'J'accuse.!': the continuous failure to address radiophobia and placing radiation in perspective

The title of this piece is deliberately provocative, reflecting upon the longstanding issue of radiophobia and the role played by a consistent failure by members of the radiation protection community in terms of placing radiation into proper perspective. In 1988, Nobel Prize laureate Rosalyn Yalow published an opinion piece in Medical Physics, charging the scientific community with failing to challenge exaggerated and unscientific claims regarding the health impacts of ionising radiation, and therefore contributing to 'radiation phobia' [1]. However, in the intervening 32 years following Yalow's article, there has been no discernible change in the approach to exaggerated or uncontextualised reports about radiation health effects from the radiation protection community. Therefore, following the tradition set by the great French naturalist writer Emile Zola, 'J'accuse' the radiation protection communities of having failed to uphold their moral and ethical obligations towards the general public in regard to low-dose radiation, and of allowing radiophobia to reign unchecked.

Radiophobia is by no means a new term, with its first known use in 1903 [2]—initially concerned with radios and radio waves—and acquired its association with ionising radiation in the late 1950s [3]. When comparing the anxiety, dread and emotive responses to radiation with the diagnostic criteria for different clinical phobias or other mental illnesses [4], it is evident that radiophobia is a misnomer. Nevertheless, radiophobia is a useful conceptual tool, which the author elsewhere defined as 'the socio-psychological and cultural relationship between individuals and ionizing radiation, characterised by a clear mismatch concerning the actual and perceived health effects of radiation exposure' [5]. After all, it is well-established that the general public's relationship with ionising radiation is complex, with a clear 'perception gap' between the risk perception of experts vis-à-vis the public, with the public consistently overestimating the risks of nuclear power and nuclear waste, whilst underrating other radiation risks [6–9].

This 'perception gap', and radiophobia, is fuelled by various mental processes—heuristics—which humans use to aid decision-making and to make sense of the surrounding environment. Most of the time, this decision-making relies on a 'system' which is automatic, involuntary, intuitive, nonverbal, narrative and experiential, using images, narratives and metaphors to encode our reality [10]. Images, both actual and recalled from memory, are cornerstones to both the conscious and subconscious mind [11] and play an important role in cognitive and perceptual-motor tasks [12]. Marks argues that our ability to create visual imagery is crucial 'whether it is the everyday problem-solving required for stability, safety, and survival at home, in the workplace, or in the community' [13]. Imagery, however, does not exist in a vacuum, and the intersection between emotions, affect and imagery (including symbolic and perceptual imagery) is crucial to decision making. The somatic marker hypothesis, argues that images acquire 'somatic markers', i.e. feelings—either positive or negative—which are linked to bodily reactions. In other words, when an image '...which defines a certain emotional response is juxta- posed to the images which describe a related scenario of future outcome, and which triggered the emotional response via the ventromedial linkage, the somato-sensory pattern marks the scenario as good or bad' [14]. Once judged, the images and their somatic markers are pooled, the intensity of these images' markers vary in strength, and are consulted when making a judgment [15]. This associative pool and its imagery '...come laden with associations in the form of feelings, e.g. attraction, calm, tranquility, fear, anger, or anticipation' [13] and upon subsequently encountering an image, different emotions would be triggered. A negative marker would, upon the encounter with a previously-known image, raise awareness and alarm, whereas an image with a positive marker would, conversely, act as an incentive [14, 16].

Radiation, especially within the context of nuclear power, have in many parts of the world acquired very powerful, and very negative, imagery. This imagery is partially linked to nuclear war, partially linked to cancers and the notion that radiation poses a threat to future generations, as well as the notion of nuclear accidents being catastrophic, high-fatality events [17]. This mental imagery has been reinforced by the fact that in the aftermath of nuclear accidents, be it Three Mile Island, Chernobyl or Fukushima, there has been claims about considerable numbers of fatalities due to radiation exposure [18–21]. These often rely on a discredited application of collective dose which calculates health detriments by multiplying very low doses (often in the microsievert range) with large populations, without accounting for uncertainties or background rates. These claims are often highly publicised and often presented without the appropriate context or perspective being offered to the audience. However, as a result of radiation's invisibility to the senses, the public is entirely reliant on the interpretations and the expertise of the scientific community—especially the radiation protection community [22]. The historic communication failures of the radiation protection community have given the impression that such alarmistic reports reflect the views of the broader scientific community. Given the importance of imagery and emotions, it is not surprising that nuclear power causes feelings of dread and anxiety—it would perhaps be more peculiar if people did not fear radiation.

