RESPECTIVE RISKS OF DIFFERENT ENERGY SOURCES

Health Risks
Due to the Use of Nuclear Energy for
Electric Power Generation
by M. Tubiana

Many attempts have been made in recent years to compare the health risks from various
methods of power production. The purpose of this article is:

1. To review the data which form the basis for an evaluation of the biological effects
of ionizing radiations;
2. To evaluate the doses received by members of the public and workers as a
consequence of nuclear power production; and

3. To examine the possible biological consequences of these exposures — both external

and internal — for members of the public and workers.

Data on which Evaluation of the Effects is based

It is often said that the effects of ionizing radiation on man are mysterious and unpredictable.
In fact, of all physical and chemical agents present in our environment, radiation is
undoubtedly the best known. Roentgen discovered X-rays in 1895, and Becquerel
natural radioactivity in 1896, and it was realized almost immediately that radiation had an
effect on man. The first cancer caused by radiation was observed in 1902. The first
experiment demonstrating the possibility of causing cancer in animals was carried out
in 1910. The mutagenic effect of X-rays has been known since 1925.
Thus, from the beginning of the century we have been aware of the biological effects of
ionizing radiation, ranging from the effects of doses of several thousands of rem
(6000-7000 rem) used for the treatment of cancer to those induced by the accumulation
of low doses. In view of the potential dangers of ionizing radiation, research on the
subject went on side by side with the rapid development in the use of ionizing radiation
in medicine (radiodiagnostics and radiotherapy). The first victims of ionizing radiation
were the very physicists and physicians who were studying the radiation and its effects.

The feelings of guilt and concern which Hiroshima and Nagasaki engendered among the
whole scientific community explain why since 1945 the effects of ionizing radiation on

Dr. Tubiana is Professor at the Faculty of Medicine Pans-Sud and Director of the Institute of Clinical
Radiology at the Institut National de laSante et de la Recherche Medicale (National Institute of
Health and Medical Research) (INSERM)

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man have been studied in even greater depth. Since then the sums spent on studying the
biological effects of ionizing radiation have run into thousands of millions of dollars.

It is paradoxical that the extent of these studies should have led to misgivings, but the
understandable fear is that their scope reflected the seriousness of the hazards. Moreover,
as the other methods of power generation (coal and oil) had been developed at a time
when less attention was paid to health risks and when some of these, such as mutagenic
or carcinogenic risks, were not known at all, there is a tendency to minimize the danger.
It is therefore understandable that as radiation risks were the first to be stressed and
quantified — by the very promoters of nuclear energy — attention should be focused
on them; so that ionizing radiation was until recently the easiest of all toxic agents to
detect, thanks to the high precision and extreme sensitivity of the detectors.

Owing to the early interest shown by radiobiologists in radiation protection and the efforts
made to quantify the risks and develop dosimetric methods, health experts are unanimous
in believing that radiation protection should serve as a model for all work aimed at
combating potentially harmful agents. The lead of radiotoxicologists over other health
experts is demonstrated by the fact that not until 50 years after the establishment of the
International Commission on Radiological Protection (ICRP) was a similar body setup
for carcinogenic and mutagenic chemicals.

Apart from experimental research, our present knowledge of the late effects of ionizing
radiation on man is derived from the study of populations exposed to known doses of
radiation — populations in which the consequences of exposure have been studied
scientifically. These groups include several tens of thousands of patients treated with
X-rays and radioisotopes for non-malignant diseases; several groups of workers (radium
dial painters, radiologists, uranium miners, etc.), and the 285000 survivors of Hiroshima
and Nagasaki who have been studied since 1945 by a team of 500 specialists established
jointly by Japan and the United States.

Many conferences and symposia have discussed these studies and several expert committees,
national and international, have analysed the whole gamut of information obtained in this
field. In particular, the 1977 report of the United Nations Scientific Committee on the
Effects of Atomic Radiation (UNSCEAR), a document of more than 700 pages, and the
reports of the United States National Academy of Sciences must be mentioned. Moreover,
in 1928 — a long time before the advent of nuclear power — groups of specialists,
radiologists, and physicists met to discuss the risks of ionizing radiation together with the
precautions to be taken to limit those risks and established the International Commission
on Radiological Protection, the first recommendations of which were published the same
year. Since then ICRP has regularly published its recommendations, made on the basis of
the most recent scientific data. These recommendations have always been accepted by
every country, and the role of the ICRP is universally recognized. In 1977 it published
its 26th report. A further point to be stressed is that all these expert groups arrived at
essentially the same conclusions and that, contrary to what is sometimes believed by
the public, there is little disagreement among experts on the nature and extent of the
biological effects caused by radiation.

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Table 1 . Main Sources of Irradiation in France

Sources: UNSCEAR 1977 and US National Academy of Sciences Report
(Washington 1980)

NATURAL IRRADIATION Average dose (mrem/yr) Variations in France

(Paris area)

Cosmic rays 30 100 at 2500 m altitude

Ground radioactivity 46 200 in granitic areas

Natural radioisotopes 24 200 in regions with
incorporated in the body high radioactivity
( * K , Ra, Th, etc.) in water

100 250 to 300 in Brittany,

Massif Central, etc.

