Faced with two institutions largely averse to self-criticism, the medical sector and the justice system, one Spanish nurse stood her ground: her long battle for recognition of the occupational nature of the cancer that affected her almost 20 years ago has finally been won. She has taken this opportunity to highlight the risks other nurses face from the cancer treatments they administer.
Georgina Angusto Zambrano does not find it easy to talk about a period of her life when, professionally-speaking, she was at her lowest ebb. But she is a woman that sees things through to the end. "I have just refused to tell my story to a Spanish newspaper because I have no desire to open up old wounds," she explains as we sit down to talk near Cabrera, the suburban district of Barcelona where Georgina spends her summers and from where she first embarked, in August 1967, on a career as a nurse working in the urology clinic of a Barcelona hospital outpatients department. She was 17 years old at the time, and could never have imagined that she was to become ill as a result of preparing other people’s medication.
Georgina recently recounted her experience to the European Parliament because Rosa María Orriols Ramos, a member of the World Health Organisation’s International Commission on Occupational Health had, quite by chance, heard of her case. She agreed to go along, with her lawyer from the time, Ana Salas Velasco (who has since become a judge) as she felt her story might be a useful one. "What surprised me most on arriving at the European Parliament was that my case could be so interesting. It seems we’ve made very little progress over the last 18 years," Georgina comments with an expression of incredulity.
From the year 2000, when her illness was diagnosed, until 2005, when the Catalan Supreme Court of Justice acknowledged that her bladder cancer was related to her handling of cytostatic drugs, Georgina fought a lonely battle. And, throughout it all, from becoming aware of the occupational origin of her illness through to the search for scientific proof, she fought it without any institutional support whatsoever. With an iron will, Georgina immersed herself in the medical literature for five long years, thus enabling her lawyer to organise her defence on the basis of scientific evidence that she painstakingly put together.
Georgina’s story illustrates the bitter failure of a system that neither informs its workers nor protects them from occupational risks. Her case is all the more serious because it occurred in a professional environment that should have known and been following preventive measures that would have enabled her to avoid this illness.
I’ll show you how to do it
During the summer of 1967, when Georgina first arrived in the urology department to replace a staff member who was leaving to have a baby, her colleague explained to her how to prepare the drugs to be administered to patients suffering from bladder cancer. "The patients who had already had their tumour removed, generally stage one or stage two, would come with their own medication, which we would pour into a sterile container. This was placed in a syringe attached to a catheter previously inserted into the patient’s urethra. This mixture was injected into the bladder."
All this preparation was undertaken with no gloves and, it goes without saying, without any protective cabinets, in the room where the nurses ate and drank their coffee. This method of preparing drugs did not change between 1967 and 2000, when Georgina’s bladder tumour was diagnosed. "When I left, they were doing things in exactly the same way as when I first arrived," she explains. The staff were at no time given any information from the hospital’s occupational risk prevention department nor any warnings from the doctors prescribing the drugs. No occupational risk assessment took place despite it being required by law.
Although she had a list of recommendations to give to patients, Georgina never felt they were running any risk because she had full confidence in her hospital’s medical team: "Patients were asked to urinate in different toilets to those used by their other family members, to flush twice and then to put a litre of bleach down the toilet bowl but at no time did we imagine that we were in danger. We didn’t have the least idea of what we were handling," she explains.
She handled these cytostatic drugs on a daily basis for years, drugs that are all designed to interrupt certain phases of the cell structure. This property justifies their use in treating illnesses such as cancer, where the cells multiply in an uncontrolled manner. The process for preparing cytostatic medications is usually conducted in hospital pharmacies. A commercially produced product is processed as necessary (reconstituted, mixed, diluted, etc.) to obtain a drug appropriate for administration to the patient. Occupational exposure to cytostatic drugs can take the form of immediate localised effects caused by accidental exposure or longterm consequences caused by continuous low-dose exposure. Cytostatic drugs are recognised as being mutagenic, reprotoxic and carcinogenic, and they are associated with cancer of the bladder, carcinoma of the nasopharynx and leukaemia. They can also result in miscarriages and birth defects.
The first sign
The first sign that something was not right in the urology department came from another nurse. "When a colleague showed me his blood-streaked urine, I guessed it had to be a tumour as there was none of the pain you would associate with colic. This nurse also knew deep down, but did not want to admit to the evidence. He underwent bladder bypass surgery," the nurse recounts of her colleague, 12 years her senior and suffering from stage 4 cancer of the bladder.
