Radon: Implications for the Health Professional
Carol A. Romano
RN, MSN, CCRN Nurse Practitioner, Twin Valley Medical Center, Morgantown, Pennsylvania, and Staff Development Instructor for Coronary Care, Intensive Care, and Stepdown Units, Montgomery Hospital, Norristown, Pennsylvania
Radon is a colorless,odorless gas formed by radioactive decay of radium and uranium, which are naturally present in the earth’scrust. When concentrated indoors, this invisible gas becomes a potential health hazard. The Environmental Protection Agency estimates that up to 20,000 lung cancer deaths annually can be attributed to prolonged radon exposure. Radon is an important health issue that should be understood by all health care professionals.This paper discusses some of the important issues regarding radon, such as the incidences of lung cancer believed to be attributable to radon, the high-risk areas in the United States, federal safety guidelines,and public apathy. These issues and their impact on the health care required by professionals, especially nurse practitioners,are discussed.
A i r pollution has traditionally meant pollution of the outside air. Pollutants that pose the greatest threats outdoors are not necessarily the same ones that pose the biggest problems indoors. This article addresses reasons why the public has ignored radon as a serious health hazard in spite of the fact that it has been reported in the news since 1984. The role of health care professionals in bringing this issue to the public’s attention is discussed.
REVIEW OF THE LITERATURE Radon is a colorless, odorless gas resulting from radioactive decay of radium and uranium, which are naturally present in geologic formations in the earth’s crust. There are scattered areas across the United States that have high radon concentrations called hot spots (see Fig. 1 for a map of the hot spots in the United States).
~
~
~
~
Addrrs correspondence t o Carol A. Romano, RN, MSN, CCRN, 3 I8 Hucklrbrrry Lane, Warleysville, PA 19438.
24
T h e link between radon gas and health was first observed in the 1920swhen data showed a high incidence of lung cancer in miners (Radford, 1985; Seve, Kunz, & Placek, 1976; National Council o n Radiation Protection and Measurements, 1984, Report No. 78). T h e fact that radon can build u p to threatening levels from natural deposits under buildings first came to public notice in 1984. Radon is constantly being released into the air from radium decay in the soil, so it is present outdoors. In the absence of a cave, tunnel, or building to trap the radon, it is quickly diluted into the atmosphere, but it becomes a potential health hazard when concentrated indoors. This gas seeps readily through very small spaces, such as those between soil and rock. It enters buildings through small cracks or openings such as sewer pipes, sump pumps, wall floor joints, cracks in concrete, and hollow concrete blocks. Radon is also soluble in water and has been found in both ground and surface water. Astudy in Maine showed a significant correlation between lung cancer and high radon levels in well water (Hess, et al., 1980). While in the air, radon further degrades into a series of short-lived, radioactive, heavy metals called radon progeny. A decay product can adhere to the surface of dust particles and tobacco smoke and deposit readily
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
1 Shaded regions am
have the greatat chance of pmducin8 high radon levels and the largest number of high radon 2 This map should not b used
as the sole source for any radon predictions. This map cannot ha used to predict locations of high radon in specific l o u l i t i a or to identify individual homa with high radon levels. 3 Local variations, indudin8 soil permeability and housing characteristics, will strongly afT& indoor radon levels and any regional radon prediction. 4 This map is only p l s l l m i n y and will k modified as rasaamh pmgressea. 5 A r e u outsid. of shaded ~ l o u ma not from of risk Emm elevated indoor radon levels.
LEGEND E x l m d C o n m d l Glriarm WUMC RC€kS wrfn > 4 PPM U r d O l m GrmW Socks wm VanlMe C'oncmtrarumcd Uranium PhoSOl7dnltC RMkl
R x k s OI Sars Wh Ym k n o w n Hcvyed lmoaraamIM)I Airas
wn (camma occunrntes d
Newwdxe 01Pamoy
d Nure
u r m Resources
Auguu I 9 8 7
FIGURE 1. Radon hot spots. (Source: American Society of Testing Materials Standardization News, December 1988.)