MAN-MADE Average value reported

IRRADIATION for total population
(in mrem/yr)

Medical X-rays 1001 Considerable individual

variations depending on
age and frequency of
X-ray examinations

Dose due, in 1977, to

fall-out from nuclear tests
in the atmosphere (mainly
carried out in 1956-1962) 5

Air travel 0.1 Considerable individual

variations: as much as
250 to 500 for air crews

Nuclear power production Small variations depending

in 1976 (external irradiation on place of habitation,
sources and internal reaching 4 mrem for persons
contamination) 0.15 living in the vicinity
of a plant

This value was calculated in the USA In France, the figure is very probably similar according to
the data of the Central Service for Protection against Ionizing Radiations and the Ministry of Health.
The average value for the whole world population is 20 mrem/yr.

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Table 1 (cont.)

MAN-MADE Average value reported Variations in France

IRRADIATION for total population
(in mrem/yr)

Dose predicted for

the year 2000 2
Luminous dial watches 0.50 Up to 10 for persons who
regularly wear certain
types of luminous watch
Miscellaneous (phosphate
fertilizer, television,
coal burning, etc.) 1

TOTAL irradiation other

than medical or military

Doses to the Public and Workers

By virtue of being present on the earth's surface, everyone is exposed to cosmic rays
and to radiation emitted by natural radioactive bodies (radium and thorium): the
average annual dose is of the order of 100 mrem at sea level. However, this dose varies
considerably from one point to another on the earth. In France, for instance, it is of
the order of 100 mrem a year in the Paris region but attains values of 200—300 mrem in
high-altitude regions (Alps) or regions withgranitic soil. In several regions of the globe,
annual doses can reach 500 or 600 mrem.

Apart from this natural exposure, there are other sources of irradiation (see Table 1). The
most important source of human origin is the medical use of ionizing radiation, mainly
in radiodiagnostics, from which every inhabitant of the earth receives, on average, an
annual dose of the order of 20 mrem. However, in some countries like the United States
and France the average dose is as much as 50 or even 100 mrem a year.

What does nuclear power contribute in comparison? In 1976, according to the UNSCEAR
report, it accounted for 0.15 mrem per annum, which is lower than natural irradiation
by a factor of about 600. In other words, the annual dose from nuclear power was, on
average, about half a day's dose due to natural radioactivity. In France, the dose
attributable to nuclear power in 1976 was the equivalent of the excess dose which a
Parisian would receive during a half-day spent in Brittany or in the Massif Central.

For the year 2000 UNSCEAR quotes values between 2 and 4 mrem per annum if
60 per cent of the electricity generated comes from nuclear power. This includes doses
due to uranium mining and processing, reactor operation, nuclear waste and pollution of
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air, water and foods, with allowance for possible concentrations along the food chain
and the resulting fixation of radioactive substances in the human body. Thus, for a
Parisian, this would be tantamount to spending a week or two in the Massif Central
or Brittany.
Contrary to what has sometimes been said, no significant difference in the frequency of
cancers or genetic malformations has been detected between regions exposed to different
doses of natural radiation.
The doses which workers at nuclear power plants receive are known accurately in all
countries. For example. Table II refers to data taken from the latest report of the United
States National Academy of Sciences. The order of magnitude of the doses is close to that
of other countries, especially France As will be seen, these doses are, on average,
appreciably lower than the ICRP limit (5 rem/yr). It should further be noted that
exposure of workers and contamination of members of the Public due to fast breeder
reactors will be lower, for a given number of kilowatt-hours produced, than from
conventional thermal-neutron reactors.

Biological Effects of Low Doses

The first type of biological effect corresponds to the immediate or delayed effects on
irradiated tissue, e g. skin lesions, reduced fertility and sterility, cataracts and impeded
growth in subjects irradiated during childhood. When the doses are quite high (above a
threshold of a few hundred or thousand rad), these effects are observed in all irradiated
subjects and the seriousness increases with dose. Conversely, if the dose is low, no effect
is detectable, there is thus a threshold dose below which no effect is observed. This
varies with the effect and the volume of irradiated tissue; it is always higher than a few
tens of rem per annum.
In the case of two other types of biological effect, namely induction of cancer and genetic
mutations, the dose-effect relationship is quite different. What varies as a function of
dose is not the biological effect itself, which remains identical, regardless of dose, but
the probability of this effect. In other words, the percentage of irradiated subjects in
whom the effect is observed increases with dose but the effect does not vary.
For example, a cancer is always a cancer, whether it occurs spontaneously or is caused
by radiation, and there is no way of distinguishing one from the other. The only way
in which induction of cancers in irradiated subjects can be shown is to demonstrate that
they have a statistically higher frequency of cancers than a group of subjects of the same
age and sex who were not irradiated.
Genetic effects have the same probabilistic or, as the experts would say, stochastic
character, there being nothing to distinguish radiation-induced mutations from natural ones.
In these two cases, therefore, the concept of threshold is replaced by that of risk varying
with dose, very low for small doses and rising with dose.
While the first ICRP recommendations were based on the non-stochastic somatic effects
of radiation and on the existence of a threshold, from the early fifties onward greater
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attention was devoted to the carcinogenic potential of low doses It had become clear
by then that random effects without a threshold, i.e. carcmogenesis and mutagenesis,
were the risks which had to be considered as a priority following exposure to low doses
of radiation. Radiation protection experts therefore placed emphasis on the evaluation
of these risks.

