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Friday, October 23, 2015

The Beautiful Blue Glow: the Goiânia Radiation Disaster

ᴛʜɪs ɪs ᴛʜᴇ  ғɪʀsᴛ ᴘᴏsᴛ ɪɴ ᴛʜᴇ ʀᴀᴅɪᴀᴛɪᴏɴ sᴇʀɪᴇs.

Everyone knows that radiation is dangerous and can kill us. We’ve all heard about the warnings that come from nuclear reactions: Hiroshima and Nagasaki, Chernobyl and Three Mile Island. We know today that our forefathers weren’t as wise.

Troops of the Battalion Combat Team, U.S. Army 11th Airborne Division, watch a nuclear blast on Yucca Flats as part of the exercise "Desert Rock I," November 1, 1951.
Troops of the Battalion Combat Team, U.S. Army 11th Airborne Division, watch a nuclear blast on Yucca Flats as part of the exercise "Desert Rock I," November 1, 1951.

We expect better from ourselves today. Considering human nature, this is folly. I’m going to tell you the stories you don’t know about humans and radiation.

Our first stop on our examination of the relationship between humans and radiation takes us to the city of Goiânia, Brazil, where one of the strangest and saddest radiation accidents in modern history unfolded in 1987.

The Source

The Instituto Goiano de Radioterapia was a radiotherapy clinic in Goiânia, Brazil. Radiotherapy is a cancer treatment in which a concentrated beam of radiation is targeted at the afflicted area. For this purpose, the IGR employed a cesium-137 based teletherapy machine.
In the radiation head, a container of radioactive cesium-137, 2 inches wide and 1.8 inches long, was housed in lead. The patient would lie on a table underneath the machine, exposing whatever cancer-stricken body part necessary. Once everyone was settled and safe, the aperture would be opened, firing its beam.

This particular machine, a Cesapan F-3000, is thought to have been made at none other than the Oak Ridge National Laboratory in the United States at some point in the seventies. It contained 93 grams of highly radioactive cesium chloride, which is a cesium salt containing the radioisotope cesium-137.
Radiation can be measured in many ways, and in this case, we're going to refer to it in Grays. The source was giving off 4.65 Gray per hour. For comparison, the accepted annual radiation dose for non-nuclear workers in the US is .001 to .005 Gy.

Instant radiation death takes place at about 50 Gy. 30 Gy will kill you overnight; anywhere from 8-30Gy will kill you in 24 hours to 2 weeks, with symptoms including nausea, vomiting, diarrhea, headache, fever, cognitive impairment, and shock. Less dramatic doses, around 5 Gy, will produce what is probably the most common image of radiation poisoning: a long, slow sickness.The body suffers “cell preproductive death”: our body’s cells are constantly in flux, dying and producing new cells to replace them; the danger is when cells fail to produce new generations of cells to replace them as they naturally die. This is not what will kill you; it is a resistance to infection, caused by the lack of white blood cells. This is called leucopenia. If you survive initially and avoid infection (which may kill you in about 4-6 weeks), you are very likely to develop cancer, especially leukemia, in around 10-20 years, and any children you have will have a high probably of genetic mutations.

The Abandonment

The Cesapan machine had been purchased in 1977, but it was now 1985 and IGR had expanded since then, and was moving to a new facility. The clinic packed up and moved out, then had to deal with the machines – as one would hope, it is not easy to move machines with radioactive materials. One was moved, but the cesium machine stayed.

The abandoned clinic was then lodged in legal warfare.
The abandoned IGR clinic.
The abandoned IGR clinic.

IGR and the St. Vincent de Paul Conference, the owners of the site, were still in court in September 1986, when the Court of Goiás stated it had knowledge of the abandoned radiological material in the building.

What happened next is unclear. Despite my best efforts, there is very little information about this incident available online. Wikipedia cites a Portuguese newspaper, Jornal Opção, whose relevant articles appear to no longer be available online, and reports that on May 4th, 1987, the director of Ipsago, an insurance institute for civil servants, "used police force to prevent one of the owners of IGR, Carlos Figueiredo Bezerril, from removing the objects that were left behind." Bezerill then wisely warned the president of Ipsago, Lício Teixeira Borges, "that he should take responsibility 'for what would happen with the 'cesium bomb.'"