along the respiratory tract where it decays within minutes emitting alpha radiation. The radiation dose delivered to the bronchial cells is the highest of any body tissue from natural radiation (Radford, 1985).The radiation of the bronchial epithelium represents the principal hazard of radon to man (National Council on Radiation Protection and Measurements, 1984, Report No. 77). The risk of lung cancer from exposure to alpha radiation is well documented (Radford, 1985; Thomas & McNeill, 1982). It is estimated that 25% or more of lung cancers among nonsmokers over the age of 60 and about 5% in smokers, may be attributed to exposure to radon in homes (Radford, 1985). Archer (1987) found significantly higher age-adjusted lung cancer rates
VOLUME 2, NUMBER 1 , JANUARY-MARCH, 1990
among residents of 16 counties within the Reading Prong (a known high-risk area located principally in Pennsylvania and New Jersey) than in those of 17 nearby control counties outside this area. This is the only current study available specific to a known high-risk area. However, the principal weaknesses of this study are the lack of information on cigarette smoking and the lack of actual radon measurements in homes. According to the Environmental Protection Agency (EPA), as many as 8 million homes in the United States may have radon levels above the recommended EPA level of 4 picocuries/liter (4 pCi/L)(Fortmann, 1988; Hanson, 1987). It is important to note that the 4 pCi/ L level is not a standard or even a health-based guideline. It is a level that can be achieved realistically in homes
25
TABLE 1. RADON RISK EVALUATION CHART
Estimated Number of Lung Cancer Deaths Due to Radon Exposure o u t of 1000 Comparable Risk
pCi/L
WL
200 100 20 4’
1 0.5 0.1 0.02
440-770 270-630 60-21 0 13-50
1
0.005
3-1 3
0.2
0.001
1-3
More than 60 times nonsmoker More than 20,000 chest x-rays/yr More than 1 pack/day smoker 365 chest x-rays/yr Nonsmoker risk of dying from lung cancer 20 chest x-rays/yr
Comparable Exposure Levels 1000 times average outdoor level 100 times average indoor level 100 times average outdoor level More than 10 times average outdoor level Average indoor level Average outdoor level
pCi/L= Picocuries per liter; WL = working level. *EPA recommended safety level. Source: United States Environmental Protection Agency and Centers for Disease Control.
after current radon reduction methods are implemented (Fortmann, 1988). Therefore, the EPA suggests that measures be taken to reduce radon when its level exceeds 4 pCi/L. Table 1 defines measurable radon levels with comparable risks. (Radon levels are given either in units of picocuries/liter or of working level. The normally accepted 4 pCi/L level is equivalent to 0.02 workmg level.) Another survey by this agency of 11,000 homes in seven states (Minnesota, Missouri, Pennsylvania, North Dakota, Arizona, Indiana and Massachusetts) found that 33% of the residences tested exceeded the agency’s recommended level of 4 pCi/L. Extrapolating from these and other studies, EPA officials further estimate that up to 200,000 homes nationwide have radon levels above 20 pCi/L. In terms of lung cancer risk, 20 pCi/L is comparable to smoking one to two packs of cigarettes a day (United States Environmental Protection Agency and Centers for Disease Control, 1986). Based on these data, the EPA estimates that between 5,000 and 20,000 lung cancer deaths per year in the United States might be due to radon exposure (Air Pollution, 1985; Nero, 1983). The accuracy of EPA estimates of lung cancer deaths is somewhat uncertain because the estimates are derived from a dose-response model of uncertain validity. That is, all estimates of lung cancer by radon are based on data from miners who have been occupationally exposed to radon (Hanson, 1987). The report by the Committee on the Biological Effects of Ionizing Radiations (1988) used similar statistical analysis incorporating cumulative dose, age, and time exposure to study the combined effects of cigarette smoking and radon exposure. Results of this report reveal that the lung cancer risk to smokers associated with exposure to radon progeny is substantially greater than the risk for nonsmokers. It is important to note that there are no studies that have determined the relationship between measured radon levels in homes and the incidence of lung cancer.
26
SIGNIFICANCE FOR THE HEALTH CARE PROFESSION The new awareness of this naturally occurring health threat has caused much confusion, frustration, and at times panic for the public (Wlazelek, 1986).The federal government has traditionally been the educator and policy maker in naturally occurring health threats of this nature. It is within the realm of health care professionals to join the federal government in educating the public. Accurate information and alternatives are essential to permit primary prevention and adequate health planning.
PUBLIC EDUCATION State and government agencies are the public’s primary resources for acquiring information on radon. The EPA has established a telephone information service to give advice about radon testing and contamination. The number is 1-800-SOS-RADON. The EPA Office of Air and radiation and state EPA Regional Offices have produced two free publications on radon specifically designed for public use. These booklets provide homeowners with information on the characteristics of radon, with respect to health risks, testing, and reduction methods. A separate publication is also available from these agencies listing companies known to be working in the field of radon reduction. On September 12, 1988, the EPA and the Surgeon General’s office urged, via the press and radio, that every U.S. home and apartment below the third floor be tested for radon (Monmaney, Hager, & Emerson, 1988). This is the first time the Government issued an official, national radon warning and recommendation. Of interest is the joint stand with the EPA by the Surgeon General. This initial acknowledgement of the dangers
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
of radon by the Surgeon General is the only official statement made to date. Congress became involved by passing a bill signed by former President Reagan on October 28, 1988. This legislation authorizes monies over a period of 3 years for state radon control programs, a national survey of radon in schools, a start-up of regional training centers for detection, the creation of 3 training centers at universities to conduct research on radon, and EPA monitoring of all child care centers for radon levels (Indoor Radon Abatement Act, 1988). The media have communicated this information to the public via newspaper, television, and radio advertisements. The official radon warning in September by the Surgeon General’s office should have alerted the public to the potential health hazards of radon.