This situation is not unique, for in numerous areas of industrial health and medicine the
same trend occured. Protection developed in the same way in the case of asbestos, for
example. Initially, asbestosis was regarded as the main hazard and the aim of industrial
medicine was to bring the exposure to asbestos dust to a level lower than that which
caused the disease. Later, when working conditions were better and workers no longer
suffered from asbestosis, they lived longer, and it was then found that they had a
slightly higher risk of lung and pleura cancers than the population in general. It was
therefore necessary to introduce protection measures taking into account the relationship
between the asbestos concentration in the air and the probability of the occurrence of cancer.
This evolution of radiation protection, from the original criterion of lesions which appear
in all irradiated subjects to a new criterion based on the probability of an extremely
serious risk that will ultimately affect only a very small proportion of irradiated subjects,
is thus a tendency frequently found in industrial medicine and is a consequence of the
improvement of general working conditions.

EVALUATION OF THE RISK OF CANCER

In quantifying the carcinogenic effects of radiation, we are helped by several studies on

populations of irradiated subjects, notably the prolonged and meticulous studies carried
out on the survivors of the atomic bomb. Of the 285 000 registered survivors at
Hiroshima and Nagasaki, 80 000 died a natural death between 1950 and 1978. It is
estimated that approximately 400 to 500 of these deaths were due to radiation-induced
cancer. Among the 1200 survivors who had received the highest doses (average dose of
330 rad, i.e. very close to the lethal dose when delivered to the whole body, which is
between 350 and 450 rad approximately), the increase in the frequency of leukaemia
between 1950 and 1974 was 1 per cent. Thus, there was undoubtedly a carcinogenic
effect but in absolute terms the number of survivors affected was relatively small and did
not appreciably change the overall survival rate of the population exposed to the
atomic bomb.

We should note in this connection that the studies on survivors did not reveal any particular
disease due to irradiation, apart from opacity of the eye lens and retarded development
of height and weight in children exposed when very young. In particular, no increase in
morbidity, acceleration in the process of aging or shortening of lifespan, apart from that
related directly to the higher frequency of cancers, was observed.

Nothing justifies us to say, as some do at times, that estimates based on the survivors are
erroneous because of high mortality during the first few years which left only the more
resistant subjects to survive longer.
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The dose received by each survivor was determined by the distance between his position
at the time of the explosion and the hypocentre. However, the radiation received by
the inhabitants of the two cities differed. The Hiroshima bomb was made of
uranium-235 and about a third of the irradiation was due to neutrons and the rest to
gamma-rays. Since the relative biological effectiveness (RBE) of neutrons is about 10,
80 per cent of the biological effect was due to neutrons. At Nagasaki, on the other hand,
the bomb, made of plutonium-239, was of a different design and released almost entirely
gamma-rays. This difference justifies separate analyses of the Hiroshima and Nagasaki
data, comparison of which provides direct information on the relative carcinogenic
effects of neutrons and photons on man.
In these two cities, the carcinogenic effect of radiation first manifested itself in an
increase in the number of leukaemia cases at the end of the forties. After passing through
a peak during the period from 1952 to 1970, the rate of leukaemia decreased consistantly
even while the frequency of radiation-induced solid tumours, mainly of the thyroid,
breasts and lungs, increased. The latent period between the time of exposure and the
appearance of cancer varied according to the nature of the tumour and the a(,e of the
subject at the time of exposure — for acute leukaemia it was 5—10 years in subjects
who were irradiated during childhood and 10—15 years in those irradiated as adults.
In the case of solid tumours, the latent period varied between 15 and 30 years and
could be even longer for cancers of the digestive tract.

It was further established that the carcinogenic effect varied as a function of age. For many
cancers the relative risk was higher in subjects exposed before the age of 20. The rate of
acute leukaemia was higher in subjects irradiated at an age less than 10 or above 50. As
for breast cancer, the relative risk was greatest in women between the ages of 10 and 19
at the time of irradiation.
Until 1975 leukaemia represented about a third of malignant tumours and accordingly
offered the best sample for a quantitative study of carcinogenic effects. At Nagasaki,
the frequency of leukaemia did not increase in subjects who had received less than
100 rad. It exceeded that observed in the non-irradiated group only in the group of
subjects who had received more than 100 rad. Above this dose, the frequency of
leukaemia rose with dose. The excess of leukaemia frequency observed in the Nagasaki
survivors corresponds to an induction rate of about 20—30 cases of leukaemia per
10000 subjects who had received 100 rad. In the Hiroshima survivors the induction
rate seems higher; there appears to be no threshold and the frequency is already
enhanced in subjects who had received more than a few tens of rad

