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Acceptable risks
Sot..Sci Ahi.Vol.24,No. II,pp.989-995, 1987 Pergamon Journals Ltd. Printed in Great Britain
BOOK REVIEWS
Acceptable Risks, by PASCAL IMPERATO and Jm MITCHELL.Viking, New York, 1985. 286~~. S15.95 From the premise that modem life is increasingly dangerous in spite of and as a result of technological scientific advances that shape it, this book explores “how risks are defined and responded to on a personal, corporate and govemmentaleven global-basis, why risks become acceptable for some and unacceptable for others.” This is an ambitious goal. Organized as a series of case studies, the first chapter, ‘Chosen Risks’, looks at how individuals opt to assume them. The authors define a chosen risk as “one taken with some knowledge of possible harmful consequences” and argue that our ability to make sensible choices about risky behaviors is often marred. First, and perhaps most important, a degree of irrationality forms part of our basic nature. “We assemble our personal-risk portfolios in an erratic.. way. Our reactions to risks are never entirely appropriate.” For example, we readily take long car trips in inclement weather but are inordinately afraid of remote threats such as being hit by lightning. Second, from our irrationality arises another impediment: denial. While denial helps us fall asleep in a dangerous world, it can be maladaptive in making risk choices. A recent National Cancer Institute survey showed that half of Americans believe that “everything causes cancer” and that “there is not much one can do to prevent cancer”. Cigarette advertising encourages this fatalistic attitude. Third, the imperfect nature of information interferes with wise choices. The facts are often “inadequate, overly complicated or just plain wrong”. To make matters worse, even experts may disagree about just how risky is a behavior. Lastly, the risk of many dangerous behaviors is in the future; the perceived benefit is immediate. Thus, the authors recount that people willingly tried to purchase the vacated homes around Love Canal. Another illustration is the dangerous jobs-take coal mining. Unemployment is a present danger for the miners while coal workers’ pneumoconiosis lies in the future. Furthermore, we tend to see occupational risks as more acceptable than nonoccupational ones, because we see them as chosen. This perception is reflected in higher exposure limits for workers than for the general public. Ironically, as the authors point out, what we perceive to be free choices may not be. The case studies on smoking and seat belts are most illustrative of personal risk issues. A more detailed section on the information on which we base our choices follows. An excellent case study outlines the adverse role that the dairy, egg and meat industries have played in influencing govemment recommendations on the American diet. After pointing out the fallacy of the notion (fostered by many regulation opponents) that individuals are free and informed in taking risks such as smoking and poor diets, the authors deal with ‘imposed risks’ that no one would argue are freely chosen. Because we are painfully aware that we have not made a personal choice to suffer the anxiety of a Three Mile Island accident, or the dangers of toxic wastes, these imposed risks of industry or of government tend to make us angry. In the case studies of benoxaprofen (the anti-arthritis drug which resulted in 43 deaths), and of the irradiation of food products, the authors point the blame both at industry, anxious to profit from products without the delay of lengthy testing, and at the inadequacy of government agencies (FDA) to safeguard our interests.