as with radon, people prefer the government to mandate some response. Accurate testing for a n invisible substance can be difficult despite tamper-proof measurement technologies because the environment tested can easily be altered by unscrupulous property owners. A level of radon can be made falsely low by opening a window prior to or during measurement thereby diluting indoor air. Therefore, the EPA recommends that windows, basement crawl spaces, and doors (except for normal entrance and exit) remain closed throughout a building for 12 hours prior to and during measurement to ensure that radon concentrations stabilize (United States Environmental Protection Agency, 1986). Mandatory testing for radon, even if instituted, would be difficult to enforce with accuracy.
DISCUSSION OF THE ISSUE: PUBLIC APATHY
Radon is not just a health concern: i t has economic implications for the public. For most people, a home is their biggest investment. In the public’s eyes, a radon contaminated house, a home with radioactive gas in the air, has a stigma attached to it. Although there has been no report of a drop in property values in known high-risk areas, consumers as homeowners and buyers/ sellers of real estate are concerned. They are worried about financial ruin first and about health hazards second. This is not a new trend. It can be understood why the public believes, based on the problems with the nation’s beaches as well as numerous television documentaries, that businesses, hospitals and government have hidden, ignored, or lied about their contribution to environmental carcinogens or health hazards for the sake of financial liability. The dollar is a powerful force in today’s society, often taking precedence over ethical right and wrong or health. Detection devices are not expensive. They range in cost from $12 to $30. If radon reduction is warranted based on test results, remediation strategies can be as simple as a fan or as complicated and costly as installing ventilation systems, which can cost u p to $5,000. The EPA publication “Radon Reduction Techniques for Detached Houses” offers technical guidance to homeowners. At this time, there is no homeowner’s insurance to pay for remediation work to lower radon levels (Airand Energy Engineering Research Laboratory, 1986).
Last year the EPA ranked radon with outdoor air pollution as one of the most dangerous cancer risks in the environment (DeCoureyHinds, 1988).Last spring 2,000 respondents in a national poll by the Roper Organization ranked radon 27th out of a list of 28 hazards (DeCourey Hinds, 1988). A recent survey of homeowners in or near the Reading Prong conducted by Rutgers University revealed that 92% had not tested for radon. Of this sample, 42% of the respondents did not test because they believed radon was not a problem in their home (DeCourey Hinds, 1988). Clearly there is a discrepancy between government and public concern about the possible health effects of radon exposure. Understanding what has caused this gap could aid in improving communication between involved parties. Speculation regarding why the public has ignored government warnings of radon can be divided into two categories: social and economic.
RADON: A SOCIAL PERSPECTIVE Radon is naturally occurring. Therefore, there is no company, no enemy, to blame. When there is a villain responsible for a problem, communities become alarmed and demand action. This is evident with hazards such as toxic dumps, which receive far more attention than radon. One can speculate that people have trouble believing their homes are unsafe, especially when the dangerous substance is odorless and colorless. People by nature are reluctant to act unless they know the risk applies to them. They tend to be apathetic about dangers and optimistic that they do not have a problem in their home. Historically, when health risks are very complicated,
VOLUME 2, NUMBER 1, JANUARY-MARCH, 1990
RADON: AN ECONOMIC PERSPECTIVE
IMPLICATIONS FOR THE HEALTH CARE PROFESSION Radon is both an environmental and a health issue. Health care professionals have relayed their concerns to the public about the hazards of cigarette smoking, cholesterol rich diets, and other health issues, but have not promoted radon as a health issue. However,
27
concerned homeowners are beginning to question health care providers about the carcinogenic effects of radon exposure when levels are above the 4 pCi/L guideline (Hanson, 1987). The health care profession, nurse practitioners specifically,must become articulate about radon because the public wants accurate information about health risks. Government, media, and health professionals can give the facts, but it is the latter group that is familiar with public concerns regarding health hazards on a personal level. The role of health care providers should be to assist their clients in knowing the implications of iadon risk and to address their concerns. Primary care settings provide a perfect forum to relay accurate radon information to people, and even more important, a setting to monitor response to public concern. Nurse practitioners can initiate discussion of radon as a health issue by inquiring about radon testing as a part of routine history taking and by having literature on radon available. Consumers are more likely to trust their family health care provider than the newspaper, television, or local EPA official. People are more inclined to act on an issue when someone they trust and consider an expert discusses a concern with them. Professional nursing and medical organizations should provide their members with current information about the significance of high radon levels in homes and the possible health effects of those levels. These organizations should take a lead in arranging joint confeierices with the EPA on the issue of radon. More studies on radon are recommended. Among the subject5 suitable for investigation are the following: (a)
What is the correlation between measurable radon levels in homes and the incidence of lung cancer in smokers and nonsmokers? (b) Does radon have a role in the sporadic clusters of other cancers such as leukemia? (Council on Scientific Affairs, 1987). Studies such as these merit the support and financial backing of private and public agencies concerned about the health and well being of our population.
