Lecture Fourteen: Environment and the New Epidemiology

The Fight for Authority

1. Self or Expert?
2. Humans as Mine Canaries
3. Is normal, natural, healthy?
4. "I'm not sick, but I haven't been well in a long time"

The People Take Over

1. Notion of available utopian health
   • The suburb
2. Lay expertise
   • Key awareness of what has changed in the environment -- Melrose Easter, S 281-1
3. Lay outrage
   • Smog - aspecific, non-point source ;radiation, inescapable
4. Local or labor power: "I don't care if my kid has unusual susceptibility"
5. Community survey medicine
   • The U.S. Health survey
   • The Framingham studies, 1948
6. Multivariate Analysis

Social Duty Defined: W.H.O. Principles, August 1948

1. Health is a state of complete physical, mental, and social well-being and not merely the absence of disease or infirmity
2. The enjoyment of the highest attainable standard of health is one of the fundamental rights of every human being without distinction of race, religion, political belief, economic or social condition
3. The health of all peoples is fundamental to the attainment of peace and security and is dependent upon the fullest co-operation of individuals and States
4. The achievement of any State in the promotion and protection of health is of value to all
5. Unequal development in different countries in the promotion of health and control of disease, especially communicable disease, is a common danger
6. Healthy development of the child is of basic importance; the ability to live harmoniously in a changing total environment is essential to such development
7. The extension to all peoples of the benefits of medical, psychological and related knowledge is essential to the fullest attainment of health
8. Informed opinion and active co-operation on the part of the public are of the utmost importance in the improvement of the health of the people
9. Governments have a responsibility for the health of their peoples which can be fulfilled only by the provision of adequate health and social measures

The Insidiousness of Social Diseases: Pellagra

1. Dermatitis (chest, hands), dementia, diarrhea
2. Diagnosed in U.S. in 1902, epidemic in the south, in institutions: Italian precedents
3. A stigma disease: Bad corn related, or ...
   • Heredity, infectious, sin
4. Therapies include: salvarsan and arsenicals, appendectomy, electric shock
5. Goldberger's intervention, 1914: mixed diet
   • Experiments on criminals: induced pellagra
   • Experiments on self and family: non-infectious
6. Attack on southern culture

Pellagra: Famine in South Carolina

1. "Famine and plague are words almost foreign to our American vocabulary, save as we have learned their meaning in connection with afflictions of landsless favored and toward which our people have so many times displayed large and generous charity"  -- President Warren G. Harding
2. "When this part of Georgia suffers from a famine the rest of the world will be dead" -- Georgia citizen
3. Goldberger: Single factor?  Or poverty of cotton economy?
   • K. Rajakumar, "Pellagra in the United States: A Historical Perspective," Southern Medical Journal 93 (2000): 272-277

The Sellars-Nash Problem: Where Does Medical Truth Lie?

1. In the test result, culture plate, or toxic screen?
2. In the expert's inspection of the household or the clinician's gaze at the body?
3. In the subject's experience?
   • Foucault's notion of total, disciplinary institutions: defining the limits of admissible experience
   • The case of lead: if no acute manifestations, no problem
   • Slow recognition of long-term effect on behavior, I.Q.

Sub-Clinical Plumbism

1. The Hamilton approach
   • The unsafe workplace; focused workplace reform, body monitoring, and good will negotiation
2. The Kehoe response
   • Get off industry's back: lead a normal constituent, harmless except in excess (controls: Mexican farmers, white collar workers at lead plant)
     1. Consultant GM, TEL (Ethyl)
3. The Sellars-Patterson critique
   • Lead typical, but not normal, insidious, anthropogenic, and harmful
   • Patterson's Los Angeles smog experiences
4. Removal of lead from gasoline by 1990

Problem: Where Do Lay Ideas of Health Come From?

1. Sellers: notion of poison, notions of good air, sunlight, dustiness, fumes
2. Worker denial or worker blame
   • Familiarity
   • Masculinity
   • Identity, fear, and anxiety: lead is my life
   • A means to alter conditions of work and wages
     1. Hours
     2. Women
3. Ambiguous modes of resistance:
   • "Turnover ...refusal to say with a job that ... managers saw as a failure of character, resistance to managerial regimes through frequent absences or insistence on rest periods and breaks" (s 274)

Environment Made Official

1. Rachel Carson, Silent Spring, 1962
   • DDT poisons food chains, poisons people
   • The model of nuclear fallout, invisible, insidious
2. Wilhelm Hueper (NCI)
   • Synthetic organics, asbestos, soot and smog, solvents abound
     1. Cancer (including lung) higher in industrial areas; cancer corridors

• NCI Cancer Atlas

Tobacco and the Assumptions of Specificity

1. If cigarettes cause lung cancer, must be due to some ingredient, must always cause cancer; lung cancer cannot have other causes
2. Disease not health: if effects cumulative, indirect, and non acute, do not exist
   • General practitioners miss lead poisoning
3. Normal environment = healthy environment

Why So Much Lung Cancer?