The next section examines the problems of defining risks. It critiques epidemiologic definitions; the public and professional skepticism of quantitative statistical findings, the inaccessible technical language used, the methodologic difficulties of defining risk factors for diseases with long latency periods. Laboratory tests to define risks may be tainted by shoddy methods or outright fraud as in the case which culminated in the conviction of officials of one of the nation’s oldest companies, Industrial Bio-Test Laboratories. Furthermore, potential conflicts of interest abound since the laboratories get most of their business from manufacturers rather than from governments. Assuming that a risk can be accurately defined, the problem of deciding whether a risk is worth taking remains. This is the knottiest problem, fundamentally political. Case studies on the oral contraceptive pill, toxic shock syndrome and the medical uses of radiation illustrate the difficulties (and politics) of trying to decide how much risk to take. The chapter, ‘Government Guardians’, discusses the antiregulation drive of the Reagan administration w-hich has decimated the agencies designed to protect the public. Countering the administration’s argument (that it is simply carrying out a popular mandate “to get government off the backs of the American people”), the authors cite data from public opinion polls which suggests the public favors even stricter safeguards. Three informative case studies follow on the controversies surrounding air bag use, the banning of urea-formaldehyde, and the relaxation of federal standards on bumpers. ‘Calculating Risks’ outlines the pitfalls of cost-benefit analysis on which policy decisions are often based. While cost-benefit appears neutral it is inherently subjective. The assignment of dollar values to a human life is inherently difficult. The authors cite a 1979 study done for the New York State Department of Health which concluded that estimates of the value of a life range from M9,226 to 61 million. To arrive at dollar values, factors such as income, productivity and treatment costs for diseases that might result from the risk are taken into account. Clearly, the method will tend to undervalue the lives of those with fewer economic resources. We need only take Imperato and Mitchell’s discussion one step further to realize that the method is blind to the social value of equity. We wiIl always come up with numbers that tell us that it makes the most sense to locate a toxic waste site where the poor reside. The concluding chapter, ‘What You Can Do About Health Risks’, focuses on smoking and dietary fats. The authors argue that physicians should take a greater role in health promotion, that large risk intervention trials should be funded, and that individuals should use the ‘Health Risk Appraisal’ to target their own self-help efforts to change. The book concludes with a discussion of the limits of the routine physical exam as a risk reduction technique. After many good chapters, this final one is disappointing. It offers no advice on how to deal with most of the health risks discussed. Indeed, many of the health risks are fundamentally political, requiring an informed, active public to demand the appropriate political solutions. By focusing on a few issues of chosen risks, the authors may be unwillingly adding to the denial which leads us to believe that nothing can be done about the imposed risks of toxic wastes or nuclear accidents. Even with respect to smoking, the authors ignore the role that the public could play in forcing elected
989
990
Book
Reviews
officials to end such practices as massive subsidies for the tobacco industry and to reimpower regulatory agencies to protect the public health. Furthermore, the authors insufficiently examine issues of equity in definitions of acceptable risk. Those with fewer economic resources are not only likely to smoke more and have poorer diets. but are more likely to have dangerous jobs. live next to sources of pollution and use potentially dangerous products because they often cost less. Although the authors do mention a few of these issues, they do not figure into the final recommendations. A further shortcoming is the lack of documentation. There are no footnotes. As a result, the style is largely anecdotal. Given the large amount of research that must have gone into the case studies, this is unfortunate, even for a book which is clearly intended for an educated lay audience. Readers may even challenge some of the book’s key assumptions. The authors state that “few people, in fact. demand a zero-risk society”, an assertion of interest to explore in light of the burgeoning of medical malpractice litigation in the United States today. Although pitched to an educated general public. the book will also make enjoyable, informative reading for medical and public health professionals. Its strength lies in the large number of case studies. Anyone who reads the volume will come away with the important lesson that we still have a tremendous amount of work to do in deciding which risks are acceptable and how we should deal with them. Deparrmenr of Medicine .Llassachuselts General Hospiral Boslon. Mass., c’.S.A.
STEPHANIE
LONDON
Reproductive Rituals: The Perception of Fertility in England from the Sixteenth Century to the Nineteenth Century, by ANGUS MCLAREN. Methuen. London, 1984. 150 pp. 525.00 cloth.
