PCBs, Pollution and Detoxification

Structural Chromosome Aberrations and Political Consequences

In late 1985,, an abnormally high - percentage of structural chromosome aberrations (SCAS) was found in a female worker, from the Semic factory, who was admitted to the University Medical Center of Ljubljana, Medical Department of Gastroenterology, for evaluation of her symptoms (presented later herein). This result prompted the selection of a group of residents and one of factory workers for further evaluation. Similar SCA levels were found in both groups (Table 3a).

SCAs are usually caused by either irradiation or chemical agents. Radiation was ruled out as no unusual radiation exposure was documented in this area. Even the subsequent Chernobyl event was not reported to have caused chromosomal damage in western Europe (Sternglass, 1986). Thus, a chemical origin was suspected.

The presence of SCAs in an otherwise normal population may signal consequences such as increased cancer incidence, higher spontaneous abortion rates and birth defects (Hassold, 1986; Hsu, 1982; Kaye et al., 1985; Lundgren et al., 1988; Natarajan et al., 1986). Significant amelioration is possible if the noxious factor is removed; most affected persons are able to repair this type of DNA damage within a year (Cherry, 1983). The evaluation of SCAs was included as part of our study in 1987. Although only seven of the eleven studied had had evaluations in 1986, a marked trend towards normalization was apparent (Table IIIb).

In 1985 it had been assumed that the SCAs could be related to elevated PCB levels, although PCBs had not previously been linked to this phenomenon. However, PCB levels were still elevated in 1987, while the SCAs were not. Considering the elevated body burdens and the long half-life of halogenated hydrocarbons (Kashimoto et al., 1981; Kimbrough, 1980; Safe, 1984; Weber and Schlatter, 1981), they could not be the causative agents. This led to the conclusion that a less persistent chemical was probably the source of the SCAs previously detected.

In 1986, after the discovery of chromosome damage in Semic, the University Medical Center Ad Hoc Committee in Ljubljana had proposed monitoring of SCAs in both workers and residents of the area and an expanded environmental screening program. When a normalizing trend was suggested by the evaluation of workers in our 1987 study, this proposal was reduced by the Public Health authorities to a voluntary screening of all newly-wed pairs planning a family, and to all uncontrolled periodic screening of workers chosen by the factory officials. These decisions were reported by the local news media, which amplified the extant polarization between the residents and the local governing bodies over the contamination issue.

The Solvency Problem - Who Pays ?

In 1984, the University of Ljubljana, Institute of Occupational, Traffic, and Sports Medicine, and the Committee of Public Health of the Republic of Slovenia initiated a two-year cross-sectional health assessment survey of 284 adults from six villages along the river and within 5 km of the factory. In addition to the 122 males and 162 females of this group, the study included all pregnant and breastfeeding women, and 60 children under 10 years of age from these villages. From the group of 284 adults, a random sample of 62 men and 55 women was selected for further evaluation. As a separate item, this study also evaluated the health status of 21 male workers from the factory impregnating halls (Crnivec et al., 1986).

The liability for environmental damage was ascribed by the Court for Commercial Affairs to the factory and its Director General in 1987, resulting in what many considered to be an inadequate penalty. Factory officials agreed to pay a substantial part of the costs of the original environmental survey, the new pipeline and landfill, monitoring of the residents and medical examinations of the workers. They refused to pay for continuous follow-up evaluations of the residents. The ensuing dispute became a public controversy.

Expenses from the initial cross-sectional health survey, although financed only in part by the community, surpassed the town's yearly budget for public health services. As the issue became more publicized, concern mounted over possible health effects from the chemicals. Consequently, an increasing number of individuals requested medical examinations. The country's socialized medical system allows patients an initial free choice of institutions but does not grant a patient the right to a second opinion. The patients, therefore, chose to go to the University Medical Center of Ljubljana for detailed evaluations. The staggering costs of continuing medical evaluations, coupled with the increasing inflation rate, created a debt that will be carried forward into the next decade. Since new resources could not be provided from the Republic's meager health budget, the demands voiced by the residents and the steady influx of bills for ongoing medical evaluations were met with strong opposition by the factory management, the community health service and the community officials.

A local ad hoc medical committee was formed to evaluate cases where damage from chemical contamination was alleged. Its purpose was to screen these cases prior to their evaluation at specialized institutions. However, the residents perceived the committee to be biased and were unwilling to follow this procedure.

To fully appreciate the response of this community, it is helpful to understand its recent history. This region is known as the birthplace of The Resistance in World War II. The death toll in this region during the war was very high. Additionally, the Republic of Slovenia was constituted in this locale in 1945. When residents recalled their contributions of the past, given to ensure a prosperous future, the feeling of being considered "expendable" in the polluted present generated protests. A representative made several demonstrative visits to governmental offices, including that of the vice president of the Republic Slovenia, to demand that the region be included in the disaster assistance plan of the Republic.

One Step Forward

The controversy was heightened when the government rejected proposals to proclaim the region a natural disaster zone. Mistrust of authorities was intensified by reports of the treatment and subsequent recovery of an occupationally exposed female worker, previously dismissed by the plant physician as a malingerer.

This particular woman had been employed at the factory since 1967. Throughout her employment she was exposed to the variety of chemicals used at the plant. In addition, she had direct exposure to PCBs for nine months in 1983, manually checking approximately 20,000 capacitors per day for leakage. She rarely wore protective equipment.

