How can victims be helped, who will pay?

How can the ill around the nation's nuclear weapons sites be helped? Suggestions vary from an advocacy program to help them better navigate the health care system to opening environmental health clinics in their neighborhoods.

Thorny issues remain: Who should be helped and who should pay?

Whatever the idea, there is growing consensus that the ill need medical care they currently aren't getting.

Here are some of the ideas:

• Create an ombudsman program. Dr. Tara O'Toole, who left her post as U.S. Department of Energy assistant secretary for health and safety last year to become a consultant, says perhaps a government- funded ombudsman could help provide medical care.

The Energy Department or the U.S Centers for Disease Control and Prevention could pay for the advocates, O'Toole says. They could give advice to the ill when insurance companies balk at paying for needed tests or when doctors don't know how to proceed with unexplained illnesses.

''I recognize people are suffering,'' O'Toole says. ''I think they deserve a humane response.''

But while the DOE could fund an ombudsman, further action must come from the nation's leaders, she says: ''The Department of Energy doesn't have the capability to address this issue. It will have to be addressed by the White House through new policy, or Congress through new laws.''

The DOE doesn't have the resources or the expertise to devote to the issue without taking away from its current responsibilities, she says.

''I'm more concerned right now about the people who are doing the cleanup'' at these sites, O'Toole says. ''People are in harm's way as we speak. We have a responsibility to prevent future disease.''

When O'Toole worked for the DOE, the department considered sending ill people around its sites to see specialists in occupational and environmental medicine, she says. That never happened because the DOE's legal department warned that recognizing people may have been harmed and trying to help them would force the government to choose whom to help. That, the lawyers said, would ensure lawsuits.

But, O'Toole says, she recognizes help not lawsuits is what ill people living around these sites want: ''They want to feel better.''

O'Toole says she doesn't believe all the illnesses are related to exposure from the nuclear sites. But, she adds, ''that doesn't mean that there aren't people out there who've been affected.''

• Use the Veteran's Affairs medical system. The nation has a moral responsibility to go a step further than providing an ombudsman, says Dr. Howard Frumkin, chairman of environmental and occupational health at Atlanta's Emory University.

The government could pay for people's health insurance through a voucher program. Or they could be allowed to use the medical program offered military veterans, he says.

''The Veteran's Affairs system serves a class of people who were put in harm's way for the nation's sake,'' Frumkin says. ''The ill people living near DOE facilities could be considered one of those groups. We know we probably put these people in harm's way. If we knew 50 years ago what we know now, we would have operated these sites differently.

''Now the least we can do is take care of them.''

A prerequisite to care would be some indication that communities are experiencing high levels of illness or highly unusual illness, Frumkin says.

Using veteran's hospitals could be a double benefit, he adds.

The nation's VA medical system is facing a decline in patients as World War II veterans age and die, he says. The VA system could use a boost to its mission, he adds. And while VA hospitals have come under criticism for their quality of care, some of the ill around DOE sites might benefit from experimental treatment being offered ill gulf war veterans, many of whom share similar symptoms.

By tapping into an existing system, costs for medical care would be lower, too.

''This would be a calculable figure,'' Frumkin says.

• Expand a federal doctor-sharing program. Another existing, though little-used, avenue of medical care might be broadened to help the ill. This one is a joint program between the Association of Occupational and Environmental Clinics and the Agency for Toxic Substance and Disease Registry. The association is a network of mostly university-based doctors specializing in toxic exposure; the agency tracks health issues around toxic waste sites, including DOE sites.

Under this 21-month-old program, association specialists are paired with doctors of people living near environmental hazards.

''The purpose of this entire project is to deal with communities' health concerns,'' says Dr. Pamela Tucker, senior medical officer with the disease registry's division of health education and promotion.

The doctors try to determine potential toxic exposures: Did the patient work with chemicals? Eat fish from a contaminated creek?

Live down wind from releases? Then, the doctors do a physical examination, looking for signs of toxic exposure and discussing how specific poisons can target different parts of the body.

The specialists log unusual cases into a database, which can be used to track trends. The program is free to the ill and can be initiated with a request from citizens of the community.

The program would have to be expanded, though, to help the hundreds of ill around DOE sites. It currently employs just over a dozen people.

• Open community environmental health clinics. One Oak Ridge advocate for the ill has met with O'Toole in Washington, talked to Frumkin in Atlanta, and wants to learn more about the disease registry's doctor-sharing program. Each idea has merit, says nurse Sandra Reid, who heads the nonprofit Environmental Health Liaison.

But more is needed, she believes.

Reid and a handful of others at sites across the nation want specialized environmental health clinics opened in their neighborhoods to give medical care, track trends in the illnesses, and research an area of medicine that is in its infancy.

''We want to bring together experts who are scientifically credible and advocates for the people to try to evaluate what can be done,'' says Reid, whose husband, William, is a physician to some of the ill in Oak Ridge. ''We want to bring people together at all of these sites.''

Reid has enlisted experts in immunology, radiation biology and other medical specialties to work on a formal proposal they hope will win grant money from government and private institutions. The plan calls for a pilot project to start by surveying the ill to define the health problems they're experiencing. It would eventually establish a full-scale clinic with the goal of developing new treatments.

''Some of what might be done for people will be experimental,'' Reid says. ''People would have to realize that. We can't waste any more time trying to figure out where all this illness came from. These people are getting more and more sick.''

By Susan Thomas, Laura Frank and Robert Sherborne, The Nashville Tennessean

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