decreased, and their sub-microscopic structure underwent certain alterations. One year later the number of lymphocytes in blood was restored, but a disorder of their ultrastructure and morphological heterogeneity remained. This fact, according to the authors, should be regarded with attention, for it is well known that prolonged suppression of the system of NK-cells has an unfavourable impact upon the health: it increases incidence of malignant tumours and promotes virus and bacterial diseases and their more unfavourable flow.
The following finding of the study attracted my special attention: The other subjects of the study were inhabitants of Kiev who stayed in the city during the first weeks-month of the accident.
I want to comment, that, in terms of the external gamma-irradiation obtained, these 2 groups are dramatically different: the maximum RA-levels registered in Kiev were about 1.5 mR/h in average (30 April, 1986), with decrease to 0.6 mR/h (local variations to max 2.2. mR/h) (1—2 May), and subsequent decrease (Chernobyl'skaya katastrofa 1995: 26). It corresponds to the dose accumulation rate of about 0.01's R/day, and to the doses several order of magnitude smaller than those of the liquidators studied. However, both groups examined had similar most frequent complaints, those about
• permanent fatigue,
• depression and apathy,
which, along with the mentioned above small number of NK-cells, constituted, according to the authors, a complete triad of main symptoms of the “syndrome of chronic fatigue”.
In my opinion, such huge (100-or-more-fold) difference in the irradiation dose, and similarity of the complaints of the both groups studied, clearly points out that radiation (at least, external radiation) has no effect upon the health state reported for the both groups studied.
2. In one of a series of more recent studies (Simonova et al. 1995), it was shown that the objectively registered pathology in the liquidators is not sufficient to explain not only the high share (69%) of the liquidators, officialy recognized as invalids in the sample, but also high share (27%) of those who refuse to work among those who are able to work. Parameters of the basic psychic processes also cannot explain the reasons of the refusal. Most of the changes were observed in the domain of psychological traits of the personality. These changes were mainly high level of frustration and anxiety, weakness of “Ego”, the phenomenon of professional alienation (83%), and low social adaptability (68%). Answers to a specially designed questionnaire revealed that the leading reason for the refusal to work is “I am not quite well” (87%), among social factors there are “negative attitude of the administration” (64%), “aggravation of the relations at the work place” (27%).
In the present situation the liquidators, in order to be officially recognised as invalids (without this status it is impossible to receive the full scope of the social privileges granted by the law), are forced to frequently be hospitalised, which may be one of the reasons of escalation of social and professional alienation. Thus, from our point of view, exactly the complex of social-psychological factors determines a continuing increase of the number of invalids among the liquidators. (Emphasis added. — S.M.)
In other words, the liquidators seem to be adversely affected by social and psychological factors of their present, post-zone life but not only by the in-zone (radiation included) factors.
3. A study of 98 liquidators, treated at the Hospital of Radiation Medicine (Institute of Biophysics, Moscow) 6-8 years after the accident, also indicated an important role of non-radiation, namely — psychological, economical and social (both the in-zone and post-zone) factors (Chinkina 1995). The majority of the patients demonstrated a set of unfavourable traits of their psychological status, namely:
— increased anxiety as a constant personal trait (56%),
— emotional lability and dyscoordination (88%),
— shifts in the structure of the objective estimation of their status (81%), including its general decrease (66%),
— psychical exhaustion of different degrees (70%),
— decreased level of the general functional psychic state (69%).
The majority (more than 70%) wanted to be officially recognised as invalids.
Interestingly, the share of those striving to continue their professional career is dramatically different for the liquidators with the university degree and with low level of education — 81% and 6%, respectively.
No significant difference in the indices studied was observed for the groups formed according to “the official dose” (2 groups: above and below *25 R), and to the time of stay in the zone (2 groups: 1986 and 1987—1988). The researcher assumed that other factors of the Disaster may have more important impact than the variation in the doses in a relatively narrow range. The researcher listed a number of non-radiation harmful factors, namely:
— increased perception of the radiation effects’ danger for the health,
— physical and psychological overstrain during work in the zone,
— important impact of the Disaster upon the society, and emphasised that for the majority of the patients studied these factors were responsible for their trauma. The trauma often involves external and intrapsychic (not connected to the accident) conflicts of the personality. The situation sometimes is used for the solution of the purely socio-economic problems of the liquidator.
