Large quantities of money, time and effort have been wasted in trying to cure a disease that appears to be more susceptible to prevention. For example, over the last fifteen years the National Cancer Institute (NCI) has heavily funded a fruitless search for the viral cause of cancer even after it was apparent that, with small exception, viruses do not cause cancer. This incorrect paradigm has been pursued for so long not because of its scientific merit but because of the influence of the dramatic cure of polio with the development of the Salk Vaccine. Other misguided attempts directed toward curing cancer include: the random screening of chemicals for antitumor properties and the development of dangerous screening programs for early detection where increased risk of getting cancer as a result of the screening-itself outweighs any benefit of early detection.
It is not simply folly, however, to search for a cure for a disease that may be prevented. Rather it is consistent with a global view underlying a system controlled by a powerful bureaucracy in government, industry and medicine. It results from an unwillingness on the part of an economic system to sacrifice profit for workers' safety, to absorb the social costs of pollution, to abandon nonecological and in the long run harmful methods of production, and transform production to a more human scale using technology to meet human needs. It results from the institutionalization of health care with the creation of an industry designed and run more for its own benefit than for that of the people it should serve. It also results from our overall worldview, honed by centuries of faith in the progress of modern scientific and philosophical thought.
Much of the modern philosophical and scientific thought is grounded in a dualistic model of existence which reinforces objectification of the individual and of the environment. This dualism is strongly expressed by the separation of mind from body and of self from other. The body has been defined as separate from and alien to the mind but under its control. Human judgment, intelligence and all of the higher qualities are attributed to the mind. The ideal of unity of mind and body with the two working in harmony has been lost. Contemporary medical attitudes often result from this same self-alienation and much of the force of medical technology and research has been directed toward interventions which
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reinforce this separation. This is most strongly expressed in attitudes toward health and sickness. The major concern of medicine is sickness rather than health. Good health, promoted by adequate preventative medicine, is unavailable because of the monopoly exercised by the medical profession. Their training, knowledge and care is directed toward curing illness and simply prolonging life instead of promoting wellness and improving the quality of life.
Similarly, there has been an objectification of the external world as separate and alien from self. This has allowed for the exploitation and neglect of the environment and the domination of other humans. This failure to conceive of or to perceive the fundamental wholeness and unity of life has prevented us from realizing that we are directly and indirectly affected by the external world and that our attitude towards it is a reflection of ourselves. The uncontrolled concept of private property is the concrete expression of this alienation. The wanton use of nuclear energy in the form of atomic weapons and in the construction of nuclear power plants is the concrete expression of the will to dominate both nature and human society. It is almost inevitable that there will be disregard for the environment when production is for profit, since the social costs of pollution are a public cost and difficult to quantify while the benefits of such pollution remain in private hands and readily translate into dollars and cents.
"Cut It Out! Poison It! Burn It!" — The No Win War
In 1971 Richard Nixon launched an "all out assault on cancer" with the National Cancer Act. It was to be a national crusade, a cure to be achieved by 1976 in time for the Bicentennial celebration. This was to be the 1970's version of the successful and equally meaningful venture to put a man on the moon. In the same year, Nixon was also directing the destruction of Indochina by bombing the Vietnamese into submission, with "peace"
BLACK ROSEto be achieved before 1972 in time for his reelection. The weapon for the War on Cancer was to be the usual one that our nation has become so accustomed to over the last forty years: massive amounts of money administered by the federal bureaucracy. The National Cancer Institute (NCI) budget immediately doubled as war was declared. Eight years and seven billion dollars later we are no closer to a cure than at the outset.