S12.95 paper
Histories of the early modern period (ISOO-1800) usually assume that the English could not and did not attempt to control fertility before the manufacture of rubber contraceptives in the nineteenth century. Not so. argues McLaren. Using insights from cultural anthropology and close reading of pnmary sources, including letters, diaries, unpublished family receipt books, herbals, folk-songs. proverbs, and court reports, he demonstrates that earlier generations were not ignorant, abject victims of biological forces. They believed that they could control reproduction, and did so with some effect. To most of us, controlling fertility means limiting family size. In England, as in most pre-industrial societies, controlling reproduction included increasing as well as decreasing the number of children born, preventing as well as causing miscarriages, setting the age of marriage, and, most important. spacing children sufficiently far apart to insure the health of mother and child. Popular beliefs about sexuality linked pleasure with reproduction. and were egalitarian. It was considered absolutely necessary that the woman enjoy intercourse for conception to occur. Conception after rape was proof of a woman’s complicity. Not until the eighteenth century, when scientific theories separated sexual pleasure from conception. were women regarded as asexual. Many English villagers apparently wished to limit their families and succeeded in doing so: completed marital fertility was well below that on the Continent. Means of control included late marriage, post-partum abstinence, prolonged breast-feeding, magical practices that McLaren argues could have had psychological effects, and herbal medicines. The reader wishes that we knew more about the pharmacological effects of the many recipes described. but this is not a treatise on biology. McLaren’s point is that
before the Industrial Revolution iorced them to abandon traditional practices, most people believed that fertility was their own social creation. McLaren stresses the importance of a ‘women’s culture’ in providing mutual aid to promote or limit fertility. Abortion was one of the most important means of fertiltty control. Unlike contraception, vvhich often requires the cooperation of the male, abortion in pre-industrial societies is under women‘s control. and is sometimes preferred over contraception. Women in most societies are not easily impressed by the formal religious or legal codes developed by male doctors, lawyers, or priests. Women in early modern England considered abortion their right in the early months before ‘quickening’. the child’s first movement in the womb. The means used were mostly pills. and though not reliable, did not require a doctor’s intervention nor eltctt prosecution. English doctors argued for the passage of abortion laws in the early 1800s in order to wrest control from women and midwives. ‘Quickening’ was a women’s definition of fetal life that gave the patient some power. In order to gain control. doctors rejected quickening as a criterion and argued that abortion should be a crime from the moment of conception. unless it was ‘therapeutic’. that is. performed by a doctor after consulting with his colleagues. Professional selfinterest, rather than a desire to save fetal life. was the major motive in the criminalization of abortion, which signaled the end of traditional reproductive rituals. In 1803. in an ironic legal trade-off. the law prescribing the death penalty for infanticide was repealed. and procuring an abortion became a capital crime. According to McLaren. “Doctors had accomplished the remarkable feat of creating a taboo which they alone could freely violate” (p. 144). The recent development of the first safe, effective abortifacient pill once again raises the issue of control. Everyone concerned with the potential societal effects of these pills. which may make early abortion a woman’s private act. as it was before 1800, should read the Introduction and the two chapters on abortion to gain historical perspective. Students of American medical history will also tind these chapters useful, as the United States followed a similar course with regard to abortion later in the nineteenth century. In general, this is a readable, well-balanced book that fills an important gap in our knowledge about fertility control in pre-industrial England. School of Public Health Boston Uni:nicersir) Boston, Mass.. L’.S.A.
DORO~H-Y C. WERTZ
The Nicaraguan Revolution in Health: From Samoza to the Sandinistas, by JOHN DONAHLT. Bergin & Garvey, South Hadley, Mass.. 1986. 185 pp. 527.95 Few aspects of a society in transformation provide as clear a window through which to view social change as does health care. This has been particularly true in Nicaragua where a neglected and fragmented health care system has been radically reorganized since the fall of the Samoza regime in 1979. This excellent book by Professor John M. Donahue analyzes both the changes in health care delivery and the process by which these changes have occurred. After a brief review of the state of health in Nicaragua during the Samoza years, Donahue discusses the Sandinista plan for the creation of a unified health care system, the creation of nationwide health organizations. the mobilization of other mass organizations. the training of popular health workers, and the development of mass popular health campaigns. Difficult internal issues, many of which still exist, such as conflicts between professional and nonprofessional health workers and between rural and urban areas, are discussed frankly and informatively.
