The phone call from Moscow came on a Sunday, at 10 in the morning. The weary voice of Dr. Robert P. Gale was barely audible: "Dick, the Soviets have agreed to let you, (Dr. Paul) Terasaki and (Dr. Yair) Reisner come. There's a 3 o'clock flight available to Moscow today. Can you make it with the supplies?"
I'd prepared myself for this for the past three days, assuming that the Soviets would grant me the visa to deliver needed medical supplies and equipment from the West and to assist Gale in transplanting healthy bone marrow to the victims of the April 26 explosion and radiation leak at the Chernobyl nuclear power plant in the Ukraine. Yet my response must have seemed cryptic. "We'll bring what we can," I told Gale, and hung up.
I was excited and apprehensive, but there wasn't time to sort through my feelings. I told the news to my wife, Mary Jane, and ran out the door and drove to my office on the fourth floor of the UCLA Medical Center in Westwood. There, two assistants and a doctor were already rapidly packing the last of the medical goods that would soon comprise a makeshift, modern blood-typing laboratory in an aging Moscow hospital.
Several of us had spent the three days since Gale's departure on May 1 collecting supplies from the UCLA Medical Center pharmacy and through connections made by Armand Hammer, the chairman of Occidental Petroleum and the man who arranged for Gale to go to Moscow. Gale had telephoned at all hours, day and night, from the private office Hammer keeps in Moscow, each time asking that yet another antibiotic be added to the list of medicines needed to help the victims fight the life-threatening infections resulting from severe radiation exposure. The Soviets, he reported, also lacked the equipment and chemicals necessary to perform large-scale bone marrow transplants--in particular, the six-inch-long, heavy-duty needles designed for extracting bone marrow from donors, as well as the reagents that preserve the bone marrow once it's been harvested.
At the medical center, Nancy Lyddane, a research nurse, Kyoung Lee, a research technician, and Dr. Drew Winston, a infectious-disease specialist, had packed six crates of drugs and supplies. They had six more to fill before the flight, now just three hours off. We waited until the last possible moment to bring out the perishable chemicals. I telephoned Mary Jane and told her to pack my bags with trail mix and jogging suits for an indefinite stay in the Soviet Union. Then we loaded the crates into a station wagon provided by Hammer.
Soon, my wife and two daughters, Stephanie, 13, and Kristin, 7, arrived to take me to L.A. International Airport. As Mary Jane drove, I went through my bags in a last-minute search to make sure I had everything I needed. There were eight jogging suits and enough undershirts to last me a year--and only a couple of pairs of slacks. I threw some of the undershirts and jogging suits into the back seat but kept the trail mix and even a few rolls of film in case I had some free time.
After pulling up in front of the Lufthansa terminal at the airport, an associate of Hammer's (who'd driven the loaded station wagon from UCLA), my wife, the two youngest members of this international effort and I hustled the crates--some of which weighed 50 pounds--from the car and lined them up in front of the airline's check-in counter. I boarded the plane carrying a briefcase, a crate with the most precious and perishable of the supplies in dry ice, several medical books on bone marrow transplants that I planned to give to the Soviets, and an overnight bag. A flight attendant refused to seat me because I'd exceeded the airline's limit of one carry-on bag. No matter that the plane was half-empty. The attendant finally took my bag and checked it in down below. I took a seat next to Paul Terasaki, an international authority in tissue typing and the director of UCLA's tissue-typing laboratory. Yair Reisner, a biochemist and immunologist from the Weizman Institute in Israel and currently a fellow at Memorial Sloan-Kettering Cancer Center in New York, would be meeting us in Moscow.
Reisner, I knew from an earlier conversation, was anxious about the arrangements. None of us had visas--they were to be issued to us upon our arrival, an unprecedented procedure. But Reisner's situation was complicated by being an Israeli citizen; since Israel doesn't have diplomatic relations with the USSR, its citizens are usually not granted visas. He'd insisted over the phone that Gale meet him at the airport, saying he wouldn't deplane unless Gale was there.
In the air, I had chance to begin to contemplate the enormity of the project, and my own nervousness grew. I'd spent the last eight years performing bone marrow transplants and administering controlled dosages of radiation to leukemia victims. Now I was about to encounter the effects of the worst peacetime nuclear disaster in history. Apart from the challenges of treating so many seriously ill patients, I also felt a scientist's exhilaration at knowing that I was on the cutting edge of medicine, that I would be witness to a drama that might one day yield great knowledge. But there was much uncertainty: How many victims would need acute medical care? What was the extent of their injuries, and how would we assess them? How would our Soviet colleagues feel about us, and what would be their level of competency and preparedness? Finally, were we risking danger to ourselves? Would the fallout reach Moscow; would our food supply be contaminated?