Indeed the language used to describe cancer borrows heavily from military metaphors and invokes the same simplistic attitudes that characterize American foreign policy with respect to wars of national liberation.' The American Cancer Society (ACS) emphasizes early detection with the "seven early warning signs" of cancer as a catechism. We are taught to keep constant vigilance on our bodies with "a checkup and a check."2 In the words of Pogo, "We have met the enemy and he is us." Tumors are often characterized as invasive, they escape their primary sites, avoid, confuse and neutralize the body's natural defenses and set up outposts of secondary metastasizes at distant sites. it is usually these metastatic growths which ultimately cause mortality and not the primary sites. Treatment involves the use of the whole arsenal of medical science including radical surgery, radiation as well as highly toxic chemicals to kill the malignant cells. These methods of treatment are very primitive, nondiscriminating and not effective in the majority of cases. In the future these methods will probably be considered with the same horror and disdain that we now reserve for medieval surgery carried out by barbers without the benefit of anaesthetics or antiseptic techniques.
The oncologist (physician who specializes in cancer) stands at the head of the team, calling on the arsenal of weapons as his judgment dictates. Perhaps a surgical strike is needed. Surgery often removes large regions of normal tissue surrounding the tumor. It is difficult to be certain whether all of the cancerous cells have been
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removed and the continued presence of even one is sufficient to reestablish it. Chemotherapy is generally nonspecific and attacks rapidly growing normal cells with the same avidity as cancerous cells. It is often difficult to distinguish between normal cells and cancer cells and nearly any damage to the body is justified if it kills cancer cells. This is quite analogous to many military operations carried out in Vietnam in which towns were completely destroyed in order to save them from themselves.
It is no coincidence that the language of the military and medicine are often interchangeable. The rigor of training and the process of initiation is similar in both cases. They both perceive themselves as defenders of human welfare, they are both hierarchically organized elites; they both reap great financial rewards from the federal government, the military through the Department of Defense and the medical through the Department of Health, Education and Welfare (HEW). They both have extensive ties to industry through either the defense industry or through the pharmaceutical and health industry. In fact, many defense contractors also supply hospitals with costly and sophisticated equipment for diagnosis and treatment.
The Theocracy of Medicine
In ancient Greece during the 4th century B.C., a gradual change in attitudes toward health and disease occurred. Most of those details are now lost in antiquity but nonetheless we are able to reconstruct in broad outline the nature of that transition. In the Museum of Athens there is a marble bust from around 380 B.C. Depicted is Hygeia, a serene benevolent maiden personifying health by her balanced and reasonable demeanor. Hygeia was not fashioned after a real person, rather she was abstracted from the concept of health and her name was taken from the word meaning health. This feminine personification of health was soon superceded by Asclepius. Apparently modeled after a living man, Asclepius
BLACK ROSEwas the first physician who mastered the use of the knife. In the iconography of the third century B.C. Asclepius is depicted as a handsome, self-assured young god accompanied by his handmaidens, Hygiea on the right and Panakeia (the goddess of the cure) on the left.
These characters put into relief current attitudes regarding health and disease as well as help to define the role that the physician plays in our society. The young masculine god Asclepius. the wielder of the knife, is the personification of the physician. He practices surgery and dispenses panaceas. Even today, the surgeon is considered the most worthy of deification in the medical hierarchy. The prestige accorded surgeons in the medical hierarchy, in the media and in terms of their salary and
position is strong evidence of the focus of contemporary medicine. The ideal of Hygeia—health resulting from the ideal of physical and spiritual balance— a self-contained attitude not relying overly on dramatic intervention, has been lost. Preventive medicine is a small step in return to this principle. Also lost or excluded is the feminine experience in this patriarchal world of medicine where woman are relegated to minor roles. We have placed our faith in Science, the religion of the 20th century, in the wielder of the scalpel and the dispensers of drugs. Unfortunately, these aids are woefully inadequate in dealing with human cancer. The ideal of Hygeia has been replaced by the theocracy of medicine with the hope and promise of a cure dispensed like a eucharistic wafer. For now this cure remains elusive while we are shepherded by government, industry and science through fields contaminated with the very causes of the disease.