This non-smoking and non-drinking woman, aged 35, was healthy prior to the onset of an increasing number of symptoms in 1969. Severe abdominal cramps with visible bloating, extreme fatigue, muscle aches and weakness with joint swelling, recurrent chloracne eruptions and enhanced skin pigmentation were her major clinical complaints. She first noticed a steady daily breast discharge which increased to approximately 50 mL/day of bluish-green fluid in 1975. Exploratory surgery in 1984, performed during a severe attack of abdominal cramps, revealed mesenterial lymph node inflammation. The removed appendix was histologically normal. A liver biopsy performed at the University Medical Department of Gastroenterology in 1985 revealed light and electron microscopy changes consistent with those reported in cases of chronic PCB exposure.

No underlying disease compatible with this patient's clinical picture could be found after repeated medical, endocrinological and surgical evaluations at the University Medical Center of Ljubljana. The diagnosis of chronic occupationally related PCB intoxication was proposed in 1985. A recently published treatment (Schnare et al., 1984), aimed at reducing levels of toxic chemicals, was suggested by her attending physician at the University Medical Department of Gastroenterology, Ljubljana, and approved by the institutional Review Board. Detoxification by the Hubbard method (Hubbard, 1980), mobilizes and removes lipophilic (fat-soluble) compounds. It had been successfully applied to patients contaminated with PCBs and other toxicants and was regularly delivered at two centers in California.

Treatment in Los Angeles was approved by the Committee of Public Health of the Republic Slovenia, which covered half of the travel and other expenses, the balance being paid by the factory. The patient and her physician (one of the authors, Z.T.) went to Los Angeles for further evaluation and treatment. The cost of treatment was borne by a U.S. non-profit organization.

At pretreatment, this woman's PCB content in fat was 102 mg/Kg, her serum level was 512 ug/L and her breast discharge contained 712 ug/L PCBs. The detoxification treatment mobilized and induced the elimination of the PCBs. At post-treatment, PCB levels in fat were lowered by 60 percent and serum levels were lowered by 34 percent (Figure 2). PCBs are generally expected to have halflives measured in years, whereas these reductions were effected in less than one month. (Tretjak et al., in preparation)

During treatment her severe symptoms subsided and the breast discharge, which had persisted for over ten years, ceased. Her attending physician and two U.S. specialists who were monitoring her clinical condition confirmed substantial improvements in her clinical profile. The patient was elated by the effects of this treatment.

Responses

From the beginning, both individual and institutional responses to the unfolding events in Semic could have been predicted. They fit the model presented in the introduction to this paper. Upon return to Semic in 1986, this woman openly discussed her elevated PCB levels, her marked recovery, and her views on the local contamination. Residents thus became aware of the personal effects caused by this contamination event.

Public disputes were heightened by extensive and frequently sensational news reporting. One television program in particular, aired in 1987, evoked a vision of outrageous death tolls due to incurable disease caused by PCBs and suggested an imminent catastrophe. These predictions were supported by dramatic interviews with affected residents and workers. Public outcry increased with a demand for clarification of the issues.

These events evoked a stern response from Republic politicians who rallied behind the community officials. They discouraged protest and demanded that the residents act with "common sense". The treated woman was discharged disgracefully from the Communist party and publicly declared "irresponsible". Factory officials, supported by political authorities, repeatedly summoned her for crossexaminations over remarks she had allegedly made. Both of her children, aged 10 and 12, were harassed at school after they ceased eating lunches at the factory and ate their own food (presumably uncontaminated), purchased in a distant town. She was prematurely retired as a handicapped, occupationally diseased patient. To enhance her discomfort, her rent allowance had to be claimed in person each month at the factory.

This ongoing stress, accompanied by constant quarrels with former coworkers and neighbors over the contamination issue, forced this woman into solitude. A year after treatment, these pressures and the added trauma of an unexpected miscarriage resulted in extreme depression and a nervous break-down.

Nevertheless, the potential of the detoxification program to produce clinical improvements and body burden reductions was appreciated. The coordination of further medical actions was assigned to the University Medical Department of Gastroenterology, which had organized the treatment of -this worker. It was agreed to conduct a pilot study under the supervision of a medical board to determine the feasibility of the treatment procedure for occupationally exposed workers. The study initially proposed included a large number of tests and controls. While their value was not disputed, severe budget restrictions precluded full implementation of the study design. In addition, the program necessitated the cooperation of local medical authorities with the somewhat alienated citizens. Establishing a bond of trust between these factions was complicated by ongoing efforts to downplay the importance of contamination in the Semic area.

These obstacles were overcome by two avenues. (1) Costs were reduced by abbreviating the project plan and (2) friction between different parties was mitigated by support from senior medical representatives within the Republic and the active involvement of outside researchers: Pacific Toxicology Laboratories in Los Angeles determined polychlorinated biphenyl (PCB) levels in serum and fat, while the Institution for Toxikologie, University and Technical Faculty of Zurich analyzed several blood samples for polychlorinated dibenzofuran (PCDF).

Associates of the Foundation for Advancements in Science and Education in Los Angeles were engaged to deliver the detoxification program. Inclusion of these organizations helped to overcome the mistrust held by the area's residents. As a consequence, individuals repeatedly volunteered for participation. In addition, the commitment of unbiased researchers tended to mollify those objecting to the work on vested interest grounds. Limited resources did confine the study to a small number of participants - eleven individuals were treated rather than the 40 intended in the preferred plan.

This study is unique in that it represents the first controlled study of this detoxification treatment on a group of people who had accumulated high amounts of PCBs. Initial findings confirmed excessive levels of PCBs in both residents and workers in this region. Symptoms from the study participants were marked. Treatment reduced both PCB and PCDF levels, improved the immune response, and significantly alleviated the symptoms, consistent with the success of the earlier treatment of the female worker. No such improvements were observed in the control group. Details of this work are presented in Appendix A.

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