BOOK REVIEWS
Acceptable Risks, by PASCAL IMPERATO and Jm MITCHELL.Viking, New York, 1985. 286~~. S15.95 From the premise that modem life is increasingly dangerous in spite of and as a result of technological scientific advances that shape it, this book explores “how risks are defined and responded to on a personal, corporate and govemmentaleven global-basis, why risks become acceptable for some and unacceptable for others.” This is an ambitious goal. Organized as a series of case studies, the first chapter, ‘Chosen Risks’, looks at how individuals opt to assume them. The authors define a chosen risk as “one taken with some knowledge of possible harmful consequences” and argue that our ability to make sensible choices about risky behaviors is often marred. First, and perhaps most important, a degree of irrationality forms part of our basic nature. “We assemble our personal-risk portfolios in an erratic.. way. Our reactions to risks are never entirely appropriate.” For example, we readily take long car trips in inclement weather but are inordinately afraid of remote threats such as being hit by lightning. Second, from our irrationality arises another impediment: denial. While denial helps us fall asleep in a dangerous world, it can be maladaptive in making risk choices. A recent National Cancer Institute survey showed that half of Americans believe that “everything causes cancer” and that “there is not much one can do to prevent cancer”. Cigarette advertising encourages this fatalistic attitude. Third, the imperfect nature of information interferes with wise choices. The facts are often “inadequate, overly complicated or just plain wrong”. To make matters worse, even experts may disagree about just how risky is a behavior. Lastly, the risk of many dangerous behaviors is in the future; the perceived benefit is immediate. Thus, the authors recount that people willingly tried to purchase the vacated homes around Love Canal. Another illustration is the dangerous jobs-take coal mining. Unemployment is a present danger for the miners while coal workers’ pneumoconiosis lies in the future. Furthermore, we tend to see occupational risks as more acceptable than nonoccupational ones, because we see them as chosen. This perception is reflected in higher exposure limits for workers than for the general public. Ironically, as the authors point out, what we perceive to be free choices may not be. The case studies on smoking and seat belts are most illustrative of personal risk issues. A more detailed section on the information on which we base our choices follows. An excellent case study outlines the adverse role that the dairy, egg and meat industries have played in influencing govemment recommendations on the American diet. After pointing out the fallacy of the notion (fostered by many regulation opponents) that individuals are free and informed in taking risks such as smoking and poor diets, the authors deal with ‘imposed risks’ that no one would argue are freely chosen. Because we are painfully aware that we have not made a personal choice to suffer the anxiety of a Three Mile Island accident, or the dangers of toxic wastes, these imposed risks of industry or of government tend to make us angry. In the case studies of benoxaprofen (the anti-arthritis drug which resulted in 43 deaths), and of the irradiation of food products, the authors point the blame both at industry, anxious to profit from products without the delay of lengthy testing, and at the inadequacy of government agencies (FDA) to safeguard our interests.
