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‘If this is what it's doing to our washing, what is it doing to our lungs?’ Industrial pollution and public understanding in North-East England
Soc. Sci. Med. Vol. 41, No. 6, pp. 883-891, 1995
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Pergamon
0277-9536(94)00380-7
Copyright © 1995 ElsevierScienceLtd Printed in Great Britain. All rights reserved 0277-9536/95 $9.50 + 0.00
'IF THIS IS WHAT IT'S D O I N G TO O U R WASHING, WHAT IS IT D O I N G TO O U R LUNGS?' I N D U S T R I A L P O L L U T I O N A N D PUBLIC U N D E R S T A N D I N G IN N O R T H - E A S T ENGLAND
SUZANNEM O F F A T T ,
P E T E R P H I L L I M O R E , R A J B H O P A L and CHRISTOPHER FOY Departments of Epidemiology and Public Health and Social Policy, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, England Abstract--An epidemiological study of the impact of industrial pollution from a coking works in north-east England on the health of a population resident nearby uncovered strong but localised public concern about the possible dangers of air pollution. This paper discusses these popular concerns in the context of empirical findings from the study which examined evidence of ill-health alongside evidence on air quality levels. The substantive issues this paper examines relate to local variations in popular beliefs about health risks, and the relation between such beliefs and measurable differences in health states and status. The methodological issues addressed centre on the difficulties of interpreting this relationship between popular beliefs and concerns, on the one hand, and health experience, or apparent health experience, on the other. Key words--environmental controversy, public views, health status, health risk
INTRODUCTION
nearby, they are suffering the perceived disadvantages, which may be viewed in terms of health or the environment. This paper arises out of an epidemiological study of the impact of industrial pollution from a coking works in north-east England on the health of a population resident nearby, the main findings are summarised elsewhere [3]. The research was undertaken in response to strong but localised public concern about the possible dangers of air pollution from this site. Evidence gathered as a by-product of the main study reinforced our awareness as researchers of the extent of public concern about coking emissions. We shall discuss these popular concerns in the context of empirical findings from the study which examined evidence of ill-health alongside evidence on air quality levels. The substantive issues this paper examines relate to local variations in popular beliefs about health risks from coking pollution, using survey data, and the relationship between such beliefs and measurable differences in health states and status. The methodological issues addressed centre on the difficulties of interpreting this relationship between popular beliefs and concerns, on the one hand, and health experience, or apparent health experience, on the other. There has been a tendency in the literature for epidemiological studies investigating the health effects of particular industries on surrounding populations to ignore studies of 'lay beliefs'* [4-6], while those interested in such beliefs have not generally been interested in how they modify our understanding of
Over the last few years, it has become increasingly common for groups and communities in the richer countries of the world to voice concerns about industrial pollution, emphasising in local campaigns unease about damage to health and environmental degradation [1]. This new wave of concern has coincided with the disappearance of much of the old industrial landscape, as coal and steel industries in particular have contracted to a fraction of the size they were barely one generation ago. But even where heavy industries survive, a bond which often existed in the past between an industry and its neighbouring population has been greatly weakened in the last 20-30 years. Local residents are less and less likely to be the workforce: the workforce are less and less likely to be local residents. Influences are various, but include: new technologies and the resultant decline in manual jobs; improved transport, making possible the geographical separation of home and work; and raised public expectations about the quality of life and the environment [2]. Not only are decreasing numbers of people gaining whatever are perceived to be the direct benefits of living close to industry; but by remaining *The term 'lay beliefs' is itself an interesting one, that only has currency in the context of an explicit contrast with the views of a more powerful group who can claim expert or authoritative status--scientists, the medical profession, the legal profession, or of course the church. Thus, views of 'lay' people by definition lack authority--and the term qay beliefs' can easily function as a euphemism for 'popular misconceptions'. 883
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health patterns [7-10]. The measurement of health differences within the population presupposes the application of standardised criteria to enable comparison of 'like with like' to take place. Popular beliefs about health, and the impact that such beliefs have on the ways that ill-health manifests itself, tend to be seen as disconcerting obstacles to epidemiological investigation, rather than as inherently relevant facets of it. Case control methodology, the cornerstone of epidemiological research, assumes that factors other than those which are the focus of investigation can be held constant• In contrast, the study of popular beliefs assumes a diversity that is the antithesis of holding variables constant. Exploration of the varied ways in which ill-health is acknowledged and enacted and finally treated, lends itself to an amplification of what is atypical and distinctive. Clarity in 'case definition' is central to the epidemiological project in this regard. Yet the further removed from the clinical setting and bio-chemical procedures that research on health moves, the more elusive and chimerical a notion case definition can become.