The long-standing debate around potential health effects of low-dose radiation, has played a crucial role in reinforcing radiophobia. There are few areas of the natural sciences that are as well-researched and as well-understood as radiation, with the research into its health effects having been studied for more than 100 years. The debate surrounding the potential health detriments associated with low-dose radiation is one which has been ongoing for many decades [23–27], and it is unlikely epidemiological evidence about health effects at or below background doses and at low rates will be forthcoming in the near future. However, it is well-established that large doses of ionising radiation can be dangerous, equally, we know that exposure to radiation doses at or below background levels have very low impacts. Whereas the academic debate pertaining to the exact nature of the dose-response below 100 mSv will continue there are three sets of conclusions that the radiation protection community should be able to agree on:

• (a)  
  The health effects of the exposure to low-dose radiation, especially at low dose-rates, would be very small. Assuming that the linear no-threshold (LNT) model holds true down to background levels of dose, the ICRP risk factor applied to fatal cancer of 5% per Sv [28], implies a risk from annual exposure of around 0.015%, a very small addition to the overall risk of dying from cancer (28% of UK deaths) [29]. Any such risk would be lower than many risks routinely encountered by individuals, including lifestyle factors, such as obesity or smoking, and environmental factors, such as exposure to significant air pollution [30], many of which can be reduced by the application of nuclear technologies;
• (b)  
  There is no epidemiological evidence of heritable effects in humans due to irradiation of parental germ cells [31–38] although it is considered prudent to assume a very small risk at low doses and the ICRP [39] use a value that is less than 5% of the very low cancer risk (i.e. 0.0002% per mSv). Whilst there is evidence of cancer risks, including childhood cancers, as a result of irradiation in utero [39, 40], the risk estimates for low doses are very low and excesses are highly unlikely to be observable in populations exposed following nuclear accidents. Malformations following in utero exposures occur above dose thresholds and would not result from low doses received following nuclear accidents, despite claims to the contrary [19, 41–43];
• (c)  
  Collective dose assessments for calculating health impacts for the purposes of risk projections should be approached with great caution, especially at doses which are at or below background levels. Consideration of background rates and uncertainties will show that predictions of possible cancer cases at low doses without context will be meaningless and misleading [39, 44].

The connection between these three points and radiophobia? By not placing radiation risks into perspective, as is customary with other risk assessments, the perceived uniqueness of radiation risks remains, thanks to heuristics and socialisation. It is crucial that the community acknowledges—irrespective of one's view on the LNT debate—that radiation doses at or below background levels (and at low dose rates) would be very small. In order to ensure effective radiation protection, radiation risks must be assessed within a proper context and perspective, ensuring that a proper balance between risks and the many beneficial applications of nuclear technology. The basic idea of radiation protection is, after all, that reduction in radiation risks should do more good than harm, ensuring economic and social factors are taken into account [39]. However, this is not always the case, where the application of the As Low As Reasonably Achievable (ALARA) principle, where dose optimisation sometimes morphs into dose minimisation [45]. A pursual of a radiation minimisation-at-any-cost policy towards radiation protection undermines effective radiation protection and inevitably creates risks and unintended consequences elsewhere. It also has resulted in considerable fiscal resources being dedicated to reducing radiation doses. This is the result of a failure to challenge radiophobia, and a failure to place radiation within perspective, and has come with considerable detrimental consequences in terms of public health. This has been especially noticeable following nuclear accidents.

The negative psychosocial effects and associated health detriment following nuclear accidents are well-established. Stigmatisation of populations affected by radiation has been seen in the aftermath of all major radiological events, be it Hiroshima, Nagasaki, Chernobyl or Fukushima, where the affected population has been discriminated against due to perceived radiation contamination [6, 46, 47]. A range of different factors, such as the dread fear, cognitive links with nuclear weapons and cancers, and the uncertainty about potential health effects of radiation exposure have caused significant mental health issues in populations impacted by nuclear accidents [48, 49]. It has been found that '...the mental health impact of Chernobyl is the largest public health problem unleashed by the accident to date' [41]. Following Chernobyl, anxiety and stress were found 100% above controls, with the self-reporting of health issues being three to four times higher than controls. However, diagnoses of mental health conditions had not increased in the 20 years following the accident, pointing clearly towards a stress response amongst the patients, stemming from the effects of evacuation and (perceived) radiation exposure, as well as feelings of helplessness and overall fatalism [41, 50, 51]. Similar findings have been made following the Fukushima accident [52].