Let us now consider the second source of information, namely subjects who have received
radiation treatment for a non-malignant disease. One of the diseases for which patients
have been most frequently irradiated is a specific form of rheumatism — ankylosing
spondylarthritis. In Great Britain a study was conducted on about 20000 subjects who
had been treated by radiotherapy for this disease with doses of some hundred rads. No
effect was observed in those who had received less than 300 rad, whereas in subjects
who had received higher doses the frequency increased with dose. The number of
leukaemia cases observed in the patients was about ten times greater than would have
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been expected, given the age and sex of the persons irradiated. Apart from this increase
in leukaemia, various other cancers showed a rise which was much smaller although
statistically significant. There was likewise an excess of laukaemia or cancer cases in
different groups of patients treated for other non-malignant diseases, while none was
observed in other studies on various diseases (cervical cancers treated by radium,
hyperthyroidism treated by radioactive iodine and so on).
A third source of information is the observation of subjects who were subjected to
irradiation for occupational reasons. Only one example of these should be cited here,
namely radiologists, they undoubtedly form the group of workers who have received the
highest doses. A study of those who practised between 1920 and 1939 — a period
when the hazards of ionizing radiations were still not very well known and precautions
such as those used today were not taken — shows that the frequency of leukaemia
among them was 10 times greater than that found in physicians who did not use
radiation, such as ear, nose and throat specialists; the frequency among general
practitioners who frequently used X-rays was intermediate.
It is interesting to note that among radiologists who practised after 1946, i.e. at a time
when the effects of ionizing radiation were better known, no increase in the frequency
of leukaemia was observed, undoubtedly because doctors and pracitioners, as generally
all workers exposed to ionizing radiation, complied with the ICRP standards. This
shows the importance and effectiveness of those recommendations.
On the whole, the numerical data from these different studies agree satisfactorily. In the
three cases we observe that the incidences are close to one another if we express the
results per 10 000 persons irradiated with 100 rem or per million persons irradiated with
1 rem, which is quantitatively the same thing. Let us note that the latter form of
expression is artificial, because no effect was observed in subjects who had received less
than 100 rem; nevertheless this is the presentation used most frequently in international
reports for reasons of simplicity. Thus, for example, for 10000 subjects who have
received 100 rem we should see about 30 cases of leukaemia, if we judge from the
observations on the Hiroshima and Nagasaki survivors. Judging from the observations
on ankylosing spondylarthritis patients we should observe only 12, but in this case
only 40% of the haematopoietic tissue, i.e. bone marrow, was irradiated. With allowance
for the percentage of irradiated bone marrow, we find for whole-body irradiation nearly
the same figure as in the Hiroshima and Nagasaki survivors. Lastly, in the case of
radiologists, it is much more difficult to evaluate the leukaemia-inducing effect because
it is not known what doses they received. In attempting to evaluate their doses, we
can take into account the apparatus used, the number of X-ray examinations per day,
the duration of practice, and so on. We thus arrive at estimates lying between 400 and
2000 rad. If the upper limit of this range is taken as the basis for calculation, the
figure would be 10 cases per million and per rad. If the lower limit is taken as the basis,
we would get 50 cases per million and per rad. Well within this range lies the figure of
30 cases per million and per rad observed at Hiroshima and Nagasaki and in patients
treated for ankylosing spondylarthritis, for whom the dose evaluation is more accurate.
The data as a whole are thus consistent and suggest that chronic irradiation may be nearly
as effective in causing leukaemia as irradiation for a shorter time.
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We have so far considered only leukaemia because this is the most frequently observed
form of cancer in irradiated subjects. Needless to say, other cancers, too, have been
studied with equal attention. For example, at Nagasaki no significant increase was found
in the frequency of other cancers at doses below 100 rad, whereas above 100 rad the
increase was statistically significant.
The susceptibility of different tissues or organs to radiation-induced cancer is highly
variable. For some tissues doses have to be very high - several thousand rad — to
cause cancers in 1 per cent of the irradiated subjects, while for others the same effect is
obtained with doses ten times smaller. The most radiation-sensitive tissues include,
in particular, the thyroid, breasts, lungs and bone marrow. For all these cancers, different
studies have provided estimates which appear to agree with one another to within the
limits of accuracy of each study. Several studies have compared the frequency of all
tumours as against that of leukaemia alone and found the ratios to vary between 3 and 5.
Knowing that the risk of leukaemia is about 2 per thousand for 100 rem, the total risk
of cancer should be of the order of 1 per cent for 100 rem. This estimate agrees quite
satisfactorily with that obtained by adding the risks for each tissue, and this is the
evaluation arrived at in the reports of UNSCEAR and ICRP.
However — and we have to come back to this question, for it is basic — these
evaluations are based on X- or gamma-ray doses above a hundred rem. A hundred rem
is already a very high dose, much higher than may be received by workers occupationally
exposed to radiations. Where lower doses are concerned, even if the possibility of an
effect cannot be ruled out, there are no data which can be used to estimate the magnitude
of the risk, because it is too low to be estimated directly. Although some results suggest
that moderate doses of X-rays — a few tens of rads — can cause cancer, they cannot
be relied upon for evaluation of the frequency of induction following such doses in view
of the large statistical uncertaingy associated with the data relating to these levels
of irradiation.