The next section examines the problems of defining risks. It critiques epidemiologic definitions; the public and professional skepticism of quantitative statistical findings, the inaccessible technical language used, the methodologic difficulties of defining risk factors for diseases with long latency periods. Laboratory tests to define risks may be tainted by shoddy methods or outright fraud as in the case which culminated in the conviction of officials of one of the nation’s oldest companies, Industrial Bio-Test Laboratories. Furthermore, potential conflicts of interest abound since the laboratories get most of their business from manufacturers rather than from governments. Assuming that a risk can be accurately defined, the problem of deciding whether a risk is worth taking remains. This is the knottiest problem, fundamentally political. Case studies on the oral contraceptive pill, toxic shock syndrome and the medical uses of radiation illustrate the difficulties (and politics) of trying to decide how much risk to take. The chapter, ‘Government Guardians’, discusses the antiregulation drive of the Reagan administration w-hich has decimated the agencies designed to protect the public. Countering the administration’s argument (that it is simply carrying out a popular mandate “to get government off the backs of the American people”), the authors cite data from public opinion polls which suggests the public favors even stricter safeguards. Three informative case studies follow on the controversies surrounding air bag use, the banning of urea-formaldehyde, and the relaxation of federal standards on bumpers. ‘Calculating Risks’ outlines the pitfalls of cost-benefit analysis on which policy decisions are often based. While cost-benefit appears neutral it is inherently subjective. The assignment of dollar values to a human life is inherently difficult. The authors cite a 1979 study done for the New York State Department of Health which concluded that estimates of the value of a life range from M9,226 to 61 million. To arrive at dollar values, factors such as income, productivity and treatment costs for diseases that might result from the risk are taken into account. Clearly, the method will tend to undervalue the lives of those with fewer economic resources. We need only take Imperato and Mitchell’s discussion one step further to realize that the method is blind to the social value of equity. We wiIl always come up with numbers that tell us that it makes the most sense to locate a toxic waste site where the poor reside. The concluding chapter, ‘What You Can Do About Health Risks’, focuses on smoking and dietary fats. The authors argue that physicians should take a greater role in health promotion, that large risk intervention trials should be funded, and that individuals should use the ‘Health Risk Appraisal’ to target their own self-help efforts to change. The book concludes with a discussion of the limits of the routine physical exam as a risk reduction technique. After many good chapters, this final one is disappointing. It offers no advice on how to deal with most of the health risks discussed. Indeed, many of the health risks are fundamentally political, requiring an informed, active public to demand the appropriate political solutions. By focusing on a few issues of chosen risks, the authors may be unwillingly adding to the denial which leads us to believe that nothing can be done about the imposed risks of toxic wastes or nuclear accidents. Even with respect to smoking, the authors ignore the role that the public could play in forcing elected
989
990
Book
Reviews
officials to end such practices as massive subsidies for the tobacco industry and to reimpower regulatory agencies to protect the public health. Furthermore, the authors insufficiently examine issues of equity in definitions of acceptable risk. Those with fewer economic resources are not only likely to smoke more and have poorer diets. but are more likely to have dangerous jobs. live next to sources of pollution and use potentially dangerous products because they often cost less. Although the authors do mention a few of these issues, they do not figure into the final recommendations. A further shortcoming is the lack of documentation. There are no footnotes. As a result, the style is largely anecdotal. Given the large amount of research that must have gone into the case studies, this is unfortunate, even for a book which is clearly intended for an educated lay audience. Readers may even challenge some of the book’s key assumptions. The authors state that “few people, in fact. demand a zero-risk society”, an assertion of interest to explore in light of the burgeoning of medical malpractice litigation in the United States today. Although pitched to an educated general public. the book will also make enjoyable, informative reading for medical and public health professionals. Its strength lies in the large number of case studies. Anyone who reads the volume will come away with the important lesson that we still have a tremendous amount of work to do in deciding which risks are acceptable and how we should deal with them. Deparrmenr of Medicine .Llassachuselts General Hospiral Boslon. Mass., c’.S.A.
STEPHANIE
LONDON
Reproductive Rituals: The Perception of Fertility in England from the Sixteenth Century to the Nineteenth Century, by ANGUS MCLAREN. Methuen. London, 1984. 150 pp. 525.00 cloth.