The Impact of Cancer
It is estimated that this year over 3/4 million people will be diagnosed as having cancer and over 400 thousand people will die from the disease. Cancer strikes all age groups, not just the elderly.3 The direct costs of can
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cer treatment are estimated at an average of 20 thousand dollars for an individual and the total national costs are estimated at 30 billion dollars yearly.4 This underestimates the real total which includes many costs still unrecognized.
There are few miracles available in treatment of cancer. Except for a small number of specific tumors which have yielded to chemotherapy, the results are disappointing. The ability of medical science to treat cancer has not improved substantially in the last half century. Improvements in the five year survival statistics are not due to advances in treatment itself so much as advances in surgical and hospital procedures including the use of antibiotics and transfusions.
The survival statistics on the treatment of breast cancer, which represents one-fourth of all female malignancy, are virtually unchanged over the last 50 years. All breast cancer patients have 25% risk of recurrence, even those with the simplest cases diagnosed early. A recent retrospective survey by a pathologist review committee indicated that of 506 diagnosed and treated minimal cases of breast cancer, between 66 and 88 of them were benign. Complete mastectomies were performed on 71 patients although there is no evidence to indicate that this form of treatment is more effective than simple excision of the tumor and surrounding tissue.
The statistics are yet more depressing for lung cancer, a disease which accounts for 22% of all male cancers. The five year survival statistics show 95% per cent mortality. Most lung cancers are so advanced by the time they are detected only 25% of all patients can be helped at all by surgery and mortality resulting from the surgery itself is considerable.
Social Change Against Social Disease
The tremendous improvements in life expectancy the world has experienced since the middle of the 19th century have been in large part due to the drop in infant
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mortality. Until that time about half of all children born in the U.S. died before the age of five of infectious diseases such as smallpox, scarlet fever and dysentery. The discovery of microbes as a primary vector of transmission of these diseases was an important finding, but microbial epidemics were not eliminated by treatment with drugs but rather by improvements in nutrition, sanitation and through human adaptation. The diseases of the 19th century in which the greatest strides were made were precisely those that responded to the social and economic reforms after industrialization. Tuberculosis is an example of a disease which followed such a course. Similarly, nutritional diseases such as ricketts in urban area, pellagra in the south, and scurvy have largely disappeared as a result of overall improved nutrition and not by vitamin treatments. This point is often overlooked but is central to this discussion, that is, changes in the social and economic structure of our society are largely responsible for the improved health we experience while medicine, although important, is secondary.
Our current need is therefore to discover and change those aspects of our lives that have led to those diseases which are endemic to the 20th century. Furthermore, we must reexamine the role that medicine has played and can play in overcoming these maladies. The magic bullet is social change not vaccination.
Lessons of History
There are many parallels to be made between the attitude toward the causes of and course of tuberculosis and that of cancer. We are concerned with the evolution in treatment and understanding of the causes, cure and prevention of TB and object lessons which can be applied to our present day situation with cancer. The decline in mortality due to TB during the latter half of the 19th century occurred even before the microbiological origin of the disease and its capacity for contagious transmission was understood.' Undoubtedly part
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of this decline is explicable by the adaptation of the exposed population by elimination of those most susceptible and increased immunity for the rest.' Urban .areas have always been a very fertile breeding ground for infectious disease due to the ease of transmission as well as the ensuing ability of the disease to be in a continuous infective state in some part of the relatively larger urban population. The lack of knowledge regarding the contagious nature of the disease certainly prevented effective isolation of patients and inhibition of the spread of the microorganism.
At the same time, however, TB found a very fertile environment in the social and economic conditions in the industrial city of the early 19th century. Long hours of exhausting work in damp, badly ventilated and heated offices and factories were the norm. Living conditions were equally bleak with overcrowding of tenements and dormitories, inadequate nourishment, and deplorable sanitary conditions. Children were employed starting at the age of seven or eight and accounts of the time describe them as pale, sickly and suffering from obvious malnutrition. In addition to physical hardship, the social fabric of their lives was ripped apart by their uprooting from Europe and by their relocation in the unhealthful environment of crowded city ghettoes. Similar disease patterns still appear in developing nations as they go through the comparable stages of industrialization despite the medical advances of the last hundred years.