SUMMARY Radon, a naturally occurring radioactive gas, can accumulate to unsafe levels indoors and increase a person's risk of lung cancer. Despite a massive campaign by the government targeting homeowners, radon has not been a health issue to much of the public. Economic and social influences can deter a consumer from acknowledging this problem and its solutions. As part of their professional practice, nurse practitioners should provide knowledge of environmental factors that could influence the health of their clients. Informing the public and providing information based on research is a service that all health care professionals can provide. Increasing public awareness is the first step toward dealing with this issue. Radon may be one of the most manageable household pollutants. Detection is easy and inexpensive, and options are now available to reduce high concentrations to acceptable levels. Primary prevention through detection and reduction could decrease the risk of developing lung cancer and thus has both personal and economic values for the public.
References Air and Energy Engineering Research Laboratory. (1 986, June). Radon Reduction Techniques for Detached Houses. (EPA 62515-861 01 9). Research Triangle Park, NC, Author. Air pollution (1985, October). Environment Reporter; p, 1046. Archer, V. E. (1987). Association of lung cancer mortality with Precambrian granite. Archives of Environmental Health, 42(2), 87-91 Committee on the Biological Effects of Ionizing Radiations. (1988). Health risks of radon and other internally deposited alpha-emitters. Washington, DC: National Academy Press. Council on Scientific Affairs. (1 987). Radon in homes. Journal of the American Medical Association, 258(5), 668-672. DeCourey Hinds, M. (1988. September 24). Radon: Making the public pay attention. New York Times,p. 56. Fortmann. R. (1988). Radon in the indoor environment. American Society for Testing Materials, Standardization News, 16(12), 50-53. Hanson, B. (1987). EPA guidelines for indoor radon levels evokes response from nuclear medicine Journal of Nuclear Medicine, 28(7). 1087-1 094 Hess, C T , Nortan, S A, Brutsaert, W F , Casparius, R E, Coombs, E G & Hess, A L (1 980) Radon 222 in potable water supplies of New England New England Water Works Assm/at/on,94, 113-1 28 Indoor Radon Abatement Act of October 28, 1988 Public Law 100551,15 U S C 2601 Monmaney, T I Hager, M , & Emerson, T (1 988, September) The risk from radon Newsweek, p 69 National Council on Radiation Protection and Measurements (1984)
28
Exposures from the uranium series with emphasis on radon and its daughters. (NCRP Report No. 77). Bethesda, MD. National Council on Radiation Protection and Measurements. (1 984). Evaluation of occupationaland environmental exposures of radon and radon daughters in the United States. (NCRP Report No. 78). Bethesda, MD. Nero, A. V. (1983). Indoor radiation exposures from 222-Rn and its daughters: A view of the issue. Health Physics, 45, 277-288. Radford, E. P. (1 985). Potential health effects of indoor radon exposure. Environmental Health Perspectives, 62*281 -287. Seve, J., Kunz, E., & Placek, V. (1 976). Lung cancer in uranium miners and long-term exposure to radon daughter products. Health Physics$30, 433-437. Thomas, D. C. & McNeill, K. G. (1982). Risk estimates for the health effects of alpha radiation. Report to the Canadian Atomic Energy Control Board, Ottawa, Canada. United States Environmental Protection Agency. (1 986, April). lnterim Indoor Radon and Radon Decay Product Measurement Protocols. (EPA 520/1-86-04) Washington, DC: Office of Radiation Programs. United States Environmental Protection Agency and Centers for Disease Control. (1 986, August). A citizen'sguide toradon. Public health services, United States Department of Health and Human Services. (OPA-86-004). Wlazelek, A. (1986, October 28). If you're a worrier, radon can make stress worse. The Morning Call, p. 11-1 2.