Instead of removing the ticking nuclear time bomb, the court instead appointed a security guard to patrol the abandoned clinic. Wikipedia reports, "Meanwhile, the owners of IGR wrote several letters to the National Commission for Nuclear Energy, warning them about the danger of keeping a teletherapy unit at an abandoned site, but they could not remove the equipment by themselves once a court order prevented them from doing so."

Despite this, the clinic winds up taking the full brunt of the blame in almost every account I've read of this story. The IAEA report does not go into detail about why the cesium machine was left abandoned, but claims that "CNEN [Comissão Nacional de Energia Nuclear; National Nuclear Energy Comission, the government agency responsible for Brazil's nuclear program] did not receive appropriate notifications of these changes in status [the abandonment of the clinic], as required under the terms of the institute's license." However, it notes, "the circumstances that led to the abandonment of the telepathy machine... have not been completely clarified. Moreover, at the time of writing they are the subject of legal proceedings." Despite the fact that it seems that the clinic owners' hands were tied by the Brazilian state of Goiás, the IAEA concludes, "Nothing can deflect from the fact that the professional and moral responsibility for the security of a radioactive source must lie with the person or persons licensed as responsible for it."

The Scavenging

On September 13, 1987, the security guard skipped work. Instead, the guard, Voudireinão da Silva, apparently used a sick day to see a cinema screening of Herbie Goes Bananas with his family.
Another view of the abandoned IGR clinic.
Another view of the abandoned IGR clinic.
I couldn't make this stuff up.

On that same day, two men, Roberto dos Santos Alves and Wagner Mota Pereira, snuck into the clinic. They were scavenging for scrap metal that they could sell to a junkyard. They found the teletherapy machine, and, thinking that medical equipment must be worth something, they loaded it into a wheelbarrow and carried it to Alves' home.

Between the 13th and the 18th, Alves worked on dismantling the machine beneath a mango tree in his yard, so they could sell the parts for scrap. On the 18th, stabbing the machine with a screwdriver, he managed to break the window of the aperture through which the radiation was released. A chalky, powdery substance spilled out. It was the radioactive cesium.

Thinking that this might be gunpowder, Alves attempted to light the powder.

I invite you to pause and think about that for a second.

Thankfully, for all involved (and the entire country of Brazil), he was unsuccessful.

Abandoning the project, Alves and Pereira sold the source assembly to junkyard owner Devair Alves Ferreira.

The Sickness

Removed from this lead encasement, the full radioactivity of the cesium began its work on the unshielded, unsuspecting humans.

The day of the 13th, both Alves and Pereira vomited. Over the next few days they grew increasingly ill, exhibiting vomiting, diarrhea and dizziness. Both assumed that this was due to food poisoning; when Pereira saw a doctor, he was informed that he had a food allergy and should “take it easy” for a week.

Pereira had also developed a burn on his hand, the exact size and shape of the window on the source capsule.

Yet no one was admitted to the hospital until the 23rd.
A skin lesion caused by radiation exposure at Goiânia.
A skin lesion caused by radiation exposure at Goiânia.

The Beautiful Glow

Ferreira purchased the machine on the 18th, and dumped it in a garage on his property. Later that night he was walking through the yard when he noticed a blue glow coming from under the door. He rushed into the garage and discovered that the beautiful blue glow was coming from the punctured capsule.

Awed by this sight, and thinking that the material must be highly valuable, if not supernatural, Ferreira brought the container into his house, intending to make a ring for his wife.

Over the next few days, the family invited their friends over to take a look at the beautiful material.

On September 21st, one of the friends managed to free several grains of the source material. These were shared among Ferreira’s family and friends, thus spreading the contamination throughout the community. That same day, Ferreiera’s wife, Gabriela Maria, began to fall ill. Once again, it was misdiagnosed as food poisoning.

Ferreria’s brother, Ivo, brought home the glowing dustlike flakes of the source material he’d scraped out of the container. He set these on the family table while they were eating a meal, and they were primarily handled by his daughter, six-year-old Leide, while she ate her dinner. Friends came to visit, and they rubbed the dust on their skin like body glitter, laughing and playing.
This is one rave you don't want to attend.
This is one rave you don't want to attend.