The inadvertant approach society took in TB treatment was primarily a social one. Social change was influenced by diverse sources including: utopians who organized model factories, unions which organized at the work place, social reformers who aroused the public through magazine serializations which graphically painted pictures of the horrible conditions in the slums, and radical groups advocating revolution. The labor movement began to win better working conditions. Public heath programs improved living conditions in the city:
pure water became available, better quality and variety of food became available, sanitation and waste disposal improved. All of this was done in the name of humanitarian ideals and was begun even before the cause of TB was discovered. In summary, improved health does not result so much from the great discoveries of medical science, more so from the social and economic patterns which have created an healthful environment. We will now observe how cancer is also susceptible to a similar analysis.
Waiting for the Cure-Causes of Cancer
Since 1970 or earlier it has been known that a large proportion of human cancer is caused by specific environmental factors.' It is currently estimated that 70-90% of all cancer is related to these factors, some of which occur naturally but most of which enter the environment through human activities. These factors include: occupational sources, in the manufacture of industrial products, chemicals now part of the production and distribution of foodstuffs, pollution in the form of hydrocarbon exhausts from tobacco and other smoke, mine tailings, radiation, diet and drugs.
Currently over 50 thousand chemicals are produced and used and nearly one thousand are introduced into the environment yearly. A large fraction of these chemicals have appeared since World War II and their production grows yearly.'
In 1978, over 90 thousand Americans died of lung cancer. Despite known risks people continue to smoke.' Along with the changed lifestyle of women we are finding an increased smoking habit and a rapid growth in lung cancer amongst women. Women began to smoke in large numbers in the 1940's, toward the end of World War II, and, with a thirty year induction period from the time of exposure until the appearance of clinical signs: we are beginning to see the effect of cigarette smoking on women. Despite this fact, little is being done to elim
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Mate cigarettes.
The urban environment in which 90% of all Ameri- cans live is an unhealthful one." The air is fouled by the presence of factory and power plant emissions and auto- mobile exhaust. Hydrocarbon pollutants resulting from the burning of fossil fuels give rise to a large variety of products known to be carcinogenic. The concentration of one of these chemicals, benzo(a)Pyrene, has been determined to be up to one hundred times more plentiful in urban areas than in rural regions. Gasoline additives include benzene, an agent known to cause leukemia as well as other carcinogens. Similarly, emissions into streams and rivers and unregulated dumping of hazar- dous wastes which eventually find their way into water supplies present further hazards.
Food
Our food is contaminated with fungicides, herbi- cides, preservatives, artifical colors and flavors. Farming has been corrupted by agribusiness, a captial intensive industry where chemicals are used heavily and profit- ability is the ultimate measure of quality. It is a produc- tion system that simplemindedly reduces complex ecol- ogies to assembly lines consisting of square miles of geo- metric arrays of monocropped fields managed by chemi- cal control. Such modes of production have enabled California to produce 70% of all fresh fruits and vege- tables in the U.S. and requires Massachusetts to import 85% of its fresh produce. Animals are pumped up with diethylstilbestrol (DES), a known carcinogen, to bring them to market more rapidly. Meats are preserved with nitrates and nitrites. The pattern of both centralized pro- duction and distribution requires the use of extensive preservatives to allow for the long journey between farm and plate and allow enough time for each middleman to handle the product.
It would be bad enough if we were only alienated from food production, but we are also alienated from
good taste and nutrition." Our dietary habits, so affected by advertising and marketing and so unobservant of our health needs, have led to large scale obesity unparalleled in the world and the subsequent popularization of artificially sweetened beverages containing saccharin (a weak carcinogen) as a means of controlling caloric intake. Furthermore, there has been shown to be correlation between lower intestinal cancer and the quantity of fat in the diet. This form of cancer has steadily increased in the 20th century.