4. Similar conclusions have been made in the research into the causes of the diseases of cardiovascular system (Khomazjuk et al. 1995). It has shown no correlation of the diseases occurrence with the “in-zone” factors (the disaster's period and the term of stay in the zone, type of work done, irradiation dose) but indicated a major importance of post-zone factors: psychogenic ones (for example, what the authors have called “psycho-traumatic events in the domain of obtaining social privileges”) and ordinary risk factors of these diseases, namely excessive weight, hereditary factors, unbalanced nutrition and harmful habits.
Regardless of the data of objective analysis, the examined liquidators considered themselves as incurably ill and eligible for the privileges and compensations; 96.6% (!) of the subjects thought the irradiation to be a reason of the development of cardiovascular system's diseases. However, according to the paper, majority of the studied lacked knowledge about both
— effects of radiation upon the human system, and
— ordinary factors of risk for the cardiovascular system.
As for these latter factors, it was established that 75% of the studied have more than 2—3 factors of risk of the diseases of the triad “hypertonic disease, heart ischemic disease, heart attack”.
The researchers conclude that the factors from this list (different from psychogenic) may play an important role in the development of the diseases of the cardiovascular system. They assume that diseases of the cardiovascular system may cause neurotic disorders, and support this statement by the high rate of the heart hypochondria, anxious and asthenic states among the survivors. The researchers view the present system of welfare for the Chernobyl-affected as an important harmful factor.
5. Most convincing data indicating the crucial role of non-radiation factors was produced in (Amirazjan et al. 1997). The researchers argue against ascribing the increased morbidity of and peculiarities of pathological processes in the Chernobyl liquidators to purely radiation factors alone. In order to back their hypothesis up, they refer to 5200 cases of the liquidators of 1986—1990, who were treated in the Kharkov Research Institute of Medical Radiology (Ukraine), and use the data of the complex examination of 520 liquidators (of 25—45 years of age) by general practitioner, nerve specialist, endocrinologist, along with general clinic tests and a set of instrumental methods (ECG, velo-ergometric examination, ultrasound testing, electroencephalogram, reo-encephalogram) and psychological tests (MMPI, Lusher's test, interview).
The results showed NO correlation between the dose of irradiation and clinico-psychological manifestations of the pathology. Instead, a different correlation was obtained — the correlation a frequency of illness, frequency of hospitalisation, dates of official recognition people as disabled, on the one hand — and socio-economic changes in the country, and the psychological state of the liquidators, on the other. The researchers concluded that social and psychological factors (but not somatic ones) have been the leading causes of the Chernobyl liquidators' morbidity, and this may be one of the reasons of the low efficiency of medical treatment. This study seems to be the most broad, detailed and convincing analysis of the possible reasons of the liquidators' health, and that is why I will present its findings in detail.
First, Amirazjan et al. (1997), having examined 5200 cases of the liquidators of 1986—1990, obtained a picture of reported diseases in different years (Table 3.3.1). Analysing the dynamics of the reported morbidity, the researchers defined three periods of the reported somato-neurologic pathology of the liquidators.
In 1986—1989 (1st period) the leading pathology was vegetative dystonia (VD). Despite the fact that most of the examined were liquidators with average (official) dose of irradiation about *25 cGy and worked in the zone during the so-called “iodine” period, almost 50% of them were considered to be practically healthy and able to work at the time of examination. However, in my opinion, this result can be explained by political and administrative pressure on doctors.
