CASSELTON, N.D. — Judith Antoine began suffering from poor health a few years after moving into her home here nearly three decades ago, but nothing confounded her doctor and her family more than when she struggled to breathe and collapsed last summer.
Family members knew of previous heart problems and serious infections but didn't recall any lung trouble, so when Judith was diagnosed with pulmonary fibrosis, or scarring of the lungs, they were surprised.
Most shocking was her chest X-ray.
"As soon as I saw it, my heart just sank," said Judith's daughter, Michelle Antoine, a nursing home administrator in Rolette, N.D.
"You could see there was only one sliver of the upper lobe working in her lungs," she said.
Judith's condition deteriorated and she died on Nov. 2 at age 72.
Michelle and oldest brother Andrew wanted to know why she developed pulmonary fibrosis. Cigarette smoking may have been a factor, they were told, but Judith hadn't smoked in more than 30 years.
Andrew Antoine, a mechanical engineer, suspected an environmental exposure in his mother's Casselton home, 22 miles west of Fargo.
As a shot in the dark, he tested the home for radon — the radioactive gas you can't see or smell.
"I got a 234 at the sump pump and about fell over," Antoine said about the alarming number.
The Environmental Protection Agency recommends homeowners take action when a radon level is four and above, referred to as 4.0 pCi/L or 4 picocuries per liter.
"Never once did I think or realize that my own mother's home was a death trap," he said.
Radon listed on death certificate
The EPA recognizes radon as the second-leading cause of lung cancer, after smoking, claiming the lives of around 21,000 people in the U.S. each year.
It says lung cancer is the only health effect with a proven tie to indoor radon exposure.
A report on the EPA's website, published by The National Research Council, highlighted a review of new studies of uranium miners who developed pulmonary fibrosis.
It said while the information supported the possibility that exposure to radon may have been a factor, the case series was insufficient to prove a link.
The Antoines, however, are convinced that chronic exposure to radon killed their mother and, apparently, so is Judith Antoine's longtime physician.
Dr. Brent Hella listed her cause of death as pulmonary fibrosis as a consequence of "radon toxicity," believed to be the first such classification on a death certificate in North Dakota.
Hella declined The Forum's request to answer specific questions about his patient's case.
The Cass County Coroner's office called Judith's family after she died to ask about radon because they'd never seen it referenced on a death certificate before.
"I think it's important because anybody looking at that needs to see this is not a natural phenomenon," Michelle Antoine said.
A radon hot spot
Justin Otto, the state health department's radon coordinator, was asked whether there are any known radon "hot spots" in North Dakota.
"The whole state," Otto said.
North Dakota and Iowa are the only two states in which every county falls into the EPA's Zone 1 "red" ranking.
Otto said 63 percent, or two out of every three North Dakota homes, test over the action level. By comparison, two out of every five homes in Minnesota are in that category.
Otto said the North Dakota numbers are based on results of radon tests — around 6,000 of them given out to homeowners every year.
Jane Kangas, a health department scientist in the Fargo field office, said proximity isn't always a good predictor of radon levels.
"You could have high radon in your house and your next-door neighbor could be at zero, so it really depends on the soil underneath your house," Kangas said.
Otto acknowledged radon numbers in the 200s, like what was reported in Casselton, are uncommon. He's only seen them a few times before.
"Down in Belfield, where there used to be uranium mines," Otto said.
Casselton residents alerted
After his mother's home in Casselton tested high for radon, Andrew Antoine consulted a radon specialist and checked other homes of friends there, finding equally disturbing numbers.
In late August, he notified Casselton Mayor Lee Anderson about what he'd learned, urging him to alert residents.
Anderson told The Forum he contacted the state health department, which offered to send out free radon test kits.
Anderson said his own home tested at 11.2 pCi/L. It wasn't as high as others, but still almost three times higher than the actionable level.
"It was enough of an eye-opener," Anderson said.
About a week after Judith Antoine died, the city of Casselton mailed out with city water bills a community health alert about radon. They went to nearly 800 water users in the city of approximately 2,300 people.
Antoine said he was told it was a one-time alert, but he thinks it should go out twice a year, so residents don't brush it off.
"This is an imminent health hazard," Antoine said.
State radon coordinator Otto applauded the public notification in Casselton.
"I think that's good, any kind of information people can get out," he said.
Judith's friends take action
The Antoines have since had a radon mitigation system installed in their mother's home, as have several other families in Casselton.
It now has a level under 1.0, a drastic reduction from the original 234 pCi/L.
A Fargo couple, friends with the Antoine family, had their home fixed after learning of Judith's death.
Walt and Jan Clinton live south of Carl Ben Eielson school and their home's radon level registered at 17.3 pCi/L.
Foundation cracks and the sump pump cover-through which radon gas can seep-were sealed, and PVC pipe and a fan were put in to vent the gas outside, where it dissipates.
Chad Matthews of Innovative Basement Systems did the installation.
"This house has a drain tile system built into it, so we were able to pull all that radon from around the house from a centralized location near the sump," Matthews said.
The cost to the Clintons was in the neighborhood of $1,400; a small price to pay, they said, for peace of mind.
"How much does a doctor visit cost? How much does a hospital, a nursing home, or hospice cost?" Walt Clinton said.
States should do more
Andrew Antoine thinks the state should do more for residents of Casselton and other cities, including trying to correlate high radon levels to reported health problems.
He's concerned that elderly residents are being exposed to radon but don't have the access, tools and resources to test for it and take action.
Bill Field, a professor of occupational and environmental health at the University of Iowa, also thinks more could be done.
"There should be more of an effort to see if it's widespread," Field said, when told about the situation in Casselton.
Field led what's known as the Iowa Radon Lung Cancer Study, which studied women with lung cancer who were exposed to radon for at least 20 years.
He said pulmonary fibrosis and radon exposure is also something he'd like to investigate.
"It could be a factor in some people," Field said.
Field thinks all states, in general, aren't doing enough about radon, in part because EPA funding is cut every year.
However, people who've conquered lung cancer caused by radon are getting the word out by becoming advocates.
"Survivors are really making a difference," Field said.
'If we had known'
A Minnesota law passed in 2014 requires anyone selling a home to disclose known radon concentrations to the buyer.
State building code also requires a "passive" radon reduction system in new home construction, to which a fan can be added later to reduce radon levels further.
North Dakota has no such laws on the books.
Two bills, similar to what's in effect in Minnesota and introduced in the last North Dakota legislative session, did not pass.
Otto said one requiring radon-resistant new home construction failed mostly due to a timing issue involving rewriting of state building code.
However, many North Dakota real estate agents know about the dangers of radon, he said, and many homes are tested prior to real estate transactions.
Still, the burden to test for radon and act on it falls squarely on the homeowner.
The Antoines wish they'd known about it sooner.
"If Mom had known, if we had known, certainly we would have taken care of this a long time ago," Michelle Antoine said.
For a free radon test kit in North Dakota, call 701-328-5188, or email firstname.lastname@example.org and put "radon test" in the subject line.