Scientific conviction amidst scientific controversy in the transatlantic livestock and meat trade

Scientific conviction amidst scientific controversy in the transatlantic livestock and meat trade

Review Endeavour Vol.29 No.2 June 2005 Scientific conviction amidst scientific controversy in the transatlantic livestock and meat trade Justin Kas...

425KB Sizes 1 Downloads 23 Views

Review

Endeavour

Vol.29 No.2 June 2005

Scientific conviction amidst scientific controversy in the transatlantic livestock and meat trade Justin Kastner1, Douglas Powell2, Terry Crowley3 and Karen Huff4 1

Department of Diagnostic Medicine/Pathobiology, K-226 Mosier Hall, Kansas State University, Mahattan, Kansas 66506, USA The Food Safety Network, Department of Plant Agriculture, University of Guelph, Guelph, Ontario, N1G 2W1, Canada 3 Department of History, University of Guelph, Guelph, Ontario, N1G 2W1, Canada 4 Department of Agricultural Economics and Business, University of Guelph, Guelph, Ontario, N1G 2W1, Canada 2

A century before the outbreak of bovine spongiform encephalopathy (BSE), Great Britain and North America grappled with pleuro-pneumonia – a disease in cattle that had equally maddening consequences. Towards the end of the 19th century, this condition was at the heart of a transatlantic trade dispute that lasted for decades and attracted the attention of livestock farmers, diplomats, shipping moguls, veterinarians, public health regulators and journalists the world over. Scientific controversy aggravated the situation when there were doubts about the scientific judgment of Privy Council veterinary officials, who were simultaneously conducting disease-diagnosis activities and pushing for tighter regulations at British ports. At this point, William Williams, principal of the New Veterinary College in Edinburgh, waded into this troubled arena. His strong convictions spawned a long-running disagreement with the British Government over the diagnoses of pleuropneumonia in cattle imported from the USA and Canada.

Introduction In the autumn of 1890, a handful of students gathered together at Edinburgh University (http://www.ed.ac.uk/). They were expecting to hear from Robert Wallace, a professor of agriculture and rural economy at the university, about the basics of the transatlantic trade in meat and livestock. The lecture that Wallace gave touched on a number of subjects related to the trade, but he eventually steered it towards ‘the burning question of the moment’ – a dispute over the ongoing diagnoses of the insidious lung disease pleuro-pneumonia in cattle imported from the USA [1]. The fact that Wallace took the time to address this topic illustrated its importance: already 11 years old, the seemingly never-ending dispute continued to attract attention. When British authorities made the first diagnosis of pleuro-pneumonia in 1879, there had been a wave of panic. Since the 1840s the disease had cost British livestock farmers millions of pounds [2,3]. The threat of Corresponding author: Kastner, J. ([email protected]).

pleuro-pneumonia being carried by American cattle prompted government authorities to insist that all American cattle be slaughtered upon arrival in the UK in an attempt to control the disease. But some doubted that the policy was really necessary, Wallace explained. Had the diagnosis of pleuro-pneumonia been correct? It had frustrated plenty of Americans, and Scottish livestock farmers remained eager to import American ‘store cattle’ for inland finishing, sale and slaughter. ‘I am quite aware that there is an impression in America that our inspectors have mistaken the appearances of pleuro-pneumonia for those present in the lungs of cattle suffering from a sporadic inflammation’, Wallace told his audience [1]. This impression had not only been embraced by American veterinary scientists, but also by one of Wallace’s contemporaries in Edinburgh. Birth of the dispute In early January 1879 the steamship Ontario, loaded with over 200 cattle from North America, departed from Portland, Maine bound for Liverpool, England. The shipment – originally sourced from markets as far afield as Chicago, Buffalo and Toronto – contained mostly American animals [4]. As the Ontario made its way eastwards across the cold Atlantic waters, veterinary authorities in London and Liverpool were busily stepping up enforcement of a new Foreign Animals Order. This order had been adopted under the Contagious Diseases (Animals) Act of 1878, and stipulated that, with certain exceptions, livestock imports were to be slaughtered within ten days of their arrival in the UK. Significantly for the approaching Ontario, American and Canadian livestock imports were amongst the exceptions. North American animals could be allowed inland alive provided that they were inspected at the dockside and certified disease-free [3]. There was much speculation within the veterinary community over how long these exemptions could last for the USA. Although Canada was generally seen to be free from pleuro-pneumonia, reports suggested that the USA was not. In an influential report, James Law, veterinary professor at Cornell University (http://www.cornell.edu/) in New York, had confirmed the existence of pleuro-pneumonia

www.sciencedirect.com 0160-9327/$ - see front matter Q 2005 Elsevier Ltd. All rights reserved. doi:10.1016/j.endeavour.2005.03.004