Gabriela Maria began to notice many people around her were falling ill at the same time, and started to put the pieces together. She is the heroine of the tale: her actions probably saved lives, and finally altered authorities to the danger in their midst.

The Plastic Bag

On September 28th, Gabriela and an employee from her husband’s company went to a rival junkyard which had been sold the remainder of the source material, collected it in a plastic bag, and traveled by bus to a hospital, the Vigilância Sanitária. The employee, identified only as G.S., carried the plastic bag on his shoulder, and set it on the floor during the bus ride. Everyone along her path was exposed to radiation – including the passengers on the bus, trapped in an enclosed space with the radioactive source for about an hour.

Once at the hospital, Gabriela presented Dr. Paulo Roberto Monteiro with the bag, telling him that it was “killing her family.” Another hero in this twisted tale, Dr. Monteiro quickly suspected the material as being radioactive - possibly from part of an X-ray machine - and isolated the material by placing it on a chair in a courtyard outside the facility. His quick response saved the casualties from further escalating. By this point, G.S. had a burn on his shoulder from where he had been carrying the plastic bag. Finally, finally, the authorities were contacted.
But it looks so innocent.
But it looks so innocent.

The Scintillation Counter

The doctors conferred, and contacted the state department, which sent a medical physicist to examine the mysterious package. The physicist (identified only as W.F. in the IAEA report) brought a Scintillation counter with him - similar to a Geiger counter, it is a device that measures ionizing radiation, borrowed from NUCLEBRAS, a government agency that works with Brazil's power plants. This device had a range of 0.03–30 microgray/hour. W.F. set off walking towards the hospital, and switched on the counter while he was still quite some distance away. The device immediately registered at the top of the scale, no matter which way he pointed it. Convinced the device was malfunctioning, W.F. returned to the NUCLEBRAS offices to retrieve another counter.

This time W.F. made it to Vigilância Sanitária, and of course, received the same results. In the meantime, the doctors had contacted the fire department. W.F. arrived just in time to dissuade the fire brigade from their initial response: removing the source material and throwing it in a river.

The Contamination

From then on, the incident was handled by the appropriate authorities. 130,000 people flooded the area hospitals, asking to be screened for radiation contamination. The city even held testing in their Olympic stadium. Using Geiger counters, 250 people were found to be contaminated, some with radiation residue still on their skin. Of these, 20 people showed signs of radiation poisoning and had to be hospitalized.

The following is a list of the key characters and the doses they received:

Roberto dos Santos Alves and Wagner Mota Pereira both survived. I cannot find a source for the amount of radiation they were exposed to, but it must have been considerable. Both suffered from vomiting and diarrhea and Pereira had a burn on his hand from handling the radiation head. The space under a mango tree in Alves' yard, where he had broken open the source, gave a dose rate of 1.1Gy, and the entire area was very contaminated. The building had to be demolished and the topsoil removed.
Demolishing one of the contaminated houses.
Demolishing one of the contaminated houses.

Devair Alves Ferreira
survived an incredible dose of 7.0 Gy and survived. The IAEA report notes that this may have been because "he spent more time out of the house and his exposure was fractionated." This happened in several cases where people survived considerable exposure. Fractionated exposure allows the body some time to heal from radiation sickness, instead of a continuous dosage.

G.S. had a significant radiation burn on his shoulder and received an estimated whole body dose of 3.0 Gy. He survived.

Dr. Paulo Roberto Monteiro received an estimated dose of 1.3 Gy and survived.