Some studies have claimed to observe an increase in the incidence of leukaemia and/or
other malignant tumours in adults who have received low doses occupationally or from
radiological examinations. The best known of these is the study by Mancuso, Stewart
and Kneale.
These authors analysed the causes of death among 2184 workers exposed to radiation
and 1336 non-exposed workers at the Hanford nuclear plant in the United States of
America, concluding that those who died from cancer had received higher doses than the
other workers. From this they deduced that the carcinogenic risk associated with
radiation was greater than had previously been thought. A second analysis based on
4033 deaths, although producing smaller differences, seemed in their opinion to confirm
the first study. However, other research workers using the same data on the mortality
of workers at Hanford arrived at completely different conclusions. The study by
Mancuso and co-workers has also been criticized from the statistical point of view by
many authors and committees of experts, who considered in particular that the
differences reported for some cancers were probably due to statistical fluctuations
caused by the use of too small a population sample. This error was compounded by
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splitting the instances of cancer into too large a number of sub-divisions. If variations
in the incidence of cancer in a large number of small populations are sought, then it is
not surprising that for some of these and for some cancers a statistical difference may
be observed which appears significant but in reality is meaningless.

It seems improbable today that this type of study will produce any insights into the
effects of low doses of radiation. Further, calculations in the UNSCEAR report show
that unless the present estimates of the total cancer induction rate are substantially in
error, it would require studies covering some millions of man-years on workers exposed
to annual average whole-body doses of more than 1 rad to assess directly the cancer risk
associated with such doses. There is thus little hope of obtaining reliable data on the
effects of low doses in the near future.

Evaluation of the Low-Level Dose Risk and the Dose-Effect Relationship

To evaluate the risk from doses to which workers or the population are exposed, a very
large extrapolation has to be made as the risk being assessed is that from doses
approximately 100 or 10 000 times lower than those for which reliable data are available.
An extrapolation of this magnitude requires accurate knowledge of the shape of the
function which links dose and effect.

The most pessimistic theory - the one which predicts the greatest number of cancers —
is the linear relationship with no threshold. This assumes that if a dose of 200 rem
delivered to 10 000 people produces 200 cancers, then a dose of 1 rem to 10 000 people
will produce one cancer. A relationship of this type is rarely observed in pharmacology.
For most medicines or toxic substances (e.g. alcohol), the effect of low doses is
proportionally very small or non-existent. The probability therefore is that this
relationship overestimates the actual risk. However, there are other theories on the
dose-effect relationship which are plausible and various sources of information can be
used to determine which of them is the most appropriate.
The first consists in analysing data on human beings. In the case of the Nagasaki survivors
exposed to a mean dose of 350 rad, the probability of radio-leucosis is 35 per million
per rad. If the dose-effect relationship were linear, the probability per rad should remain
the same for people exposed to 100 rad. The effect per rad is in fact almost halved,
which means that between 100 and 350 rad the relationship is definitely not linear.
This reduction of the effect as a function of dose suggests strongly though not
conclusively that the dose-effect relationship in Nagasaki survivors is not linear but
rather a power function (of the type y = bx n ). For doses less than 100 rad no increase in
the incidence of leukaemia has been noted, the incidence observed actually being slightly
lower than normal although this difference is not statistically significant. It should be
pointed out, however, that although a linear relationship fits the data less well, it cannot
be entirely excluded.

On the other hand, in the case of people irradiated at Hiroshima in whom the leukemogenic
effect is due to neutrons, the dose-effect relationship seems to be linear — in other words,
the leukaemia incidence is proportional to the neutron dose.
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This difference between the forms of the dose-effect relationship for X-rays and neutrons
is consistent with experimentally observed effects on cells and with theoretical predictions.
Without going into details, the effect is proportional to the dose in the case of densely
ionizing particles such as neutrons, because there is a very high probability that a single
particle will create serious lesions in the nucleus of a cell (rupture of the two chains of
the desoxyribonucleic acid (DNA) molecule). In this case, an effect proportional to the
dose is expected — that is, a linear relationship (N = aD).
However, in the case of weakly ionizing particles such as X- or gamma rays, energy
transfers are much smaller and the lesions caused by the passage of each particle are much
less serious and much easier to repair, except when two or more particles pass almost
simultaneously through the same region of the cell nucleus (the breaking of the two chains
of the DNA molecule usually requires the joint action of two particles). The probability
that two particles will pass through the same volume is proportional to the square of
the dose (0D2).