Review

Endeavour

Vol.29 No.2 June 2005

Figure 1. Inspecting cattle. During the winter of 1878–1879, veterinary inspectors for the Privy Council intensified their scrutiny of American livestock imported into British ports. Reproduced with permission from a reprint on p. 83 of Smithcors, J.F. (1975) The Veterinarian in America 1625–1975, American Veterinary Publications, Inc.

in several locations along the eastern seaboard of the USA [4,5]. This was substantiated by a Canadian scientist – Duncan McEachran – conducting investigations in the eastern USA, who informed the British authorities [4]. In Britain, George Fleming – a frequent writer on behalf of the British veterinary elite [6] – highlighted the prevalence of pleuro-pneumonia in American cattle and urged for the immediate slaughter of all livestock imports from the USA [7]. Such reports did not bode well for those with a stake in the lucrative trade in North American store cattle. Those involved in the ‘store’ trade at Liverpool and other British ports responsible for receiving North American cattle feared the possibility that they would have to slaughter their cattle. American and British businessmen alike believed that if the authorities put an end to live imports, the supply of meat would dwindle and prices rise. Others expressed concern because in an over-stocked market compulsory slaughter within ten days would prevent them from holding onto their animals until prices recovered [8]. On Sunday 26 January 1879, the Ontario arrived into port at Liverpool. Just fewer than 200 animals, two of which were dead, were brought ashore. The Veterinary Inspector for the local authority of Liverpool examined the lungs of one of the dead animals and suspected pleuropneumonia. Following orders, he took samples of the lungs and forwarded them to the Veterinary Department of the Privy Council in London. The London-based authorities confirmed the diagnosis. The Duke of Richmond, who was Lord President of the Privy Council, instructed the director of the Veterinary Department, George Brown, to www.sciencedirect.com

79

send an inspector to Liverpool to oversee the slaughter of the entire Ontario cargo [9,10] (Figure 1). On Wednesday 29 January 1879, the Ontario animals were transferred to a nearby abattoir. After they had been slaughtered the Privy Council veterinary authorities noticed that several animals had respiratory inflammations resulting from exposure to cold weather. But they also found ‘the distinctive appearances of pleuro-pneumonia’ in the lungs of 12 animals [9]. The following day, the British Foreign Secretary, Lord Salisbury, announced by telegram that it was time to withdraw the exemption of American cattle from compulsory slaughter [4]. The industry reacted. In the USA, regulatory authorities haphazardly tried to rescue embarrassed livestock exporters: US Treasury Secretary John Sherman quickly instigated a program to inspect and certify cattle and US Commissioner of Agriculture William G. Le Duc sent two men to inspect and certify cattle at Chicago stockyards and New York ports [11]. The 1 February 1879 issue of The New York Times put it best: there was ‘alarm and anxiety’ in the transatlantic livestock-trading community [12]. Not only had Secretary Sherman and Commissioner Le Duc acted without consulting each other, they had acted too late. Although shipments of American cattle would arrive in Liverpool in a healthy condition over the next several days [4], the diagnosis of pleuro-pneumonia in the cattle from the Ontario had all but guaranteed that subsequent shipments would be subjected to immediate slaughter. If they wanted the British authorities to maintain the exemption of American cattle from the Foreign Animals Order, they were going to need to put together an unusually compelling scientific argument. This they would find from Professor William Williams, principal of the New Veterinary College in Edinburgh (Figure 2). In The New York Times, shipping mogul Timothy Eastman conceded that pleuro-pneumonia existed in certain pockets along the east coast of the USA, but he questioned the diagnosis of pleuro-pneumonia in the Ontario shipment. Eastman insisted that pleuro-pneumonia was entirely confined to dairies in the east of the USA and did not threaten export cattle, which (based on his experience) were sourced from the western states [12,13]. Commissioner Le Duc and veterinary leaders in the USA could see weaknesses in Eastman’s argument [14], but they embraced this line of thinking as allegations emerged that the British veterinary authorities had erred in their diagnosis. Moreover, additional reports – one citing the Liverpool Cattle Trade Association – seemed to bear out Eastman’s suggestion that the animals aboard the Ontario had simply ‘caught cold’ [12]. Conventional bronchitis, not pleuro-pneumonia, appeared to be the problem aboard the Ontario [14]. As Eastman levelled these accusations, Liverpudlian importers called in ‘veterinary surgeons of high repute, to act as a check upon the Privy Council Inspectors’ [12]. The consultants were the principals of the three veterinary colleges in Scotland: James McCall of the Glasgow Veterinary College, Thomas Walley of Edinburgh’s Royal (Dick) Veterinary College (http://www.vet.ed.ac.uk/) and William Williams of Edinburgh’s New Veterinary College. Walley, who was accompanied by McCall, observed several