A year later, Georgina discovered blood in her urine. The diagnosis was the same. A tumour in the bladder. When she told her colleagues of her symptoms, they all said, "Surely not! There are plenty of other things it could be." The ultrasound, however, very soon confirmed the presence of a tumour. "They made me wait more than an hour in the ultrasound room, which only confirmed my suspicions and, when they arrived, they told me, 'Well, it’s not serious. It is a bladder tumour but only a tiny one. We’ll remove it next week and that will be that.'"
When Georgina came across her sick colleague in the department, she very nearly exclaimed, "You’ve contaminated me," but quickly thought better of it. "That’s when I realised that cancer isn’t contagious," recalls the nurse. This awareness was like a sledgehammer blow for someone who, like Georgina, loved her job with all her heart and who had devoted herself body and soul to her work. No time to linger over such considerations then; she had to defeat her illness. "Luckily, the tumour was found to be at stage 1 TA, i.e. less aggressive, but I was extremely surprised when the oncologist told me that I was not to take any treatment. Why do all the other patients take it and not me?", asked Georgina. "Isn’t it strange that two nurses in the same department have developed bladder cancer?", she ventured to an anatomic pathologist. The latter categorically denied any link but this only reinforced the nurse’s suspicions.
Georgina’s concerns continued, so she asked to be given the anatomic pathology slides and then changed oncologist. This second specialist was the first to evoke, subtly, the dangers of handling anti-cancer drugs. At that time, she was on sick leave as the position of her bladder surgery had left her with a hip injury and she was no longer able to walk. "The doctors were worried and took some exploratory bone samples as they were concerned they might find metastases in the bone. The examination showed nothing but I had to remain in bed on anti-inflammatories," she explains. Following a meeting with her oncologist, Georgina contacted the library at Barcelona Medical School to request the technical instructions for all the drugs she had ever administered over the years. What she learned left her in shock. "These drugs were extremely dangerous and we had been administering them without following any of the precautions advised in the instructions."
Scientific proof and the legal battle
Georgina then went to the Catalan Government’s occupational risk department to find a 1976 document that gave a whole series of recommendations for handling hazardous drugs, which, in her case, had not been followed. This document was based on another from the World Health Organisation from 1975. She contacted a firm of lawyers immediately. Ana Salas shared her client’s intuition as to the occupational nature of her illness. Suspicion is one thing, but scientific evidence is another.
The nurse began to undertake exhaustive bibliographic research in reference medical publications such as The Lancet, the Journal of the National Cancer Institute and the Journal of Urology. "Each reference sent me to additional documentation. I studied mountains and mountains of articles, most of them in English and a good number of which I had to translate with the help of a childhood friend or by calling on the paid services of the Escuela Oficial de Idiomas (Official Language School). It became clear that research highlighting the dangers of cytostatic drugs had been published since the 1980s. The obvious question was: 'Had no one at the hospital read these articles?'."
There was plenty of information on cytostatic drugs but her lawyer did not feel that any of it was conclusive. It would take more than this to discourage the nurse and so she threw herself into her research with even more determination. And then one day she found the crucial element: a study published in July 1993 in the Journal of the National Cancer Institute. It described the case of a 39-year-old pharmacist who had been handling cytostatic drugs for more than 10 years, especially one of those administered by Georgina, and who had developed a tumour of the bladder despite presenting no other risk factors. The researchers showed that the cabinet in which the pharmacist had been handling the drugs had been equipped with a horizontal laminar flow extraction system rather than a vertical one, so that the fumes drifted out towards the pharmacist’s body and into the room in which they were working. "And we were preparing these mixtures without any cabinet at all!", says a still shocked Georgina.
On the basis of these documents, Ana Salas drew up an entire action strategy prior to going through the courts: first, they submitted a complaint to the Spanish Health and Social Security Inspectorate, and provided the evidence relating to the handling of cytostatic drugs and resulting health risks. Once the Inspectorate had acknowledged the occupational nature of the illness, Georgina then went to the Toxicology Department of Barcelona University to undergo genetic tests to establish that the disease was not hereditary. Ms Salas and Georgina finally won the battle in the courts. Her cancer was recognised as an accident at work and she can now benefit from the social security provided for occupational illnesses. Following this victory, the nurse embarked on another no less complex journey: she was 50 years old and had to rebuild her life outside a job that not only provided her with an income but that also represented a crucial source of personal fulfilment for her.
"I’ve put all that behind me now, but I find it difficult to look back on it, even though the final battle was won. It still pains me to remember how powerless we were. I find it difficult to believe that no one in the hospital had read those scientific articles and even more difficult to understand their silence," she concludes, her voice full of life, positive and kind, a tone used by those who know that – when the time came – they did the right thing.•