For most human cancers, a linear relationship seems statistically unlikely and appears to
overestimate the effect of low doses. However, some data on human beings, particularly
on thyroid and breast cancers, are equally compatible with a quadratic or a linear
relationship, thus making it impossible to exclude either of these types of dose-effect curve.

What information can we expect to gam from experimental research to help us to choose
the correct dose-effect relationship?
It is generally accepted that the induction of a tumour is the final outcome of a succession
of separate events. The study of cancer induced by chemical products shows that at
least two separate stages can be distinguished: initiation and promotion. Initiation is
a fast, irreversible process which confers neoplastic characteristics on a normal cell.
Promotion is the process whereby a transformed cell gives rise to a tumour capable of
growing and invading neighbouring tissues. The promoters are usually agents which
stimulate cell proliferation. Initiation is probably associated with a lesion in the genetic
material, and some data suggest that for this transformation a linear relationship for
low doses of X- or gamma-rays would overestimate the effect. However, "transformation"
and "carcmogenesis" cannot be equated, particularly as the "initiated" or "transformed"
cell may remain in a "dormant" state without proliferation indefinitely.

The difficulties associated with the transformation from cellular initiation to cancer as
such are underlined by the considerable variations in cancer induction depending on the
tissues concerned, following total irradiation in which all cells have received the same
dose. Thus, the incidence of cancer is relatively high in the thyroid and breast and very
low or virtually zero in the prostate and testicle, but the reason for these differences
remains unknown. Moreover, very appreciable differences are observed in a given tissue,
depending on age; in the case of women, for example, the susceptibility of the breast to
radiocarcinogenesis is relatively high between the ages of 15 and 20, but very low before
puberty and in adult and elderly women.

The appearance of tumours following irradiation has been the subject of extensive study
in animals. For tumours following exposure to X-rays, the effect per unit of absorbed
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dose decreases with the dose rate; this is not true for heavy particle irradiation. For most
tumours observed in animals (leukaemias, kidney, skin and lung tumours), data on
carcinogenesis due to low X-ray doses can be represented by a quadratic polynomial
or by a linear dose-effect curve with a threshold or quasi-threshold, whereas cancer
induction by heavy particles is better represented by a linear dose-effect relationship.
In some cases the incidence of tumours actually decreases at low doses, while in one
instance (mammary neoplasia in the Sprague-Dawley rat) a linear no-threshold curve
was obtained after exposure to X-rays. These differences in the mathematical form
of the dose-effect relationship are not surprising in view of the diversity and complexity
of carcinogenic processes.

Radiation protection is concerned with the effect of low doses delivered over long periods.
Ideally, therefore, one should not just estimate the effect of low doses on the basis of that
observed for high doses: one should also take into account the fact that the dose rate
is much lower. All experimental data suggest that when a given radiation dose is spread
over a longer period of time its effect is reduced — for example, the mutagenic effect
of radiation at low dose rate is three times less than at a high rate. This is also true of
most other toxic agents (the effect of drinking a litre of alcohol in an hour is not the
same as drinking it over a month). Nonetheless, this factor is deliberately disregarded
and, for radiation protection purposes, the risks associated with low rates are considered
to be the same as those associated with high rates.

To sum up, although extensive data exist which allow us satisfactorily to assess the risk
to man posed by high doses and dose rates, they do not allow definitive conclusions
regarding the form of the dose-effect relationship for carcinogenesis in man nor regarding
the effect of low X-ray doses. Theoretical analyses and data obtained from simple or
animal systems suggest that for X- or gamma-rays a relationship of the linear type
overestimates the effect of low doses, and all information concurs to suggest that for
doses of the order of a few rads the real risk is probably 4—10 times lower than that
predicted by the linear extrapolation. The risk is probably still lower for smaller doses
and low dose rates.

However, in any evaluation of a harmful effect it is preferable to overestimate than

underestimate the risk. It is probable therefore that a linear no-threshold relationship
will continue to be used for some time in risk estimations.

GENETIC RISK EVALUATION

The human environment contains a large number of mutagenic agents which, when the
mutations affect the cells of the ovary or testicle, are capable of causing genetic damage.
Radiation was the first of these to be discovered and is the best known, but there are
other agents — molecules produced during the burning of coal, oil and tobacco are
mutagenic, for example. The most recent data suggest that the genetic risk to man from
radiation is smaller than had previously been thought. The most important fact in this
respect is that the Hiroshima and Nagasaki studies revealed no abnormal genetic effect;
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the data obtained on the frequency of congenital defects, morphology and life expectancy
have shown no discernible effects in the descendents of Hiroshima and Nagasaki survivors
by comparison with the children of parents who had not been irradiated. In studies
on animals, more than 100 generations of mice have been exposed to 200 rads per
generation without it being possible to detect any adverse effect on the viability or
fertility of their descendents. The results of these intensive radiation studies are
thus reassuring.