Incidence of diseases of the Chernobyl liquidators (%)
|Icshemic disease of heart
|Pathology of stomach-
|Chronic non-specific lung
|Invalids of 2nd and 3rd
Since 1989 (it is the beginning of the 2nd period, of 1989—1992) a number of visits of the liquidators to medical institutions increased, especially in the first months of 1990 (January — 60 visits per week, April — 230: almost 4-fold increase!). Because most of the patients were not satisfied with the examination at the local polyclinic, they were hospitalised and were examined more thoroughly, which resulted in diagnosing more diseases. However, no specific radiation features were found both in the clinical picture and dynamics of the diseases. Diagnosis “vegetative dystonia” (VD) was gradually replaced by “dyscirculatory encephalopathy” (DE). The authors consider transformation of vascular pathology from VD to DE to be a natural biological phenomenon.
However, I have to comment here, that this fact may be explained as well by a social cause: following the politically-motivated instructions of the Ministry of Health, one and the same basic set of symptoms may be named differently. Probable importance of the political factors in interpreting the medical picture can be illustrated by a rather paradoxical situation discovered in the study:
The rate of development of DE did not depend on the dose and the dates of stay in the zone, at least not in the expected way:
— about 50% of the liquidators of 1986—1987 years (with average official irradiation dose —17.8 cGy (*17.8 R)) received the diagnosis “VD” several years after their return, and the rest of them were considered practically healthy, while
— the liquidators of 1989—1990 years —(3.8 cGy, (*3.8 R) had diagnosis “VD” established immediately after their return, and no practically healthy persons were indicated in the group.
Despite the documented doses for the both groups (especially for the first, of 1986—1987 years) are unlikely to be reliable, the radiation load of the second group, of 1989—1990, was substantially (possibly, by order(s) of magnitude) lower than that for the first group (see (Chernobyl'skaya katastrofa 1995: Ch.2.4)). However, one should keep in mind, that these “medical” events were unfolding against the background of gradual “softening” of the political climate (perestroika) where Chernobyl and its consequences represented one of the battlefields between conservative forces and radicals, central-USSR and national-republics' authorities. In August 1991 the USSR disintegrated, and since then the newly independent states were to take care about the mitigation of Chernobyl consequences and the health of the Chernobyl-affected by themselves — instead of demanding additional funding from the central USSR budget, as it had been before.
The third period (from 1992) is characterised by domination of the diagnosis DE at the background of slight increase of somatic pathology. The researchers state that, while in the previous years only clinically evident and objectively confirmed pathology had been reflected in the diagnoses, during this period it included any pathology, even if confirmed to the minimal degree by additional methods. It was the reason why diagnoses embraced large number of diseases in a state of remission with minor clinical manifestations. Except for thyroidopathies, Amirazjan et al (1997) attributed the increase of reported somatic pathology to the improvement of diagnostic technique (wide implementation of ultrasound testing), and increased attention of the doctors to the state of thyroid gland.
This period is characterised by a noticeable increase of the number of liquidators officially recognised as disabled (“invalids”). In more than 70% of these cases the leading diagnosis was DE, and (I want to emphasise this) a long term of stay in hospital and absence of positive subjective results of medical treatment were taken into consideration as a reason for the official recognition of disability (“invalidity”). — Such were the results of study of 5200 cases of the liquidators of 1986—1990.
The results of the clinical and functional examinations of 520 liquidators, done in this study (Amirazjan et al. 1997), have shown no substantial difference in pathology of the liquidators and intact population.
During neurological examination DE was diagnosed in more than 80% cases. There was a discrepancy between the large number of almost similar complaints and the low (objective) micro-symptomatology. For the majority the disease was in remission (72%). The clinical picture of DE was, in its essential features, the same for the liquidators and intact population. However, in the liquidators with DE the incidence of paroxysmal states in 1991—1992 was much higher as compared to the earlier years (in more than 70% of cases vs. singular cases), and there was a substantial discrepancy between their incidence reported in anamneses and that objectively observed in hospital (72% vs. 25%). In my opinion, the latter fact can be interpreted as an evidence of malingering. This opinion coincides with the finding of another study of this group (Amirazjan et al. 1996): 20% of the examined liquidators were reported to expose “subconscious phenomenon of medical malingering”.
Comparison of the level of physical working ability showed no considerable difference of this integral index of the health state between the groups of liquidators and industrial workers.