Occupation
The harmful effects of carcinogens is seen most clearly in the human guinea pigs exposed at the workplace." Occupational cancers are most evident because of the extremely high levels and long periods of exposure and are illustrated by the following examples. Eighty years ago it was discovered that aromatic amines cause bladder cancer among German dye workers. In addition, a later British report indicated that exposure to one of these chemicals (2-naphthylamine) causes bladder cancer with an incidence 80 times greater than the population at large. These substances were banned at least 20 years ago in most of the European industrial nations; in the U.S. workers are still exposed.
Asbestos is widely found in the environment, due to its use in construction, shipbuilding, insulation, textile and automotive industries. It is detected in significant concentrations in urban areas13 but is present at the most hazardous concentrations in occupational settings in the mining and processing of the ore and its fabrication into products. Epidemiological studies indicate a four fold increase in the overall incidence of cancer and an 8-fold increase in lung cancer, including an otherwise exceedingly rare form called mesothelioma (in the lining of the lungs). The effects of such industrial pollution are not limited only to workers. All people exposed suffer increased risk. For example, a 42 year old man whose
26 the dream of a time BLACK ROSE SPRING 80 whose consciousness it nit ow possess 27
father worked at an asbestos plant for three years until he was 11 years old, and a 40 year old woman whose father worked in a plant for five years during one of which she delivered lunch to him, both developed mesothelioma as a result of seemingly insignificant exposure.
Energy
The demand for energy by an overcentralized consumerist society is a further present and ever increasing future risk. The options currently considered by the federal government and the energy industries to meet future energy needs are a choice between two poor alternatives: synthetic fuels and nuclear power. The future risks resulting from the production and combustion of synthetic fuels are probably less dangerous than the pandora's box opened by nuclear power. Nuclear energy production in its totality including extraction, refining, utilization and disposal of wastes is destructive of our health and potentially lethal to human life. The mining of uranium is an extremely hazardous job which causes an incidence of lung cancer ten times higher for miners than for the population at large. The wastes produced at the mine known as tailings contain high concentrations of arsenic (a probable carcinogen) and radioactive "daughters" of uranium (known carcinogens). The tip of the toxicological iceberg has surfaced in Butte, Montana, where it was found that people are being exposed to high levels of radiation through the leakage of gaseous radon from nonferrous mines located beneath the town, and again in several places in Colorado where people were forced to abandon homes with concrete foundations constructed with radioactive mine tailings. Aside from the probable results of a nuclear meltdown or similar disaster such as nuclear war, the problems of transporting and storing for 250,000 years the increasing quantities of high level nuclear wastes represents the ultimate in egotism. By their own inadequate standards, the Nuclear Regulatory Commission admits that there is no present solution tothe storage of high-level radioactive wastes. One gram of plutonium spread around the world is enough to give lung cancer to each human now alive. There are many
possible energy alternatives to nuclear power. However, the current choices have been made on the basis of short term economic benefits without including the costs of present and future public health: our costs and their benefits.
Cleaning Up Our Act— Possibilities and Problems
We are losing time and present and future lives by waiting for a cure. The causes of cancer are primarily environmental. Economic and social factors, not scientific ignorance, prevent us from eliminating cancer as a major disease.Cancer is not a disease with a single causative agent. It is a family of diseases initiated by a wide variety of environmental factors. Therefore, different strategies to minimize human exposure to the many different carcinogens are required. Simpleminded sweeping regulation, the great strength of bureaucratic organizations, will not adequately solve the problem. 14
The structure of the medical profession and of health care in our society has prevented us from perceiving cancer as a public health problem and has suffocated progressive change. Predictably, most cancer directed medical resources go towards diagnosis and treatment. Resources need to be directed more toward prevention. Cancer needs to be recognized as preventable. Attempts by medical science to identify high-susceptibility populations is yet another way that it serves special interests and reinforces the status quo. Identification of such populations is a variation on "blaming the victim" and does not justify or ameliorate chemical hazards. It is clear that medical services must be made more responsive to human needs. Reliable and inexpensive health care is a human right as important as any other human freedom. The women's movement has provided a useful critique of the patriarchal nature of medi
28 in order to actually live it. BLACK ROSE SPRING 80 29
cine, but the replacement of men by women as doctors and women by men as nurses, seen as adequate goals by liberals, does not address the problems of lack of patient information and control over their care, problems resulting from hierarchy and domination_ Hospitals should not be centers for the practice of divine intervention, they should be part of a human support system fostering good health and prevention of disease. Moreover, the environment is an important part of our support system.
