In the literature of quality management, a “near miss” is described as an event that might have had terrible consequences but did not – because they were averted by alert personnel, by the discovery of something unusual and/or unexpected, or by simple happenstance. Many quality management personnel have suggested that their most common response to a near miss is to feel thankful and to move ahead.
For the more astute, however, a near miss serves as the trigger for a “near-miss analysis.” New policies and processes to prevent a future calamity usually would be the principal benefits that would result from that analysis. One of the best examples of near-miss analyses, followed by quality improvements, has been set by the major airlines of the world. Although airline crashes still occur, systemic failures that are investigated and found to have been preventable are aggressively corrected.
The Litvenenko/Polonium 210 Incident
On 1 November 2006, a previously healthy 43-year-old male became suddenly ill and was taken to a local medical facility. His initial illness was thought to be a form of food poisoning from a sushi meal he had eaten earlier that day. Instead of the improvement expected after his hospitalization, the man became gravely ill – because, it was later determined, his bone marrow failed to produce red and white blood cells; he also suffered from continuous bloody diarrhea and vomiting, and required several transfusions.
Several medical specialists were consulted and many theories were ruled out. Only after the man had lost his hair were his own claims of an attempted assassination heeded. After additional testing, Polonium 210 was found in the urine of Alexander Litvenenko, a former KGB colonel and an outspoken critic of then-Russian President Vladimir Putin. Litvenenko died on 22 November 2006.
Polonium 210 is an extremely lethal radiation isotope that emits only alpha particles. The alpha particle is the largest form of particulate radiation but, because of its low penetration capabilities, is not considered a “contact” risk. However, it is a high-grade risk when ingested or inhaled because, once it is in the human blood stream, the alpha particle wreaks great damage on the cells with which it comes into contact.
Polonium 210 is 250,000 times more toxic than cyanide. It also is an isotope that does not occur naturally. It can be produced, though – but only in small quantities – by bombarding Bismuth 209 inside a nuclear reactor. Polonium 210 rapidly degrades to lead, and has a half-life of 138 days. For practical, including forensic, purposes, that means that within about one year it becomes very difficult to detect within a human body. Making detection even more difficult is the problem that alpha particles are not detected by a standard Geiger-Mueller counter; more specialized and considerably more expensive equipment is needed. The world’s leading producer of Polonium 210 is Russia.
Delayed Recognition and Contamination
Following the discovery of high levels of Polonium 210 in Litvenenko, British law-enforcement, health, and intelligence authorities investigated the possibility that Litvenenko had been intentionally exposed. These efforts resulted in the discovery – on 26 January 2007, almost three months after the attack – of a tea pot from the Millennium Hotel that was highly contaminated with Polonium 210. The current theory is that the tea was intentionally contaminated by a Russian agent named Andre Lugovoi, whom Litvenenko met in London on 1 November 2006. In the 87 days that had passed between that date and the discovery of the contaminated tea pot, several airlines and their employees (plus passengers), a number of hotel employees, and an unknown but possibly very large number of private citizens may also have been exposed to the deadly isotope.
The case of Alexander Litvenenko’s murder demonstrates the need for a forensic epidemiology system – or, preferably, an international network of such systems. What in Litvenenko’s case was a deadly disease represents a simultaneous public-health emergency, a hazardous-materials event, a crime, and possibly an act of war. Although only Litvenenko is known to have suffered adverse effects from the 2006 poisoning, the situation may well have been quite different – if the isotope had been more toxic; or if Litvenenko had expelled the isotope more rapidly; or if the possibility of Polonium 210 was not considered a “possible cause” by the physicians treating Litvenenko.
Although no one person might have understood all of the facts and information that eventually resulted in this case being recognized for what it was, the ability of experts in different fields to communicate across a broad range of professional disciplines was the key to arriving at the eventually correct diagnosis. Rapid access to all of the information that might be needed – with appropriate safeguards built into the system – is and should be the core of a reliable and effective forensic epidemiology system.
Footnote: At least one intelligence source has suggested that almost 80 percent of Russia’s senior government officials were associated in one way or another, earlier in their careers, with the former Soviet KGB or Russian FSB (Russian Security Agency). The most prominent of those officials, of course, is Putin, who was once the director of the KGB. Which leads to a relevant question: If the murder of Litvenenko was in fact carried out by Russians, how many other Polonium 210 murders may have been committed in recent years that have gone undetected because of the lack of a forensic-epidemiology network?