In general, probability of diagnosing somatic pathology, according to Amirazjan et al. (1997), directly correlates with the depth of medical examination. Based on the results, the researchers define the following characteristic features of the liquidators' pathology:
• discrepancy between rather moderate (objectively established) symptomatology and large amount of polymorphic complaints;
• persistent character of the complaints, absence of (or short-term) positive effect of the repeated courses of hospital treatment (despite the results of additional methods of examination showed certain improvement);
• presence in the structure of somatic pathology neurosis-like disorders in form of anxious-phobic, hypochondriac, astheno-depressive syndromes, which affect the general state of the patients' health;
• formation of iatrogenic diseases caused by the frequent hospitalisation and polypragmasy38.
The researchers use a term “the Chernobyl syndrome” to describe rather similar neurological symptomatology and diverse somatic pathology (the later having no qualitative differences from the one of intact population) in the Chernobyl liquidators. “The Chernobyl syndrome” should include, according to the authors, both psychological traits of the patients and their causation by social-economic reasons.
Psychological study of the liquidators (both recognised officially as invalids of 1st, 2nd and 3rd “groups” (degrees) 39, and those having no official invalidity), unexpectedly came up with the most unsatisfactory results in the invalids of the 3rd group (with the smallest officially recognized handicap). This group was characterised by the highest levels of memory disorders and of reactive and personal anxiety. This paradoxical fact might be explained by the highest level of motivation in this “transitional” group, as compared to both non-invalids (that obtain modest basic compensation and privileges) and members of the groups of graver degrees of invalidity, entitled to substantially higher amount of compensation and privileges.
“The complex of victim”, exacerbation of “pre-morbid characteristics” of the individuality, elevation of emotional and psychic tension, along with the symptoms of the personality disintegration, decrease of adaptive abilities, low social adjustment with presence of asocial features of behaviour (refusal to work, alcoholism) are reported to be dominating psycho-emotional reactions. These changes are said to be most expressed in the persons with low level of education, the observation corresponding to that of Chinkina (1995).
These features, according to the authors, have led to the impossibility for people to exist in their usual social environment, and have adversely affected the health (somatisation of the anxiety, development of the psychosomatic pathology).
The researchers consider that in the last years the domination of psychological component of the Chernobyl liquidators' morbidity has become a clear tendency. It is this tendency, according to Amirazjan et al. (1997), that explains the low efficiency of medical treatment,
because recognition of success of the therapy, according to the legislation in force, leads to the loss of social protection (elimination of the official recognition of invalidity).40
6. More detailed analysis of the impact of psychological and social factors upon the liquidators was the objective of two recent studies of the same group of researchers (Amirazjan et al. 1998; Simonova et al. 1998). For this purpose, attempts were made to take the influence of radiation factors out of the consideration, by comparison of the irradiated liquidators — with irradiated professionals, the latter having been in a different life situation and had a different motivation. In the first of these two studies the comparison — with respect to the value of the irradiation factor, the dose — can be considered as qualitative, in the second, final one — as quantitative.
6a) Amirzanjan et al. (1998), compared 100 liquidators of 1986—1987 (average dose about —13 cGy (*13 R)) and 120 irradiated professionals. The comparison showed no significant differences in ability to perform physical work and objective neurological symptomatology of the groups, and outlined the importance of psychological (motivation) and economic (welfare) factors. This research has qualitatively shown insignificant role of the radiation factor with respect to the state of health of the subjects.
At the neurological examination, the liquidators (unlike the professionals) showed the domination of subjective component and stable neurosis-like symptomatology (the latter is 3—3.5 times more frequent among the liquidators). The changes of the main rheoencephalographic parameters were of the same type for the both groups. The researchers believe that the high number of complaints and high level of anxiety of the liquidators were connected with chronic stress and with motivation of the person. The professionals studied had different motivation and active life position, they wanted to continue their professional activity. The liquidators' ability to work was shown to rather depend on the psychological traits of individuals of this group rather than on somato-neurological.