80

Review

Endeavour

Vol.29 No.2 June 2005

Figure 3. Gayfield House, Edinburgh, UK. Early on in the dispute, the US Commissioner of Agriculture directed Charles Lyman to proceed to Scotland and confer with Professor Williams at his New Veterinary College, which was based at Gayfield House. Image reproduced from a postcard given by Trevor Harding, resident of Gayfield house, to Justin Kastner in July 2002.

second edition of his book, originally authored in September 1879 but reprinted in subsequent editions, was devoted to the pleuro-pneumonia dispute:

Figure 2. Professor William Williams, Principal of the New Veterinary College in Edinburgh. Image reproduced from [24].

of the detained Ontario cattle coughing and, after viewing the lungs of two slaughtered animals, saw ‘without a doubt’ the lesions of pleuro-pneumonia. Williams also saw the animals before and after slaughter, but crucially he diagnosed the suspect animals with conventional bronchitis. There was no sign of pleuro-pneumonia, he argued [9,10]. Nevertheless, the inevitable occurred: on the basis of the diagnoses of its Veterinary Department, the Privy Council ordered that as of 3 March 1879, American cattle would no longer be exempt from compulsory slaughter [4]. The transatlantic veterinary community became engrossed in a heated debate. In March 1879, Williams wrote from his veterinary college at Gayfield House (Figure 3) to a colleague in New York. In the letter, which surfaced in The New York Times some weeks later, Williams reported that ‘the lungs said by Privy Council Inspectors to have pleuro-pneumonia’ showed signs of bronchitis but nothing more. ‘I have the specimens most carefully preserved, and am ready to show them to the whole world, and his wife, if necessary’, Williams wrote [15]. Conviction and controversy Williams voiced his opinions and displayed the lung specimens widely. He had assumed the presidency of the Royal College of Veterinary Surgeons (http://www.rcvs. org.uk/) in May 1879 [6] and was fast becoming an internationally sought-after scientific consultant [16]. Coloured plates of his specimens appeared in his internationally acclaimed textbook, The Principles and Practice of Veterinary Medicine (Figure 4). The preface to the www.sciencedirect.com

The existence and characteristics of PleuroPneumonia Contagiosa and Bronchitis.were lately the subject of differences of opinion between the Veterinary Officers of the Privy Council and the Author, in connection with the alleged existence of Pleuro against American Cattle imported into this country, and slaughtered at Liverpool to prevent contagion.The Author does not deny the existence of Pleuro in some of the Eastern States of America, but it has not yet been proved that this contagious malady prevails in the Western States, from whence cattle are brought to this country. Of this, however, he is confident, that in none of the diseased lungs of the cattle referred to did he find the characteristics of Contagious Pleuro; but, in all, those of Bronchitis [17]. A Member of Parliament, Anthony John Mundella, would give public voice to Williams’ insistence that the British authorities had made a ‘gross mistake’ in diagnosing American cattle with pleuro-pneumonia [18]. Many in America doubted the diagnoses made by the British authorities, and Williams clearly offered them a valuable British voice in the debate. In January 1880, Commissioner Le Duc hired Charles Lyman of Harvard University (http://www.harvard.edu/) to re-evaluate the prevalence of pleuro-pneumonia in the USA. When Lyman reported back to Le Duc in April, he confirmed that pleuro-pneumonia still persisted in several eastern states, but after examining hundreds of lungs from western cattle he had detected no signs of pleuro-pneumonia [9]. American zeal grew for the contention that cattle sourced west of the Allegheny Mountains did not present a threat of infection to British cattle. In June, Le Duc instructed Lyman to head to Britain and to inspect for himself the American cattle being landed at Liverpool and London [9]. On 4 July 1880, Lyman arrived at Liverpool. He went straight to Edinburgh to confer with Williams, who