Following Chernobyl, there was an observed increase in induced abortions, due to anxieties stemming from the perceived risk that even minute doses of radiation might pose to the foetus, despite no evidence supporting such claims [42, 53]. This anxiety was clearly fuelled by the perception which the LNT model has resulted in, aided by assorted heuristics. Anecdotal evidence suggests significant anxiety amongst expectant mothers which, especially in the Eastern Bloc, resulted in elective abortions following the Chernobyl accident [54, 55]. However, due to methodological issues and uncertainties, it will be difficult to ascertain with any certainty the number of abortions across the world as a result of post-Chernobyl anxiety. It has been found that abortions did increase following the accident in e.g. Denmark [56], Italy [57] and Finland [58], with some estimates stating that between 10000 and 200 000 foetuses were aborted following receiving incorrect medical advice [59]. This phenomenon was not seen in all parts of Europe—for instance, there was no statistical increase in abortions in e.g. Sweden [60], Norway [61] or Hungary [62]. There were fears that a similar picture would emerge following the nuclear accident at Fukushima Daiichi; however, evidence so far suggests that this is not the case [63–65]. Nevertheless, the current perception of radiation risk causes considerable harm, harm which could be prevented if a normalisation of radiation risks were to be achieved. The risk perception of radiation also causes harm in the way governments may respond to nuclear accidents. Following the Fukushima accident, more people died (2259) as a result of 'disaster-related deaths', i.e. evacuation following the nuclear accident, than from the earthquake and tsunami itself (1829 reported deaths, some 20 000 across Japan) in Fukushima prefecture [66]. Analysis of four different response scenarios during the Fukushima accident, found that the risk (loss of life expectancy) posed by rapid evacuation (which took place) was significantly higher than the radiation risk, even in the high-exposure scenarios [67]. Indeed, Waddington and colleagues found in their analysis that the evacuation was unnecessary from a radiological viewpoint, and that other measures should have been taken instead, such as sheltering in place. Similarly, the same study concluded that the majority of evacuations following Chernobyl were unjustifiable on the grounds of radiological health benefit [68]. Whilst it is important to acknowledge that there will always be uncertainties during nuclear accidents, the harms of evacuation and relocation are well-established. However, these actions further highlight the failure to place radiation risks into proper perspective where actions taken to reduce radiation doses (however small), cause more harm than the risk posed by radiation.

A further example of unintended consequences of radiophobia is the issue of air pollution. Air pollution is a considerable public health issue, playing a major contributory role in the development of diseases such as lower respiratory infections, ischaemic heart disease, ischaemic stroke, haemorrhagic stroke, and chronic obstructive pulmonary disease [69]. The Global Burden of Diseases, Injuries, and Risk Factors Study 2015 ranked ambient and indoor air pollution as leading causes of global disease burden [69], and the World Health Organization has identified air pollution as one of the top three global risk factors causing illness and contribution to increase mortality [70]. The combustion of fossil fuels (especially coal) for electricity generation, cooking, and transport are significant contributors to particulate (PM_2.5) air pollution, and it has been estimated that these emissions caused 10.2 million premature deaths in 2012 [71]. Unlike coal-fired power plants, nuclear power emits virtually no air pollutants during operation [72]. Modelling suggests that the use of nuclear power has prevented approximately 1.84 million premature deaths related to air pollution, by way of displacing mostly coal as an electricity generator, and could—depending on the magnitude of nuclear deployment and the amount of fossil fuels it would replace—prevent further air pollution-related premature deaths by 2050 [73].

However, whilst there is ample evidence to suggest that air pollution have significant population health effects, the impacts on individuals are often small, with many confounding factors and associated uncertainties [74], not unlike chronic exposure to low-dose radiation. In the broader spirit of this paper, it would be equally pertinent to ensure that the potential risks of low levels of air pollution be put into perspective, with any remedial actions against air pollution accounting for uncertainties and, ultimately, doing more good than harm. Whilst there are uncertainties related to low levels of particulate air pollution, meta-analyses of the available cohort studies on PM_2.5 and mortality showcases a clear, statistically significant association between the two [75], and not undertaking measures to decrease especially the highest concentrations of air pollutants on the grounds of uncertainty would be unjustified [74]. From this perspective, it is clear that deployment of nuclear reactors would provide the greatest benefits from a public health perspective in regions with the highest levels of particulate air pollution (Asia, especially China and India, and the Middle East) [76], as well as in areas where increased access to electricity would likely depend on fuel sources with high particulate emissions (e.g. Sub-Saharan Africa).

The example of air pollution is instructive as it serves to highlight the importance of placing radiation risks into perspective, whereby any risks associated with the operation of nuclear power plants must be compared with the risks associated with other electricity generators. Looking at radiation risks in isolation (or any public health risks generally), whilst appropriate in some settings, is not appropriate in the realm of policy or public debate, as it only aids in reinforcing the notion of radiation as uniquely dangerous, and could hamper policy actions to counter activities that are associated with greater risk. Nuclear power can act as a response to air pollution, especially in areas currently suffering from high levels of air pollution (remedial action), and areas likely to suffer from high levels if current developments continue as a result of increased access to electricity (preventative action).