However, this does not mean that radiation has no genetic effect. The absence of
deleterious effects in individuals suggests rather that the body's safeguard mechanisms
eliminate most embryos with serious genetic defects right at the beginning of pregnancy.
This mechanism is not, however, taken into account in genetic risk evaluations, which
are based on a large number of studies measuring the frequency, per unit of dose, of
various types of genetic mutations induced in mice and insects, in particular the fruit fly,
or drosophila. Comparison with recent studies on cultured human cells suggests that
at the cellular level the dose-effect relationship takes the same form in all species.

UNSCEAR, ICRP and BEIR recently carried out independent reviews of the huge volume
of data currently available on genetic effects, and their conclusions, although not
identical, confirm each other.
The UNSCEAR and the BEIR reviews estimate the number of induced defects at a little
under 200 in the descendants of a million subjects who received 1 rem. Of these, perhaps
a quarter or half are likely to be expressed in the first generation and the remainder in
the next 10—15 generations. The ICRP critical review reached similar conclusions for
all generations. If we consider the dangers to which an individual is exposed, the genetic
harm of greatest personal impact may be thought to be that of the risk of abnormalities
in children, grandchildren and great-grandchildren. The average risk would be 30—40 genetic
defects per million children following the exposure of their parents to 1 rem, or about
j of the figure obtained for the somatic risk of cancer. To put this risk in its proper
perspective it should be compared to the so-called natural incidence which is about
107 000 per million.

Further, when assessing the harm per man-rem distributed through a working population
aged 20-65, or among the population as a whole, it must be remembered that j of the
man-rem will have no harmful genetic consequences since they will affect individuals
who are going to have no more children in any case. Similarly, it should be pointed out
that the cancer risk for workers is overestimated because average induction rates are
used whereas it is known that the rates are higher for children and adolescents.

RISKS TO THE PUBLIC AND TO WORKERS

The maximum total risk, including both the carcinogenic risk and the genetic risk for
descendents, is 1.3 X 10" 4 per rem. It is thus easy to assess the maximum risk limit
knowing the doses received by the public from the UNSCEAR estimations and by workers
from direct measurements (Table 2). It should be noted firstly that this risk is relatively
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Table 2. Occupational Irradiation

(In the USA, from the National Academy of Sciences Report, Washington 1980)

Average dose
(mrem/yr)

200 000 occupational^ exposed to medical X-rays 300-350

(doctors and technicians)

200 000 occupationally exposed to dental X-rays 50—125

(dentists and technicians)

100 000 occupationally exposed medical personnel 260-540

handling radioisotopes
(doctors and technicians)

30 003 occupationally exposed in civilian nuclear 600—800

power plants and reactor installations

35 000 occupationally exposed in naval nuclear propulsion plants 130-330

(submarines etc )
100 000 occupationally exposed in research and development 130—330
(civilian research centres, universities etc.)

low even with very high, near-lethal doses. The excess in the number of cancers is
relatively small by comparison with that caused by other human activities; for example,
in the group of atomic bomb survivors who received the highest doses, it is equivalent
to the excess observed in Californian women treated with oestrogen for menopause
problems or, to give another example, the number of cancer deaths caused by radiation
in the Hiroshima and Nagasaki survivors is at least twenty times lower than the number
of cancer deaths in that population caused by the use of tobacco. It is, furthermore, the
very fact that the effect is so small which explains the difficulties involved in carrying out
a precise evaluation.

For a population dose of 2 mrem/yr in the year 2000, this would mean that in a
population equivalent to that of France (50 million inhabitants) the use of nuclear power
for electricity production would cause about 2—10 cancer deaths each year This figure
may seem large, but it should be emphasized that, on the one hand, it is calculated on
the basis of a deliberately pessimistic assumption and that the actual figure may be
lower or even zero, and, on the other hand, that this risk is small compared to the total
number of cancer deaths (about 120 000 annually in France, see Table 3) and that
cigarettes alone cause 20000 cancer deaths in France every year. The table gives an
indication of the mam causes of death in France and this allows us to compare radiation
risks with others.
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Table 3. Main Causes o' Death in France

Causes Number of deaths per annum Annual risk rate

(France) (per 106 persons)

Total death rate = 600 000 11 500

Traffic accidents s15000 285

Accidents in the home = 5000 = 100
Accidents on holiday =3600 180
Industrial accidents and
occupational illnesses ^2300 160
Fires =2100 40
Lightning =25 0.5
Electrocution S200 =4

Total cancers = 120000 2 300

Leukaemias =4 000 77
Tobacco =70000 1300
Alcohol =40000 750

The risk attached to other elements of everyday life can also be assessed in the same
way — take for example the carcinogenic effect of tobacco. Statistical data compiled
on several million people show that from three cigarettes a day (about 1000 cigarettes
a year) upwards there is a significant increase in the risk of lung cancer; if ten cigarettes
are smoked a day, this risk is increased by a factor of about 8 and, for 20 cigarettes a day,
by a factor of about 20. If we assume a linear relationship between the number of
cigarettes smoked and the effect, the risk from one cigarette smoked a day, or a year,
or in a lifetime can be assessed using a rule of three. Similar assessments can be made for
the risk of alcohol-induced cirrhosis or cancer of the oesophagus due to one gram of
alcohol, the risk of a fatal traffic accident per kilometre travelled and so on.