Review

Endeavour

Vol.29 No.2 June 2005

Figure 4. ‘So-called’ Pleuro-pneumonia. The inside front cover of Professor Williams’ textbook on veterinary medicine signaled his doubts about the diagnoses made by the Privy Council. Reproduced by permission of the British Library (shelfmark: W25/1098 DSC).

brought out several samples from the Ontario animals. They did not indicate pleuro-pneumonia, he said, but rather conventional bronchitis [9]. Seeking to secure a range of opinions, Lyman then paid a visit to Walley, who had also inspected the Ontario livestock. In the post-script to his book on cattle diseases, which had just been published, Walley had voiced support for the policy of immediate slaughter of American cattle. However, he did remain open to the idea that cattle from the western USA were free from pleuro-pneumonia [19]. Walley reiterated his agreement with the conclusion made by the Privy Council Veterinary Department that some of the Ontario cattle had been suffering from the disease. However, he also told Lyman that he had seen other samples, also taken from American cattle condemned at Liverpool, which were not infected with pleuro-pneumonia [9]. Lyman proceeded to London and the Veterinary Department of the Privy Council. There he met with the www.sciencedirect.com

81

head of the Department, George Brown, and the chief inspector, A.C. Cope. Lyman put the ‘disease-free west’ argument to Brown, who flatly replied that a sufficient regulatory infrastructure did not exist in the USA to guarantee such a claim. Lyman insisted that the various state and railroad authorities could ensure the safe passage of cattle and that the federal inspection of them at the ports was adequate, but Brown was unmoved. While he was at the Veterinary Department, Lyman was also shown several lung samples of ‘American pleuro’. Preserved in fluid, the specimens exhibited the signs of contagious pleuro-pneumonia but were, according to Lyman, very different from the samples from the Ontario that he had seen in Williams’ collection. Aware of Lyman’s scepticism, Cope encouraged Lyman to visit the ports of Liverpool and Deptford, where Privy Council authorities could show him more samples. Lyman did just that, accompanying Privy Council veterinary inspectors in their supervision of American cattle imports in July and August 1880. During Lyman’s time in Liverpool, Privy Council inspectors examined 10 670 animals, six of which were found to have pleuropneumonia [9]. Lyman doubted that the disease was in fact pleuro-pneumonia, but he stopped short of accusing the British authorities of deliberate intrigue. However, Lyman and others in Washington continued to point to Williams’ contention that the Privy Council was mistaking bronchitis for pleuro-pneumonia. One of Lyman’s reports was followed by a six-page chapter, authored by Williams, for the US Government Annual Report of the Commissioner of Agriculture [20]. Professor Williams’ never-ending disagreement with the diagnosis of the British Government was but one part of a larger context in which microbiological science was still finding its feet. Microbiological analyses were not routinely used to diagnose pleuro-pneumonia. Instead, the naked eye was relied upon. As Lyman learned in Liverpool during the summer of 1880, British inspectors would conduct an ante-mortem inspection, singling out live American cattle that they suspected of having pleuropneumonia. Once the entire cargo had been slaughtered, the lungs of any suspicious animals were subject to postmortem inspection, during which the inspectors looked for certain visible lesions and symptoms [9]. This visual approach left a dangerous amount of room for interpretation, as Lyman noted during his tour of the Privy Council Veterinary Department. Microbiological science itself was still maturing. Louis Pasteur’s experiments of 1861 and Robert Koch’s validation of the germ theory of disease in 1876 meant that spontaneous generation seemed an increasingly unlikely explanation for disease. Nonetheless, such ideas were still new, and it was not until John Tyndall (1876) and Ferdinand Cohn (1877) demonstrated that bacterial spores were resistant to heat that the notion of spontaneous generation of disease was finally discredited. Furthermore, Koch did not formally elaborate his famous ‘postulates’ until his etiological study of tuberculosis in 1884 [21,22]. The novelty of such pioneering discoveries was evident in the attitude of the American and British veterinary community during the 1870s; late in the decade, both Walley and Law took the time