Terasaki and I scanned a newspaper, but the contradictory accounts of Western diplomats--which later proved to be greatly exaggerated--only added to our confusion about the magnitude of Chernobyl. Compounding all this, neither Terasaki nor I had been to an Eastern Bloc country before, much less the Soviet Union.
About halfway through the flight, Terasaki moved to a back row of seats and slept. But I couldn't sleep during the 16-hour flight and the two-hour layover in Frankfurt. I worried that some stiff and formal Soviet customs official, unaware of our purpose, would destroy our perishable materials by delaying them at the airport.
During our first hour in the Soviet Union--we landed in Moscow in the late afternoon--we were greeted by Gale and five Ministry of Health physicians who'd act as our translators and chaperons for the next 13 days, taken to a VIP room off to the side of the terminal while our bags and medical supplies were being cleared, and minutes later driven to Hospital No. 6.
I was exhausted, but now the adrenaline was carrying me. Together, Terasaki and I had 22 crates of supplies and equipment, almost all of which cleared customs without delay. We immediately began unpacking the perishables and placing them in a freezer. Then we started setting up our lab, with its microscopes and trays that would be used for testing and matching the tissue types of patients and potential donors. One microscope, which enhanced the contrast between blood cells, was misplaced, and found four days later in a corner of the airport's baggage claim area. Until it was tracked down, we had to borrow another.
When Gale met Reisner at the airport the next day, our team was complete. We stayed at the Sovietskya Hotel, first-class lodging by Russian standards and usually reserved for diplomats. The hotel is old and regal and somewhat stuffy, with red carpets and large, high-arched rooms. I never quite recovered from my initial exhaustion and jet lag, and I had trouble sleeping more than four or five hours a night.
We were ushered to and from the hotel by our Ministry of Health guides. Last-minute changes of schedule were nearly impossible to accomplish. Our only unaccompanied moments came before breakfast, from 6:30 to 7, when Gale and I would jog up and down the thoroughfare in front of the hotel. Once we ran the six miles to Red Square. No one seemed to know who we were, but we attracted considerable attention--particularly Gale, who wore a "USA" athletic shirt.
Though our movements were not formally restricted, we were there to help the accident victims, not to be tourists. We seldom met Soviet people outside the medical profession. Western reporters in Moscow would approach us and ask detailed questions that we were unable to answer--in fact, we learned more from them than they did from us. We felt extremely isolated. We knew only what was taking place in Hospital No. 6.
We worked 12 to 15 hours a day. We'd arrive at the hospital between 9 and 10 each morning and make rounds with Dr. Angelina Guskova and Dr. Alexander Baranov, the two senior physicians at Hospital No. 6. We interacted very well professionally; the Latin-based terminology of medicine transcended the cultural and language differences. Guskova and Baranov supervised a hard-working group of junior physicians who reminded me of American medical resident doctors. Many of these young Soviet doctors, who are mostly women, spent days at a time in the hospital caring for the most critically ill Chernobyl victims.
We all tried to avoid talking politics. One of the physicians, a Dr. Veshesslov Stepanov, liked to tell jokes that played off the tensions in U.S.-Soviet relations, but even he would dance around certain questions that could not even be considered to be political. Every now and again, during an idle moment, I'd ask a question with political overtones. The Soviets were artful dodgers. "How is Stalin regarded today by your people?" I asked one of the Ministry of Health officials. He pondered for a moment and then announced: "Stalin made some mistakes, but he led the Soviet Union during a critical period of history."
Angelina Guskova, the hospital's chief physician, is a stout, no-nonsense woman in her 50s; Alexander Baranov, in his mid-40s, bald and thin, is a hematologist in charge of bone marrow transplants. Both of them speak some English, though we'd still depend on the Ministry of Health officials to act as translators. When we began discussing patient care, it quickly became clear that both Guskova and Baranov were excellent clinicians with a longstanding interest in the effects of radiation. Guskova had studied the few previous nuclear-facility mishaps worldwide as well as cases in which health-care workers had been inadvertently overexposed to laboratory radiation. She'd formulated an important method of estimating the dose of radiation absorbed by individuals during accidents. Because it wasn't possible to know how much radiation each victim had been exposed to, her method proved an invaluable tool in our assessment of the Chernobyl victims. Based on those projections, we decided which patients needed bone marrow transplants; we only gave transplants to those victims we estimated had received 500 or more rads of radiation.
Guskova's method estimates the amount of exposure by using a formula based on how quickly the victim's white blood cell count drops and the degree of breakdown in the chromosome structure of the blood and bone marrow. The Soviets had tabulated the daily fall of white blood counts during the first four days following the explosion.