If we now compare these risks to those from irradiation (Table 4), we see that the risk
attached to one cigarette is equivalent to that from the radiation dose received by
workers during half a day of irradiation at the maximum permissible dose or from three
years of living in the vicinity of a nuclear plant.
If the risk is to be assessed objectively in the case of workers, it must be seen in the light
of other occupational risks.
Table 5, taken from Reissland, indicates the order of magnitude of the average reduction
in life expectancy which, under the most pessimistic hypotheses, would result from
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Table 4. Comparative Risks

The following incur a one in a million risk of death:

650 km air travel

100 km car travel

§• cigarette

1.5 minutes mountaineering

20 minutes of life at age 60

Use of oral contraceptive pills for 2y weeks

y bottle of wine
Exposure to 10 mrem ~2 day exposure at maximum permissible dose
(occupational)
or
living three years in the vicinity of a nuclear plant.

Based partly on Pochin.

Table 5. Average Reduction in Lifespan (in days) (New Scientist 13.9.79)

For one year of working For 35 years of

life (person aged 40) working life

Deep-sea fishing 31.9 923

Coal mining 3.6 103
Oil refinery 2.6 74
Railways 2.2 63
Construction 2.1 62
Industry (average value) 0.5 13.5
Occupational exposure to
radiation at 5 rem/yr 1.3 32
Occupational exposure to
radiation at 0.5 rem/yr 0.1

Based on Reissland.

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irradiation at the maximum permissible dose. It is comparable to that observed in

common occupations. Moreover, the average dose received by exposed workers is, as
experience has shown, on average ten times less than the permissible dose. The nuclear
industry is thus to be classed with moderate-risk occupations.

Finally, many papers (which are reviewed elsewhere and which have been presented at
several scientific meetings) have attempted to compare the risks to the population and
workers of the different methods of energy production. For the purposes of comparison
these risks must be related to the production of 1 MWe/yr by each system. It should be
pointed out, however, that the nuclear power industry suffers from a serious handicap
in these comparisons. Statistical data are available on the health effects of other systems
but since no health effects have ever been noted in the nuclear industry, the risk is
evaluated on the basis of theoretical considerations which, as has been seen, result in
an overestimation of the risk for the sake of caution. Moreover, risk estimation for
nuclear power includes the genetic risk for descendants; this is not the case in
traditional health methodology nor in the risk estimation applied to the other
systems.

It will no doubt be pointed out that while nuclear power risks may be minimal during
normal operation, they can soar if there is an accident. The answer to this is, firstly,
that the experience already acquired (several thousands of reactor years) shows that
accidents are rare and, secondly, that they are statistically predictable (see the Rasmussen
report among others). Most reports include in the health risk estimation those risks
caused by contamination from accidental releases (Windscale or Three Mile Island type)
and even the possibilities of a nuclear disaster. Even when these are taken into account
the risk to health presented by the nuclear power industry remains low in comparison
with the risks associated with other types of power production; nor does the nuclear
industry have a monopoly on accidents — they occur in all power systems. One need
only recall breaks in hydroelectric dams, accidents during the transport of oil or methane,
fires in refineries, accidents in coal mines and so on.

In sum, thanks to the extraordinary sensitivity and accuracy of measurement methods

and to the research carried out since the end of the 19th century, the risks from ionizing
radiation are undoubtedly among the best-known. They seem to be, relatively speaking,
very low in the vicinity of nuclear plants which have benefited from radiological
protection measures developed by radiologists to protect themselves and to protect those
who are ill. The health effects of accidents can be estimated and they seem to be low
as a result of the elaborate safety measures taken — lower than or comparable to the
risks from accidents in traditional industrial or hydroelectric plants. Paradoxically,
anxiety has been aroused precisely by the cautious attitude adopted and the extremely
sophisticated nature of the precautions taken as well as perhaps by the special
connotations which the word "atom" evokes in the minds of the public and even
some scientists.

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References

CROW, J F., "Can we assess genetic risks? ".

Proceedings of the Sixth Congress of Radiation Research (Ed. Tokada, et al.), Tokyo (1979) 70-8.
FINCH, C.S , "Hiroshima and Nagasaki", A review of 30 years of study
Proceedings of the Sixth Congress of Radiation Research (Ed Tokada, et al.), Tokyo (1979) 50-8
ICRP Report No.26, Recommendations of the International Commission on Radiological Protection,
Annals of the ICRP, Vol 1, No 3, Pergamon Press, Oxford (New York City, 1977)
United Nations Scientific Committee on the Effects of Atomic Radiation, 1977 Report to the General
Assembly, Sources and Effects of Ionizing Radiations, United Nations publication Sales No.E.77.IX.,
Vol 1 (New York, 1977) 1-725.
Collogue sur les nsques compares des differents modes de production d'energie (Paris, janvier 1980).

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