On an individual level, informed change in personal habits and lifestyle can have a strong impact on the chances of getting cancer. We have the greatest degree of control over the products we consume: the food we eat, the beverages we drink, the weeds we smoke, the drugs and cosmetics we use. The large differences in the incidence of organ-specific cancers in different nations of the world, in different regions of the same country, and in different ethnic and social populations in the same region point out the importance of lifestyle and personal choice. Until recently, however, due to lack of interest by the NCI and the presence of strong special interests in the medical community, the role of nutrition and environment in cancer has not been adequately investigated. People must realize that everything is not carcinogenic and that reasonable choices are available. The myth that everything will give you cancer is a convenient excuse for those who profit by it. Unfortunately, the control we have over our lives and circumstances is limited by the nature of our society. We are dependent on the testing and labeling of consumer products. We often have little control over public decisions and institutional choices which determine our exposure to many carcinogens.
In the workplace, the nature, organization and control of work must be transformed. The workers themselves must determine their safe exposure on the job. This constrasts markedly with the present situation in many factories where the employees are kept ignorant of tions to define and provide for our perceived needs.
It is almost unavoidable that mass technologies applied in centralized ways will lead to profound and harmful effects on the earth's ecology- Such technologies result from a knowledge-monopoly controlled by industry and government. Knowledge and technique is fostered to yield the best returns in profitability and control. As a result we are always left with few real alternatives with which to restructure our lives and social change is rendered much more difficult. At the same time, a theory of "Small is Beautiful" as proclaimed by E.F. Schumacher and others is inadequate without understanding and dealing with the problems of domination and control in both monetary and human terms and their effects on social organization. The potential for human freedom is not achieved by simply making the scale smaller, especially if profit remains the ultimate social determinant. It can be achieved when people are empowered by the acts of redefining and reclaiming control over their lives.
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ever present risk, where the determination of risk levels is falsified, where workers are denied access to medical records and other information and where simple safety procedures are denied for the sake of profit. In many cases the regulatory agencies have to rely on statistics of carcinogenic risk provided by the industry itself. The community in which the factory is located must have control over the levels of pollutants it is exposed to. The profitability of carcinogens must be eliminated. The threat of job loss, a means of avoiding compliance to minimum standards, is a common ploy when profit is the bottom line.
Public policy decisions are often made by federal and local government based on political considerations resulting from the pressure of special interests. For example, the militant anti-smoking campaign started by HEW was squelched under pressure from the Carter administration trying to curry favor in the tobacco growing states. Such policy decisions are often molded and played out in the forum of mass media where a balanced viewpoint is rarely obtained because of industry's resources and their access to advertising. Special interests focus on the immediate loss of jobs and the increased cost consumers will be required to pay for goods and services. This is the extent of their social consciousness—no more than a disguised profit and loss statement. Balanced against their red ink are present and future social losses which are enormous but difficult to quantify. Mass movements such as the anti-nuclear movement can have important impact by challenging the hegemony of business interests and demanding not only safety and health but economic autonomy and freedom. But, "No Nukes" is not enough! Visions of a nonnuclear future must be developed or we will be forced to accept the future vision of corporate socialism, whether nuclear or non-nuclear. More fundamental is the pressing need to deinstitutionalize our lives. We can not and must not depend on government and private institu
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