The Deaths

37-year-old Gabriela Maria Ferreira, who saved countless lives by reporting the incident to authorities, died of radiation sickness on October 23, 1987. She sustained a dose of 5.7 Gy. Her condition worsened as time went on, and she suffered internal bleeding in the limbs, eyes, and digestive tract, as well as hair loss.
Israel Baptista dos Santos and Admilson Alves de Souza were two of Ferreira's employees assigned to work on removing the source from its lead encasement. Dos Santos received a dose of 4.5 Gy and suffered serious respiratory and lymphatic complications, dying on October 27, 1987 at age 22. De Souza received a dose of 5.3 Gy and suffered lung damage, internal bleeding, and heart damage. He died October 18, 1987 at age 18. Their lung problems were likely from inhaling the dustlike particles of the radioactive source material that would have been dispersed in the air as they worked.
Leide das Neves Ferreira suffered a dose of 6.0 Gy. When an international team of medical professionals arrived to treat her, they found her shunned to an isolated room in the hospital because hospital staff were afraid to go near her, for fear of radiation contamination. Because she had actually physically consumed the source material, her symptoms were particularly nasty, including swelling and massive internal bleeding. She died on October 23, 1987.


The government's response to the disaster was adequate, but misinformation flourished, and the public was understandably terrified of the risk of contamination. The four bodies of the victims were buried in lead-lined coffins surrounded by tons of concrete. Maria Gabriela's coffin weighed over 1000lbs (500kg), and inside was a layer of lead half a centimeter thick. A window was opened in the front, allowing the family to look in and see Maria and say their good-byes. Little Leide's coffin was even heavier, because she was even more irradiated -- over 1500lbs (700kg). Her coffin did not have a window. After the coffins were lowered in graves already coated with a foot of concrete, it took 2 hours to fill the tombs with cement.

Even more terrible, to even get to the graveyard the families and bodies had to wade through a sea of protesters, frantically attempting to prevent the burial from taking place. They piled rocks in the roads and some even tried to fling themselves in the way of the convoy. The video below shows some of this dramatic footage. (The voice-over is in Portuguese, but I've already summarized everything they said above.)

Legal repercussions

As I said before, IGR takes the brunt of the blame. The three doctors who owned and ran the Instituto Goiano de Radioterapia were charged with criminal negligence; namely, that they left behind a machine containing deadly radioactive waste. The moral of the story is, of course, that you need to keep close track of your nuclear waste (a lesson we would all hope it wasn't necessary to learn - alas, such is not human nature). On the bright side, this is now a legal requirement in many countries, and handled by the government, not private authorities.

Wikipedia reports, "In 2000, CNEN, the National Nuclear Energy Commission, was ordered by the 8th Federal Court of Goiás to pay compensation of R$1.3 million and to guarantee medical and psychological treatment for the direct and indirect victims of the accident and their descendants down to the third generation." For various complicated reasons, the owners of IGR could not be found liable; one had to pay a fine for the derelict condition of the building.

The junkyard where Devair Ferreira and his family lived, as it appears today.
The junkyard where Devair Ferreira and his family lived, as it appears today.

What was the blue glow?

We don't really know. Typically, radioactive material does not glow. A chunk of plutonium just looks like a plain, boring lump of metal, even if it is radioactive enough to kill you overnight if you come within a yard of it. Radioactive materials do not glow green, the way they do in cartoons. They are depicted as such because most of the early radioactivity experiments (most famously, those of Marie Curie) were done with radium, which does glow green in the dark.

That said, this blue glow is not completely unheard of. The IAEA report notes that "the phenomenon of the blue glow was observed by individuals from ORNL and United States Department of Energy's Radiation Emergency Assistance Center/Training Site (REAC/TS) at Oak Ridge, USA," during an experiment in early 1988, and "Further study is in progress in OAk Ridge to determine the nature of this blue glow." (You will remember that the radiation source itself is thought to have been manufactured in Oak Ridge -- see how our story has come full circle!)

The glow is thought to be linked to Cerenkov radiation, which is difficult to summarize simply. It happens when a charged particle passes through a dielectric medium (usually water) faster than the speed of light in that medium. This causes the charged particles to polarize and switch back to their ground state, emitting radiation. Suffice to say: when you put radioactive things in water, it glows.

This phenomenon is demonstrated in the following video of a nuclear reactor "pulse" at the Nuclear Engineering Teaching Lab (NETL) at UT Austin. The caption of the video explains, "All the Control Rods are removed simultaneously allowing the nuclear reaction to proceed un-dampened, bringing the energy output of the reactor to 680 Megawatts in 50 milliseconds." The reactor is, you can see, sitting in a tub of water, causing the Cerenkov radiation.

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