S12.95 paper
Histories of the early modern period (ISOO-1800) usually assume that the English could not and did not attempt to control fertility before the manufacture of rubber contraceptives in the nineteenth century. Not so. argues McLaren. Using insights from cultural anthropology and close reading of pnmary sources, including letters, diaries, unpublished family receipt books, herbals, folk-songs. proverbs, and court reports, he demonstrates that earlier generations were not ignorant, abject victims of biological forces. They believed that they could control reproduction, and did so with some effect. To most of us, controlling fertility means limiting family size. In England, as in most pre-industrial societies, controlling reproduction included increasing as well as decreasing the number of children born, preventing as well as causing miscarriages, setting the age of marriage, and, most important. spacing children sufficiently far apart to insure the health of mother and child. Popular beliefs about sexuality linked pleasure with reproduction. and were egalitarian. It was considered absolutely necessary that the woman enjoy intercourse for conception to occur. Conception after rape was proof of a woman’s complicity. Not until the eighteenth century, when scientific theories separated sexual pleasure from conception. were women regarded as asexual. Many English villagers apparently wished to limit their families and succeeded in doing so: completed marital fertility was well below that on the Continent. Means of control included late marriage, post-partum abstinence, prolonged breast-feeding, magical practices that McLaren argues could have had psychological effects, and herbal medicines. The reader wishes that we knew more about the pharmacological effects of the many recipes described. but this is not a treatise on biology. McLaren’s point is that
before the Industrial Revolution iorced them to abandon traditional practices, most people believed that fertility was their own social creation. McLaren stresses the importance of a ‘women’s culture’ in providing mutual aid to promote or limit fertility. Abortion was one of the most important means of fertiltty control. Unlike contraception, vvhich often requires the cooperation of the male, abortion in pre-industrial societies is under women‘s control. and is sometimes preferred over contraception. Women in most societies are not easily impressed by the formal religious or legal codes developed by male doctors, lawyers, or priests. Women in early modern England considered abortion their right in the early months before ‘quickening’. the child’s first movement in the womb. The means used were mostly pills. and though not reliable, did not require a doctor’s intervention nor eltctt prosecution. English doctors argued for the passage of abortion laws in the early 1800s in order to wrest control from women and midwives. ‘Quickening’ was a women’s definition of fetal life that gave the patient some power. In order to gain control. doctors rejected quickening as a criterion and argued that abortion should be a crime from the moment of conception. unless it was ‘therapeutic’. that is. performed by a doctor after consulting with his colleagues. Professional selfinterest, rather than a desire to save fetal life. was the major motive in the criminalization of abortion, which signaled the end of traditional reproductive rituals. In 1803. in an ironic legal trade-off. the law prescribing the death penalty for infanticide was repealed. and procuring an abortion became a capital crime. According to McLaren. “Doctors had accomplished the remarkable feat of creating a taboo which they alone could freely violate” (p. 144). The recent development of the first safe, effective abortifacient pill once again raises the issue of control. Everyone concerned with the potential societal effects of these pills. which may make early abortion a woman’s private act. as it was before 1800, should read the Introduction and the two chapters on abortion to gain historical perspective. Students of American medical history will also tind these chapters useful, as the United States followed a similar course with regard to abortion later in the nineteenth century. In general, this is a readable, well-balanced book that fills an important gap in our knowledge about fertility control in pre-industrial England. School of Public Health Boston Uni:nicersir) Boston, Mass.. L’.S.A.
DORO~H-Y C. WERTZ
The Nicaraguan Revolution in Health: From Samoza to the Sandinistas, by JOHN DONAHLT. Bergin & Garvey, South Hadley, Mass.. 1986. 185 pp. 527.95 Few aspects of a society in transformation provide as clear a window through which to view social change as does health care. This has been particularly true in Nicaragua where a neglected and fragmented health care system has been radically reorganized since the fall of the Samoza regime in 1979. This excellent book by Professor John M. Donahue analyzes both the changes in health care delivery and the process by which these changes have occurred. After a brief review of the state of health in Nicaragua during the Samoza years, Donahue discusses the Sandinista plan for the creation of a unified health care system, the creation of nationwide health organizations. the mobilization of other mass organizations. the training of popular health workers, and the development of mass popular health campaigns. Difficult internal issues, many of which still exist, such as conflicts between professional and nonprofessional health workers and between rural and urban areas, are discussed frankly and informatively.