1. Toxic workplace
2. Rise of paved roads (1930s)
3. Rise of auto exhaust (1910s)
4. Decline of TB and ageing population
5. Long term effect of 1919 flu
6. Cigarettes?
   • Not a strong enough link for single agent
   • Too simplistic for complex causation

Textbook Stages (from Greenwood and Ackerman et al.)

1. 1935: Cancer as generally unitary; as irritation phenomenon, age phenomenon
2. 1947: Lung cancer increase noted; links to prior infection, occupation; tobacco discounted - women don't get it
3. 1954: Same, but more "circumstantial evidence" on tobacco
4. 1962: Same, but more on occupation, chemicals, air pollution, but strong "correlation" with smoking
5. 1970: Same, but even more on smoking, though still "correlation" as greatest risk factor
6. Modern: Genetic predisposition; mechanisms complex but particular

Stages in Convergence

1. 1950: Retrospective case control studies associating smoking and cancer; Wynder & Graham, Hill and Doll
   • Smoking and cancer may be both linked to underlying lifestyle or genetic factor (stress)
     1. People misremember their smoking behavior
     2. Leading interview techniques
     3. Doubters ACS, SG
2. Beginning in 1940s: Pathological studies of cancer deaths showing smoke induced cellular change; Auerbach
   • Dead smokers had this, but live healthy smokers? Variability of path. description
3. 1950s: Mouse-painting experiments with tobacco-carcinogens; Graham and Wynder
   • Animal paintings-inhalations don't reliably produce cancer; we don't paint skin with cigarettes
4. Later 1960s: Prospective community studies; Doll and Hill, Hammond and Horn
   • Distinct populations (region, race, sex) do not have same smoking-cancer rates
     1. Critics: Berkson, Mayo, RA Fisher

The Case Against Smoking: Replacing Koch's Postulates?

1. Hill's criteria: good induction or the defense attorney's friend?
   • Strength
   • Consistency
   • Specificity
   • Temporality
   • Gradient: dose-response
   • Plausibility
   • Coherence (convergence of methods)
   • Experiment
   • Analogy

The Emergence of a New Science: Is "Only Statistical" Enough?

1. Long-term discrete disease: cancers, ulcers
2. Long-term less discrete diseases: degenerative conditions, heart disease
3. Underminings of health: stress, susceptibility

Taking Over Medical Research

1. AIDS ACT UP, 1980
   • What's wrong with drug research
2. Environmental Justice Movement, McFarland, California
   • What's wrong with epidemiology
     1. National comparisons vs. comparisons with healthy places
     2. Inadequate spatial subdivision

California

1. Bodies move through a pesticide environment; Harm from
   • Variable susceptibility
   • Synergistic effects of multiple toxins
   • Multiple work sites
   • Uneven concentrations of pesticide
2. Environment moves through bodies
   • Contamination of water, air, by synthetic organics
   • Especially women's bodies
   • Especially fetal bodies

What has changed since 1950?

1. Health is place
2. Risk factors
3. Race
4. Personal constitution
   • Toxicogenomics
   • Victim blaming

The Regulator's Dilemma: Why the People Took Control of Science

1. The age of mass tort litigation; obfuscatory (junk) science
   • Tobacco Industry Research Council, 1953
   • Council on Tobacco Science, 1964
     1. Clarence Little, ACS executive director
     2. The Heuper argument
2. "I'm on your side," but
   • "my budeget allows me to deal with only one problem a year"
     1. "I really want to get home"

The Rational Response of HIV-AIDS to Clinical Trials

1. Best science model: emphasize perfection in protocols (double-blind, large control groups); participate in trials, await results, slow FDA approval
2. No science model: self-medicate
3. Modified science model: Epstein-AIDS activists
   • Informed citizen choice: medical consumerism
   • Citizen-researcher groups
   • Ethical obligations to diversity of affected population (what is true for all may be false for some)
   • Ethical obligations to placebo takers
   • Notion of general clinical experience over general laws of therapeutic operation
   • Creative use of statistics