But the estimates didn't prepare us for the tremendous amount of injury to the victims' soft tissues. According to Guskova's estimates, many of them had received less radiation exposure during the blast than a typical cancer patient receives during standard radiation treatment. We routinely give higher dosages of therapeutic radiation for leukemia patients but never see the degree of soft-tissue damage that the Chernobyl victims suffered.
Why Guskova's estimates of radiation exposure didn't parallel the extensive tissue damage of the victims is unclear. One possible explanation is that great amounts of radioactive particles were either inhaled or swallowed, and showed up as damage to the mouth, intestines and lungs. That damage wouldn't be reflected in the condition of the white blood cells or of the bone marrow. It's also possible that Guskova's formula may have been inaccurate because of the lack of information shrouding the Chernobyl accident.
Our primary task was to assist with the evaluation and care of 35 critically ill radiation victims. Before we arrived, nine of the most severely affected had been given transplants, some using bone marrow and some using tissue taken from the livers of stillborn or aborted babies. This second procedure, known as a fetal liver transplant, is generally less effective than a bone marrow transplant and so is a last resort, employed only when a matching donor can't be found or when the patient's white blood cells are so depleted that a tissue typing between donor and patient can't be performed. (Fetal liver is very similar to the bone marrow in that it contains the blood-forming cells. In fetal development, these cells travel from the yolk sac to the fetal liver and finally to the bone marrow, where they reside for the remainder of that individual's life. The disadvantage to using fetal liver cells is that there often are not enough of them for a transplant and this increases the chances for rejection.)
We helped perform a total of 10 bone marrow transplants, assisting in the extraction of bone marrow from donors and the infusion of it into patients. We were introduced as American doctors to all the patients and many members of their families, who were allowed to visit but, like the physicians and nurses, had to wear sterile masks, boots and gowns--the urine, blood, stool and secretions of these patients were potentially radioactive. Though touching and hugging were not forbidden, there was little physical contact between family members. The sterile outfits interfered, and besides, the burned skin of the injured victims was extremely sensitive. Each person would find a moment to thank us for coming. They seemed comforted knowing that American medications would be used in their care.
Despite the addition of our supplies, the Soviet doctors had to cope with a critical shortage of technology and with equipment that dates back 20 years or more. Compared to most American hospitals, the facilities were stark. The building itself was in disrepair and lacked air conditioning. The Soviets buy most of their hospital equipment from United States and other Western countries and manufacture very little themselves. It was apparent that they aren't equipped to handle a large number of casualties, a fact brought home most clearly by the absence of an automated blood-cell counter. Instead of determining blood counts in 20 seconds with a piece of equipment that can be found in the most Beverly Hills hematologists' offices, the Soviets count blood cells under a microscope--a process that takes 30 minutes. (During our last days in the USSR, a French company donated a $100,000 blood-cell counter. The Soviets were assembling it as we left.)
We had to contend with frequent breakdowns, which forced us to work longer hours to keep from delaying any transplants and risking lives. During our first transplant procedure, a very old lab hood, used to maintain sterile conditions, began to smell like burnt rubber. When working properly, the hood blows filtered air over the table-top surface to prevent airborne bacteria from contaminating the bone marrow preparation. The hood never worked again, but fortunately none of the bone marrow ever became contaminated. We made sure of this by preparing cultures of every bone marrow specimen.
On another occasion, just 24 hours after Reisner had finished setting up his lab in Hospital No. 6, he had to pack up all 10 crates of equipment and move it to a nearby facility because the hospital's only available centrifuge broke during the second transplant. Though we lost a portion of bone marrow when the machine broke down, we were able to recover enough cells to proceed with the transplant--an aggravating, but not life-threatening, delay. The centrifuge, which separates the heavy cells from the light in its dizzying spin, is absolutely essential in processing bone marrow before a transplant. Only the light-density cells, which are the ones capable of restoring the immune system, are used in a transplant. The heavier, more mature cells, do not proliferate. Reisner had to work late into the night for the next two days to get back on schedule.
All the bone marrow transplants were obtained from family members whose tissue types most closely matched that of the patient. Though matching tissue types entails a great deal of painstaking work, the actual transplant is relatively simple. The donor is given general anesthesia, and the six-inch needle is inserted into the hip bone, the easiest and safest place to extract marrow. More than 200 punctures are made to the bone marrow over the course of an hour. The material--which is the source of blood and the foundation of the immune system, and looks very much like blood itself--is sucked into a syringe a teaspoon at a time until about one pint, or 10% of the body's bone marrow, is collected. It's then placed in a bag and injected into the patient in a procedure similar to a blood transfusion. Traveling through the bloodstream, the donor's bone marrow cells find their way to the patient's bone marrow. For the donors, the process is similar to giving a unit of blood.