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
Carol A. Romano
RN, MSN, CCRN Nurse Practitioner, Twin Valley Medical Center, Morgantown, Pennsylvania, and Staff Development Instructor for Coronary Care, Intensive Care, and Stepdown Units, Montgomery Hospital, Norristown, Pennsylvania
Radon is a colorless,odorless gas formed by radioactive decay of radium and uranium, which are naturally present in the earth’scrust. When concentrated indoors, this invisible gas becomes a potential health hazard. The Environmental Protection Agency estimates that up to 20,000 lung cancer deaths annually can be attributed to prolonged radon exposure. Radon is an important health issue that should be understood by all health care professionals.This paper discusses some of the important issues regarding radon, such as the incidences of lung cancer believed to be attributable to radon, the high-risk areas in the United States, federal safety guidelines,and public apathy. These issues and their impact on the health care required by professionals, especially nurse practitioners,are discussed.
A i r pollution has traditionally meant pollution of the outside air. Pollutants that pose the greatest threats outdoors are not necessarily the same ones that pose the biggest problems indoors. This article addresses reasons why the public has ignored radon as a serious health hazard in spite of the fact that it has been reported in the news since 1984. The role of health care professionals in bringing this issue to the public’s attention is discussed.
REVIEW OF THE LITERATURE Radon is a colorless, odorless gas resulting from radioactive decay of radium and uranium, which are naturally present in geologic formations in the earth’s crust. There are scattered areas across the United States that have high radon concentrations called hot spots (see Fig. 1 for a map of the hot spots in the United States).
~
~
~
~
Addrrs correspondence t o Carol A. Romano, RN, MSN, CCRN, 3 I8 Hucklrbrrry Lane, Warleysville, PA 19438.
24
T h e link between radon gas and health was first observed in the 1920swhen data showed a high incidence of lung cancer in miners (Radford, 1985; Seve, Kunz, & Placek, 1976; National Council o n Radiation Protection and Measurements, 1984, Report No. 78). T h e fact that radon can build u p to threatening levels from natural deposits under buildings first came to public notice in 1984. Radon is constantly being released into the air from radium decay in the soil, so it is present outdoors. In the absence of a cave, tunnel, or building to trap the radon, it is quickly diluted into the atmosphere, but it becomes a potential health hazard when concentrated indoors. This gas seeps readily through very small spaces, such as those between soil and rock. It enters buildings through small cracks or openings such as sewer pipes, sump pumps, wall floor joints, cracks in concrete, and hollow concrete blocks. Radon is also soluble in water and has been found in both ground and surface water. Astudy in Maine showed a significant correlation between lung cancer and high radon levels in well water (Hess, et al., 1980). While in the air, radon further degrades into a series of short-lived, radioactive, heavy metals called radon progeny. A decay product can adhere to the surface of dust particles and tobacco smoke and deposit readily
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
1 Shaded regions am
have the greatat chance of pmducin8 high radon levels and the largest number of high radon 2 This map should not b used
as the sole source for any radon predictions. This map cannot ha used to predict locations of high radon in specific l o u l i t i a or to identify individual homa with high radon levels. 3 Local variations, indudin8 soil permeability and housing characteristics, will strongly afT& indoor radon levels and any regional radon prediction. 4 This map is only p l s l l m i n y and will k modified as rasaamh pmgressea. 5 A r e u outsid. of shaded ~ l o u ma not from of risk Emm elevated indoor radon levels.
LEGEND E x l m d C o n m d l Glriarm WUMC RC€kS wrfn > 4 PPM U r d O l m GrmW Socks wm VanlMe C'oncmtrarumcd Uranium PhoSOl7dnltC RMkl
R x k s OI Sars Wh Ym k n o w n Hcvyed lmoaraamIM)I Airas
wn (camma occunrntes d
Newwdxe 01Pamoy
d Nure
u r m Resources
Auguu I 9 8 7
FIGURE 1. Radon hot spots. (Source: American Society of Testing Materials Standardization News, December 1988.)