In psycho-emotional sphere, the liquidators were characterised by a stable disorder which manifested itself primarily in the increase of personal and reactive anxiety. For the majority of the professionals, the parameters of personal anxiety were within the average range, but parameters of the reactive anxiety were also noticeably increased. This fact, according to researchers, was caused by the importance of the examination results for both groups though motivation was diametrically opposite: the liquidators were interested in formal obtaining or confirmation of their disability (and, hence, receiving the related welfare and privileges) while the professionals wanted to be allowed to continue their work in the nuclear industry. 6b) In the next comparative study of the liquidators and radiation-exposed professionals (Simonova et al. 1998), both groups had the same dose and the same rate of its accumulation. Hence, the influence of the radiation factor on the health of the two groups was take out of consideration, and the impact of non-radiation factors has become quantitatively evident.
Two groups of men of 30—50 years — 150 liquidators of 1989—1990 years and 100 professionals — had been exposed to radiation not exceeding *5 cZv41 (*5R) and approximately the same regime of the dose accumulation (the liquidators spent in the zone 4—6 month). Both groups were examined with respect to their main clinical, laboratory, instrumental and psychological parameters, upon which the assessment of their physical and intellectual working ability became possible.
The researchers concluded that both groups had no noticeable differences in pathology, determined based on the objective parameters.
The structure of pathology for the both groups was identical and included the most widespread diseases of cardiovascular and digestion systems. Essentially higher number of various complaints from liquidators lead researchers to examine the liquidators more thoroughly and diagnose a wide set of diseases, which were, as a rule, in a state of remission. Ability for physical work, tested by bicycle ergometric testing, showed no essential differences. During neurological examination, discirculatory encephalopathy was discovered in 100% of the liquidators and 25% professionals, which was explained by persistent various complaints from the liquidators, while the professionals complained only when they were thoroughly questioned42.
Despite the fact that objectively established pathology for the both groups had no significant differences, 69% of the liquidators were officially recognised as disabled while 100% of professionals consider themselves able to work with no limitations. The researchers assumed that the crucial influence upon the liquidators' ability to work is imposed by “a complex of social-psychological circumstances”. Indeed, in the course of psychological studies the liquidators have shown high levels of personal anxiety, lack of social and psychological adaptation, combined with the inclination “to escape from the reality”, with formation of asocial forms of behaviour (the latter was more frequent among persons with lower level of education), and distortion of the structure of personal motivations connected with the refusal to work. They concluded that non-medical factors made an “important contribution” into the phenomenon observed, and, without changes in the social and economic situation and in the legislation, an improvement of ability of this category to work can hardly be expected.
The series of research may be concluded with an eloquent quote (Amirazjan et al. 1996; emphases added), extremely important for the purpose of my study:
The majority of the problems connected with the rehabilitation of the liquidators, is outside traditional tasks of medicine. It is a complex bio-social problem, and in its solution medical treatment should play an essential but not the leading role.
Concluding this sub-chapter, dedicated to the analytical studies of the present health state of the liquidators, I want to make only one comment (rather than criticism) to the research, presented in the subchapter, and to many other medical studies of the Chernobyl liquidators. This is a comment on a slightly unusual (and not evident for the medical doctors and Chernobyl outsiders) possible bias of the samples studied:
It is possible that the medical researchers in such studies almost exclusively deal with those in “the sight” of their medical institutions, i.e. those liquidators who apply for the aid, for hospitalisation. The liquidators who are outside this contingent, who are not in frequent contact with the medical institutions (or even do not apply for medical aid at all, or do not apply through official channels), are less available for the research. From my experience I can state that a group of those who do not apply for the official medical treatment consists of both those who have good health — and, surprisingly, those who are too ill to withstand all the procedures required to receive the official status of invalid, who feel that a rather psychologically (and not only psychologically) traumatic way of the official medical treatment (e.g., psychological influence of a long-term stay in a hospital ward, of participation in the “welfare race”) — may irreparably destroy their health. This important circumstance should be kept in mind while interpreting the medical research on the Chernobyl-affected.
Design by: M.Opalev
Studio ARWIS Kharkov, 2001