We were unable to find perfect donors for several of the victims. But in the last five years, Reisner has developed an innovative procedure to prevent graft-versus-host disease, which occurs when the cells of the donor's immune system, residing in the bone marrow, recognize the transplant recipient as foreign tissue and attack the recipient in the same way it would fight an infection. Reisner's technique removes the bone marrow cells that cause graft-versus-host disease without destroying the cells necessary to regenerate new bone marrow and immunity in the patient. The procedure takes six hours. Four of the transplant patients required Reisner's help.
The most challenging part of bone marrow transplants is keeping the victim alive, using antibiotics and other supportive measures, until the bone marrow has had a chance to engraft. It takes two to four weeks for bone marrow cells to grow sufficiently to restore blood production. Until that time has elapsed, there's no way to know whether the transplant will be successful. It's a race between infection and the recovery of the body's immune system. Of the 19 transplant recipients, 13 died before the transplant itself had a chance to grow. As of mid-June, the other six are still alive. Since returning to the United States, Gale and I have continued to communicate daily, via telex, with the Soviet physicians regarding patient condition and care. We've secured additional medical supplies for them. Gale has made a second trip, and plans to return again in late July to formalize an agreement for international cooperation in assessing the effects of Chernobyl.
Two patients stand out vividly in my memory. One was a firefighter in his mid-20s who'd been part of a group called in immediately after the explosion to put out the fire. They were the first inside the plant, and his injuries were among the worst. He knew that he'd received a potentially fatal dose. But he wasn't terrified. He had the same stoic yet frightened look of many of my leukemia patients back at UCLA.
It was inexplicable that he was dying and the firefighter in the adjacent hospital room had suffered very little tissue damage. The two men had fought alongside each other, maybe 20 feet apart. Apparently the radiation exposure had been patchy, unevenly distributed. A matter of 20 feet made the difference between life and death.
His condition deteriorated over the course of a few days because of extreme radiation damage to his intestines. The first cells radiation kills are the fastest growing ones, the cells that line the mouth and the gastrointestinal tract. The cells that grow more slowly can repair the radiation damage before they divide, thus enhancing their chances for survival.
He died in the early morning. When I arrived at the hospital to make rounds, his wife stood weeping outside his door. She was being comforted by nurses while children roamed the hallway.
The other patient who does not leave my mind was in his 30s, a Soviet doctor, not much younger than I, who lived near Chernobyl. He was introduced as a hero: Knowing the risks, he'd gone into the nuclear-reactor building in an attempt to rescue people injured in the initial explosion. He'd sacrificed himself consciously and in the process saved many lives. When I met him, he was still conscious, though intermittently delirious. He said hello, very simply, in Russian.
He was already showing the early signs of severe radiation exposure. His injuries were the worst of all, and his suffering grew from one day to the next. In his mouth and on his face were large black herpes simplex blisters, often the first symptoms of the condition. His skin literally broke down before our eyes. First, the sensitive folds around the groin and under the armpits became red and ulcerated, and then slowly these ulcers spread across his entire body. In a matter of days, he was covered with red, weeping skin burns. He was barely rec
ognizable toward the end. We administered morphine, constantly increasing the dosage, but even that did little to ease his misery. The membranes that lined the young doctor's intestines had eroded and he suffered severe, bloody diarrhea. He died about 12 days after the explosion, a week after receiving a transplant.
The Soviet physicians by training seemed to rise above and handle the conditions well. We were careful not to usurp their role. We had more experience in bone marrow transplants, but they had greater knowledge in the area of accidental radiation. It was a good partnership. Early on, Gale, Terasaki, Reisner and I discussed whether we should focus on the operations and patient care, or whether we should also invest time training the Soviets in the field of bone marrow transplants. We all agreed on the latter course. The instruction and training we gave to junior Soviet physicians and technicians, and the books and technology we left behind, stand as a legacy of which I'm proud.
Fortunately, none of my fears about fallout in Moscow materialized, and only once did the meter at the exit of Hospital No. 6 detect any radiation on my clothes. One evening my left shoe prompted a positive reading, and I wiped the radiation off on a floor mat.
The disaster at Chernobyl demonstrated the devastating effects of radiation exposure. It illustrates the fact that adequate medical care would be impossible in a larger nuclear catastrophe. As a cancer doctor, I'm accustomed to dealing with patients who die. This was different; I was overwhelmed by the human suffering. But the fact is that the damage and human misery that would be wrought by nuclear weapons would be immeasurably worse. Chernobyl would pale by comparison.