along the respiratory tract where it decays within minutes emitting alpha radiation. The radiation dose delivered to the bronchial cells is the highest of any body tissue from natural radiation (Radford, 1985).The radiation of the bronchial epithelium represents the principal hazard of radon to man (National Council on Radiation Protection and Measurements, 1984, Report No. 77). The risk of lung cancer from exposure to alpha radiation is well documented (Radford, 1985; Thomas & McNeill, 1982). It is estimated that 25% or more of lung cancers among nonsmokers over the age of 60 and about 5% in smokers, may be attributed to exposure to radon in homes (Radford, 1985). Archer (1987) found significantly higher age-adjusted lung cancer rates
VOLUME 2, NUMBER 1 , JANUARY-MARCH, 1990
among residents of 16 counties within the Reading Prong (a known high-risk area located principally in Pennsylvania and New Jersey) than in those of 17 nearby control counties outside this area. This is the only current study available specific to a known high-risk area. However, the principal weaknesses of this study are the lack of information on cigarette smoking and the lack of actual radon measurements in homes. According to the Environmental Protection Agency (EPA), as many as 8 million homes in the United States may have radon levels above the recommended EPA level of 4 picocuries/liter (4 pCi/L)(Fortmann, 1988; Hanson, 1987). It is important to note that the 4 pCi/ L level is not a standard or even a health-based guideline. It is a level that can be achieved realistically in homes
25
TABLE 1. RADON RISK EVALUATION CHART
Estimated Number of Lung Cancer Deaths Due to Radon Exposure o u t of 1000 Comparable Risk
pCi/L
WL
200 100 20 4’
1 0.5 0.1 0.02
440-770 270-630 60-21 0 13-50
1
0.005
3-1 3
0.2
0.001
1-3
More than 60 times nonsmoker More than 20,000 chest x-rays/yr More than 1 pack/day smoker 365 chest x-rays/yr Nonsmoker risk of dying from lung cancer 20 chest x-rays/yr
Comparable Exposure Levels 1000 times average outdoor level 100 times average indoor level 100 times average outdoor level More than 10 times average outdoor level Average indoor level Average outdoor level
pCi/L= Picocuries per liter; WL = working level. *EPA recommended safety level. Source: United States Environmental Protection Agency and Centers for Disease Control.
after current radon reduction methods are implemented (Fortmann, 1988). Therefore, the EPA suggests that measures be taken to reduce radon when its level exceeds 4 pCi/L. Table 1 defines measurable radon levels with comparable risks. (Radon levels are given either in units of picocuries/liter or of working level. The normally accepted 4 pCi/L level is equivalent to 0.02 workmg level.) Another survey by this agency of 11,000 homes in seven states (Minnesota, Missouri, Pennsylvania, North Dakota, Arizona, Indiana and Massachusetts) found that 33% of the residences tested exceeded the agency’s recommended level of 4 pCi/L. Extrapolating from these and other studies, EPA officials further estimate that up to 200,000 homes nationwide have radon levels above 20 pCi/L. In terms of lung cancer risk, 20 pCi/L is comparable to smoking one to two packs of cigarettes a day (United States Environmental Protection Agency and Centers for Disease Control, 1986). Based on these data, the EPA estimates that between 5,000 and 20,000 lung cancer deaths per year in the United States might be due to radon exposure (Air Pollution, 1985; Nero, 1983). The accuracy of EPA estimates of lung cancer deaths is somewhat uncertain because the estimates are derived from a dose-response model of uncertain validity. That is, all estimates of lung cancer by radon are based on data from miners who have been occupationally exposed to radon (Hanson, 1987). The report by the Committee on the Biological Effects of Ionizing Radiations (1988) used similar statistical analysis incorporating cumulative dose, age, and time exposure to study the combined effects of cigarette smoking and radon exposure. Results of this report reveal that the lung cancer risk to smokers associated with exposure to radon progeny is substantially greater than the risk for nonsmokers. It is important to note that there are no studies that have determined the relationship between measured radon levels in homes and the incidence of lung cancer.
26
SIGNIFICANCE FOR THE HEALTH CARE PROFESSION The new awareness of this naturally occurring health threat has caused much confusion, frustration, and at times panic for the public (Wlazelek, 1986).The federal government has traditionally been the educator and policy maker in naturally occurring health threats of this nature. It is within the realm of health care professionals to join the federal government in educating the public. Accurate information and alternatives are essential to permit primary prevention and adequate health planning.
PUBLIC EDUCATION State and government agencies are the public’s primary resources for acquiring information on radon. The EPA has established a telephone information service to give advice about radon testing and contamination. The number is 1-800-SOS-RADON. The EPA Office of Air and radiation and state EPA Regional Offices have produced two free publications on radon specifically designed for public use. These booklets provide homeowners with information on the characteristics of radon, with respect to health risks, testing, and reduction methods. A separate publication is also available from these agencies listing companies known to be working in the field of radon reduction. On September 12, 1988, the EPA and the Surgeon General’s office urged, via the press and radio, that every U.S. home and apartment below the third floor be tested for radon (Monmaney, Hager, & Emerson, 1988). This is the first time the Government issued an official, national radon warning and recommendation. Of interest is the joint stand with the EPA by the Surgeon General. This initial acknowledgement of the dangers
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
of radon by the Surgeon General is the only official statement made to date. Congress became involved by passing a bill signed by former President Reagan on October 28, 1988. This legislation authorizes monies over a period of 3 years for state radon control programs, a national survey of radon in schools, a start-up of regional training centers for detection, the creation of 3 training centers at universities to conduct research on radon, and EPA monitoring of all child care centers for radon levels (Indoor Radon Abatement Act, 1988). The media have communicated this information to the public via newspaper, television, and radio advertisements. The official radon warning in September by the Surgeon General’s office should have alerted the public to the potential health hazards of radon.