It is crucial that the radiation protection community places its work and research within the appropriate perspective and context, something that is far too rarely the case in discussions on radiation matters outside of the scientific community. A recent example of this is the controversy surrounding the radioactive water being stored at the Fukushima Daiichi site. Following the approval of the Japanese government (and a review by the International Atomic Energy Agency) to allow TEPCO to release the water into the ocean, Greenpeace published a report criticising the decision. The report claims that the release of the water, which contains small amounts of tritium and carbon-14, would pose a significant public health risk and that therefore the water could not be released into the ocean [77]. One passage in the report serves as a helpful illustrative point: '... carbon-14 is a major contributor to global human collective dose over time, and doses in an exposed population can be converted into the corresponding number of health effects. It is integrated in cellular components, such as proteins and nucleic acids, particularly in cellular DNA. The resulting DNA damage may lead to cell death or potentially inheritable mutations.' [77].

A quick survey of nine major news outlets from across the world that covered the issue [78–86] found that many of the outlets were running with headlines along the lines of 'Fukushima water release could damage DNA'. Given the extremely low radiation doses that the radioactive elements would theoretically result in, it is fair to say that any impact on DNA would be far below background radiation and could—de facto—be considered negligible. Nevertheless, the vast majority of the outlets in the sample did not attempt to contextualise these claims, and did not bring in radiation experts to provide a much-needed perspective. This only serves to reinforce already-held views on radiation by the public, as well as implicitly surrendering the duties of scientific interpretation to interest groups—in this case Greenpeace—a long-standing opponent to the use of nuclear power.

We must not forget that radiation protection is not a goal in itself, but is rather an integral part of activities which are associated with different benefits, be it the early discovery of potential cancers or the generation of low-carbon electricity by way of nuclear energy. Radiophobia harms people and poses a real threat to the long-term provisions of many of these activities, and we all have a responsibility to challenge it. Choosing not to speak up against the excessiveness that has come to define the public conversation surrounding radiation is a failure by the radiation protection community to exercise its professional duty of care towards the general public. This decision, whilst perhaps motivated by a fear of reprisals or becoming targeted by anti-nuclear groups, ensures the survival of radiophobia. Each member of the radiation protection community has an ethical, professional and moral obligation to set the record straight, to challenge the misconceptions, the myths, and the lies that surround radiation, as well as putting it into the proper perspective and context. The public discourse on radiation should be based on facts, rather than sensationalist claims. Such a discursive change will prove crucial in addressing the public perception issues faced by nuclear technologies which, unless improved, might risk the many benefits of these technologies being withheld. Equally, the radiation protection community must acknowledge the facts alone will never change the conversations that will take place around radiation. The vivid imagery that radiation has acquired over decades will provide a significant challenge, and the fact that radiation is scary to many of the public must be acknowledged. By doing so, and by incorporating the many breakthroughs seen in psychology, cognitive science, and the social sciences, significant progress towards establishing a more balanced discourse about radiation will be possible.

Whilst some uncertainties still exist about the exact health effects of low-dose radiation, enough is known to do so. The harms of radiophobia, especially following nuclear accidents, are well-established. The radiation protection community has, inadvertently, aided the emergence and survival of radiophobia, and has a duty to help address it. Unless the community starts to speak up with a strong, unified voice, the harms of radiophobia will remain. As pointed out by Paul Slovic, a pioneer in the fields of risk perception and risk communication, following the Fukushima accident: 'Enough is known about radiation and risk communication to enable experts to design effective messages...the challenge is that communication strategies must be considered a priority—in terms of time and money—to be effective. Messages should be created and tested before the next emergency. If they are not, the next disaster response will, in hindsight, cast a harsh light on officials who failed to prepare for the known communication challenges' [6]. The gauntlet has thus been thrown, the radiation protection community now needs to respond, and by placing radiation risk into its proper perspective and context, significant progress will be made.

The author would like to acknowledge Prof Geraldine 'Gerry' Thomas and Agneta Rising for their thoughtful discussions on these topics, as well as their helpful comments and suggestions on earlier versions of the manuscript. The author would also like to thank two anonymous reviewers for their very useful comments which has considerably strengthed this article. Any remaining errors are, naturally, my own.

Elements of this paper are based on a presentation 'An appraisal of the impacts of "radiophobia" on effective radiation protection, and the need for a new communications paradigm', given in November 2020 at the International Conference on Radiation Safety, hosted by the International Atomic Energy Agency.

This research has been supported by the UK Economic and Social Research Council, grant number 2104527.

The author is affiliated (through part-time employment) with the World Nuclear Association, a trade body representing the global nuclear industry. This article is written in a personal capacity, and the views and opinions expressed in this piece are those of the authors and do not necessarily reflect the official policy or position of any other agency, organisation, employer, or company.