82

Review

Endeavour

Vol.29 No.2 June 2005

Box 1. Further reading Battista, C., Kastner, S. and Kastner, J. (2002) William Williams and the Transatlantic Trade Dispute Over Pleuro-Pneumonia. Available at http://fss.k-state.edu/research/multimedia/Williams.ram (online video produced by the Food Safety Network). Warwick, C.M. and Macdonald, A.A. (2003) The New Veterinary College, Edinburgh, 1873–1904. The Veterinary Record 153, pp. 380–386. Williams, J. (2001) William Williams. Veterinary History 11 (new series), pp. 9–19.

to refute arguments for the spontaneous generation of disease [4,19]. Nevertheless, the pleuro-pneumonia dispute was not dominated by debates about the spontaneous generation of disease or the germ theory. Veterinary scientists understood pleuro-pneumonia was a contagious disease – Fleming, Williams and Walley agreed that it was some sort of contagion – but the precise nature of the etiological agent would remain a mystery until 1898 [23].

Conclusion In the absence of this etiological evidence, it is easy to see how the dispute over the health of North American cattle came about. Pleuro-pneumonia is a disease with visible symptoms similar to non-contagious and less fatal respiratory diseases, such as bronchitis, that might develop during a stressful transoceanic voyage. But was Williams right? It is indeed possible that Professor Brown and his team of inspectors might have incorrectly diagnosed American cattle with pleuro-pneumonia. Although unique in Britain, Williams’ arguments were by no means far-fetched (for further details see Box 1). In addition to American veterinarians and diplomats, Canadian officials benefited from Williams’ convictions; when Canada lost its pleuro-pneumonia-free status in 1892, Williams returned to the fray. Alongside his challenge to the British authorities stood the ‘diseasefree west’ claim by the US Government, which the British Government continued to reject. Lyman joined his American colleagues in questioning the British diagnoses, but he could also see the larger and more important picture: as long as the USA did not have a robust regulatory system for inspecting cattle and certifying their health, the British Government would continue to order their immediate slaughter when they arrived in the UK. Lyman and other American public-health pioneers urged Congress to rectify this problem. These appeals, coupled with a growing appreciation in America for the risks posed by pleuro-pneumonia, prompted federal action and the eventual eradication of the disease in 1892. American diplomats continued to challenge the British Foreign Animals Order until the end of the 19th century. However, changes in the economic landscape soon made the matter less of an American preoccupation. After 1900, increasing demand for beef in the USA made British markets less crucial for American traders [8], and it was this, rather than any agreement over the diagnosis of pleuro-pneumonia, that resolved the dispute. www.sciencedirect.com

Epilogue On 12 November 1900, Professor Williams passed away. One tribute stressed the legitimacy of his scientific convictions, held for decades amidst the fires of controversy: The principal was a man whom no consideration could cause to swerve from what he considered just and right, and in the matter of public appointments he suffered greatly from the determined position which he took up against the Government veterinary authorities.in regard to the so-called pleuro-pneumonia in.cattle, the Principal holding that the malady in question was not pleuro at all, but was neither more nor less than bronch-pneumonia, which is non-contagious in character [24].