as with radon, people prefer the government to mandate some response. Accurate testing for a n invisible substance can be difficult despite tamper-proof measurement technologies because the environment tested can easily be altered by unscrupulous property owners. A level of radon can be made falsely low by opening a window prior to or during measurement thereby diluting indoor air. Therefore, the EPA recommends that windows, basement crawl spaces, and doors (except for normal entrance and exit) remain closed throughout a building for 12 hours prior to and during measurement to ensure that radon concentrations stabilize (United States Environmental Protection Agency, 1986). Mandatory testing for radon, even if instituted, would be difficult to enforce with accuracy.
DISCUSSION OF THE ISSUE: PUBLIC APATHY
Radon is not just a health concern: i t has economic implications for the public. For most people, a home is their biggest investment. In the public’s eyes, a radon contaminated house, a home with radioactive gas in the air, has a stigma attached to it. Although there has been no report of a drop in property values in known high-risk areas, consumers as homeowners and buyers/ sellers of real estate are concerned. They are worried about financial ruin first and about health hazards second. This is not a new trend. It can be understood why the public believes, based on the problems with the nation’s beaches as well as numerous television documentaries, that businesses, hospitals and government have hidden, ignored, or lied about their contribution to environmental carcinogens or health hazards for the sake of financial liability. The dollar is a powerful force in today’s society, often taking precedence over ethical right and wrong or health. Detection devices are not expensive. They range in cost from $12 to $30. If radon reduction is warranted based on test results, remediation strategies can be as simple as a fan or as complicated and costly as installing ventilation systems, which can cost u p to $5,000. The EPA publication “Radon Reduction Techniques for Detached Houses” offers technical guidance to homeowners. At this time, there is no homeowner’s insurance to pay for remediation work to lower radon levels (Airand Energy Engineering Research Laboratory, 1986).
Last year the EPA ranked radon with outdoor air pollution as one of the most dangerous cancer risks in the environment (DeCoureyHinds, 1988).Last spring 2,000 respondents in a national poll by the Roper Organization ranked radon 27th out of a list of 28 hazards (DeCourey Hinds, 1988). A recent survey of homeowners in or near the Reading Prong conducted by Rutgers University revealed that 92% had not tested for radon. Of this sample, 42% of the respondents did not test because they believed radon was not a problem in their home (DeCourey Hinds, 1988). Clearly there is a discrepancy between government and public concern about the possible health effects of radon exposure. Understanding what has caused this gap could aid in improving communication between involved parties. Speculation regarding why the public has ignored government warnings of radon can be divided into two categories: social and economic.
RADON: A SOCIAL PERSPECTIVE Radon is naturally occurring. Therefore, there is no company, no enemy, to blame. When there is a villain responsible for a problem, communities become alarmed and demand action. This is evident with hazards such as toxic dumps, which receive far more attention than radon. One can speculate that people have trouble believing their homes are unsafe, especially when the dangerous substance is odorless and colorless. People by nature are reluctant to act unless they know the risk applies to them. They tend to be apathetic about dangers and optimistic that they do not have a problem in their home. Historically, when health risks are very complicated,
VOLUME 2, NUMBER 1, JANUARY-MARCH, 1990
RADON: AN ECONOMIC PERSPECTIVE
IMPLICATIONS FOR THE HEALTH CARE PROFESSION Radon is both an environmental and a health issue. Health care professionals have relayed their concerns to the public about the hazards of cigarette smoking, cholesterol rich diets, and other health issues, but have not promoted radon as a health issue. However,
27
concerned homeowners are beginning to question health care providers about the carcinogenic effects of radon exposure when levels are above the 4 pCi/L guideline (Hanson, 1987). The health care profession, nurse practitioners specifically,must become articulate about radon because the public wants accurate information about health risks. Government, media, and health professionals can give the facts, but it is the latter group that is familiar with public concerns regarding health hazards on a personal level. The role of health care providers should be to assist their clients in knowing the implications of iadon risk and to address their concerns. Primary care settings provide a perfect forum to relay accurate radon information to people, and even more important, a setting to monitor response to public concern. Nurse practitioners can initiate discussion of radon as a health issue by inquiring about radon testing as a part of routine history taking and by having literature on radon available. Consumers are more likely to trust their family health care provider than the newspaper, television, or local EPA official. People are more inclined to act on an issue when someone they trust and consider an expert discusses a concern with them. Professional nursing and medical organizations should provide their members with current information about the significance of high radon levels in homes and the possible health effects of those levels. These organizations should take a lead in arranging joint confeierices with the EPA on the issue of radon. More studies on radon are recommended. Among the subject5 suitable for investigation are the following: (a)
What is the correlation between measurable radon levels in homes and the incidence of lung cancer in smokers and nonsmokers? (b) Does radon have a role in the sporadic clusters of other cancers such as leukemia? (Council on Scientific Affairs, 1987). Studies such as these merit the support and financial backing of private and public agencies concerned about the health and well being of our population.