References 1 Wallace, R. (1890) Edinburgh University, Session 1890–91. Introductory Lecture to the Agriculture Class on American Cattle and the American Export Trade in Beef and Live Cattle to Great Britain, Wednesday, 22nd October 1890, Oliver and Boyd, Edinburgh, UK p. 18 and p. 20 2 Fisher, J.R. (1980) The economic effects of cattle disease in Britain and its containment, 1850–1900. Agricultural History 54, 278–294 3 McCarron, K. (1991) Meat at Woodside: The Birkenhead Livestock Trade 1878–1981, Merseyside Port Folios and the National Museums and Galleries on Merseyside Birkenhead, UK, pp. 19–21 4 The UK Parliament. Correspondence connected with the detection of pleuro-pneumonia among cattle landed in Great Britain from the United States of America. Sessional Papers LVIII (1878–1879), pp. 349–364 5 US Congressional Serial Set, S. Ex. Doc. No. 35, 45th Cong., 2nd Sess. (1878). Message from the President of the United States communicating.information in relation to the disease prevailing among swine and other domestic animals, pp. 142–145 6 Pattison, I. (1984) The British Veterinary Profession, 1791–1948, Allen, London, UK p. 73, p.82 and p. 121 7 Fleming, G. (1878) The Times 1 July, p. 11 8 Perren, R. (1978) The Meat Trade in Britain 1840–1914, Routledge & Kegan Paul, London, UK pp. 110–111, p.157 and p.162 9 US Congressional Serial Set, S. Ex. Doc. No. 5, 46th Cong., 3rd Sess. (1880). Documents.relative to contagious diseases of cattle, p.2, pp. 4–9, pp. 17–18 and pp. 23–25 10 US Congressional Serial Set, H. Ex. Doc. No. 53, 46th Cong., 2nd Sess. (1880). Pleuro-pneumonia in Neat Cattle, pp. 3–4 11 US Congressional Serial Set, S. Ex. Doc. No. 71, 45th Cong., 3rd Sess. (1879). Letter from the Secretary of the Treasury in relation to the exportation of live animals.and recommending legislation for an inspection.before shipment, p. 4 and pp. 6–8 12 The New York Times 1 February (1879), p. 5 13 Eastman was the largest American exporter of live cattle between 1877–1885, buying his cattle from representatives based in Kentucky and Illinois. Zimmerman, W.D. (1962) Live cattle export trade between United States and Great Britain, 1868–1885. Agricultural History 36, pp. 46–52 14 US Congressional Serial Set, S. Misc. Doc. No. 71, 45th Cong., 3rd Sess. (1879). Information on.pleuro-pneumonia among cattle, pp. 5–6 and p. 9 15 The New York Times 20 April (1879), p. 10 16 Amongst other international-consulting accolades, Williams was invited to the Ontario Provincial Exhibition to judge an essay contest on pleuro-pneumonia and other cattle diseases. Duncan, J.T. (1880) Contagious Diseases of Cattle: Prize Essay, MacLean, Roger & Co. Ottawa, Canada 17 Williams, W. (1888) The Principles and Practice of Veterinary Medicine, John Menzies & Co., Edinburgh, UK p. xii 18 The UK Parliament (1879) Hansard’s Parliamentary Debates CCXLVI (9 May–16 June), columns 128–129 19 Walley, T. (1879) The Four Bovine Scourges: Pleuro-Pneumonia, Foot-

Review

Endeavour

Vol.29 No.2 June 2005

and-Mouth Disease, Cattle Plague, Tubercle (Scrofula) With An Appendix on the Inspection of Live Animals and Meat, MacLachlan and Stewart, Edinburgh, UK pp. 8–9 and p. 206 20 Lyman, C.P. (1881) Report on contagious pleuro-pneumonia. In Annual Report of the Commissioner of Agriculture for 1880, pp. 571–584, US Government Printing Office Washington, DC, USA 21 Beck, R.W. (2000) A Chronology of Microbiology in Historical Context, ASM Press, Washington, DC, USA p. 81 and pp. 93–95

22 Brock, T.D. (1988) Robert Koch: A Lifetime in Medicine and Bacteriology, Science Tech Publishers, Madison, WI, USA p. vii, p. 2 and p. 139 23 Klieneberger-Nobel, E. (1962) Pleuropneumonia-Like Organisms (PPLO) Mycoplasmataceae, Academic Press, London, UK pp. 6–7 24 (1900) Editorial: The late principal Williams. The Veterinary Journal New Series 2, pp. 299–315

Elsevier joins major health information initiative Elsevier has joined with scientific publishers and leading voluntary health organizations to create patientINFORM, a groundbreaking initiative to help patients and caregivers close a crucial information gap. patientINFORM is a free online service dedicated to disseminating medical research and is scheduled to launch in 2005. Elsevier will provide the voluntary health organizations with increased online access to our peer-reviewed biomedical journals immediately upon publication, together with content from back issues. The voluntary health organizations will integrate the information into materials for patients and link to the full text of selected research articles on their websites. patientINFORM has been created to allow patients seeking the latest information about treatment options online access to the most up-to-date, reliable research available for specific diseases. ‘Not only will patientINFORM connect patients and their caregivers with the latest research, it will help them to put it into context. By making it easier to understand research findings, patientINFORM will empower patients to have a more productive dialogue with their physicians and make well-informed decisions about care’, said Harmon Eyre, M.D., national chief medical officer of the American Cancer Society.

For more information, visit www.patientinform.org www.sciencedirect.com

83