SUMMARY Radon, a naturally occurring radioactive gas, can accumulate to unsafe levels indoors and increase a person's risk of lung cancer. Despite a massive campaign by the government targeting homeowners, radon has not been a health issue to much of the public. Economic and social influences can deter a consumer from acknowledging this problem and its solutions. As part of their professional practice, nurse practitioners should provide knowledge of environmental factors that could influence the health of their clients. Informing the public and providing information based on research is a service that all health care professionals can provide. Increasing public awareness is the first step toward dealing with this issue. Radon may be one of the most manageable household pollutants. Detection is easy and inexpensive, and options are now available to reduce high concentrations to acceptable levels. Primary prevention through detection and reduction could decrease the risk of developing lung cancer and thus has both personal and economic values for the public.
References Air and Energy Engineering Research Laboratory. (1 986, June). Radon Reduction Techniques for Detached Houses. (EPA 62515-861 01 9). Research Triangle Park, NC, Author. Air pollution (1985, October). Environment Reporter; p, 1046. Archer, V. E. (1987). Association of lung cancer mortality with Precambrian granite. Archives of Environmental Health, 42(2), 87-91 Committee on the Biological Effects of Ionizing Radiations. (1988). Health risks of radon and other internally deposited alpha-emitters. Washington, DC: National Academy Press. Council on Scientific Affairs. (1 987). Radon in homes. Journal of the American Medical Association, 258(5), 668-672. DeCourey Hinds, M. (1988. September 24). Radon: Making the public pay attention. New York Times,p. 56. Fortmann. R. (1988). Radon in the indoor environment. American Society for Testing Materials, Standardization News, 16(12), 50-53. Hanson, B. (1987). EPA guidelines for indoor radon levels evokes response from nuclear medicine Journal of Nuclear Medicine, 28(7). 1087-1 094 Hess, C T , Nortan, S A, Brutsaert, W F , Casparius, R E, Coombs, E G & Hess, A L (1 980) Radon 222 in potable water supplies of New England New England Water Works Assm/at/on,94, 113-1 28 Indoor Radon Abatement Act of October 28, 1988 Public Law 100551,15 U S C 2601 Monmaney, T I Hager, M , & Emerson, T (1 988, September) The risk from radon Newsweek, p 69 National Council on Radiation Protection and Measurements (1984)
28
Exposures from the uranium series with emphasis on radon and its daughters. (NCRP Report No. 77). Bethesda, MD. National Council on Radiation Protection and Measurements. (1 984). Evaluation of occupationaland environmental exposures of radon and radon daughters in the United States. (NCRP Report No. 78). Bethesda, MD. Nero, A. V. (1983). Indoor radiation exposures from 222-Rn and its daughters: A view of the issue. Health Physics, 45, 277-288. Radford, E. P. (1 985). Potential health effects of indoor radon exposure. Environmental Health Perspectives, 62*281 -287. Seve, J., Kunz, E., & Placek, V. (1 976). Lung cancer in uranium miners and long-term exposure to radon daughter products. Health Physics$30, 433-437. Thomas, D. C. & McNeill, K. G. (1982). Risk estimates for the health effects of alpha radiation. Report to the Canadian Atomic Energy Control Board, Ottawa, Canada. United States Environmental Protection Agency. (1 986, April). lnterim Indoor Radon and Radon Decay Product Measurement Protocols. (EPA 520/1-86-04) Washington, DC: Office of Radiation Programs. United States Environmental Protection Agency and Centers for Disease Control. (1 986, August). A citizen'sguide toradon. Public health services, United States Department of Health and Human Services. (OPA-86-004). Wlazelek, A. (1986, October 28). If you're a worrier, radon can make stress worse. The Morning Call, p. 11-1 2.
JOURNAL OF THE AMERICAN ACADEMY OF NURSE PRACTITIONERS