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Moreover, where questions of disease prevalence and uneven distribution have disputed or potentially controversial causes, the more likely it is that popular beliefs will be regarded not simply as an irrelevance but as an obstacle to scientific enquiry• In such contexts, beliefs are liable to be seen as the reflection of a 'sensitised' population, distorting clarification of 'real' levels of ill-health. This paper is written against such a stance, using our research on the health impact of the Monkton Coking Works as a case study. We shall argue that there is a need to bring together these two facets of health. On the one hand, epidemiological research that attempts to put to one side local concerns and popular beliefs thereby distorts the very reality it so assiduously seeks to describe. On the other hand, because illness strikes unevenly and unequally a focus on the ways that people think about and experience illness without reference to the causation of that illness is incomplete, because it ignores the contrasting material conditions and constraints shaping people's lives.
AREA AROUND MONKTONCOKINGWORKS 1937 SHOWING CONTEMPORARYHOUSING ~ ~_,~ :.. /./,./
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Industrial pollution in north-east England We begin, however, by sketching the background to concerns about the contribution of the Monkton Coking Works to ill-health in the surrounding population. BACKGROUND
The controversy which led to the study described here goes back not to the commissioning of the Monkton Coking Works in 1937, but to the completion of a housing estate in the early 1950s which at its closest point was just 250 m from the works. At the time of Monkton Coking Works' construction, the nearest housing was approx 1.5 km north (Fig. 1). With the exception of a few farms, no housing existed to the south and west for several kilometres. This particular location offered considerable advantages: proximity to raw materials; easy distribution of coke via railway, road and sea; and it was sufficiently distant from built-up areas to minimise any adverse effects from the pollution caused by the coking process.
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After the Second World War, slum clearances took place on a large scale in Hebburn and Jarrow (the relevant local authorities prior to 1974), with a correspondingly large programme of new house building throughout the 1950s, 1960s and early 1970s. A good deal of new housing was built within 2.5 km of the Works (Fig. 2). All except one of the estates surrounding the Works are council-owned and the estates to the east and south whose boundaries lay within 0.75 and 1.0 km of the Works were the last to be completed in the early 1970s. In 1968, Hebburn and Jarrow became smokeless zones. The Coking Works may have been built before the wave of post-war housing estates were created, but the prevailing expectation among local residents by the later 1970s seems to have been that the plant was in the later stages of its useful life. However, in 1980, the Works returned to two-battery production (66 ovens) after a period of 20 years in which only one battery had been in operation (with the exception of a few months in 1972). In the same year, a Residents Action Group was formed to campaign about the pollution from the
AREA AROUND MONKTON COKING WORKS 1967 SHOWING CONTEMPORARY HOUSING
Fig. 2
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works. Numerous complants were lodged with the Local Authority Environmental Health Department. Their authority was limited, for as a scheduled industrial process the Monkton Coking Works came under the jurisdiction of Her Majesty's Inspectorate of Pollution (HMIP), an organisation with no requirement to respond to the concerns of individual residents. The Works was closed during the 1984-85 Miners' Strike, and was not reopened until January 1986. By this time, only about 4% of the workforce came from the locality (about 10 men). The residents resumed their campaign after production restarted, focusing by this time particularly on the potential health effects of air pollution. In 1987, however, a planning application by the company to use flared gas to generate electricity galvanised local opposition to the Works and escalated this long-running dispute in which the company, the local community and the Local Authority were by this stage all at loggerheads. Local residents continued registering complaints with the Environmental Health Department, and repeatedly called for a health study. In the end, in 1989, the Residents Action Group carried out their own health survey, covering some 1400 households. This survey helped persuade South Tyneside MBC that an independent study was required, in the hope that it would answer once and for all whether or not pollution from coking production caused or contributed to ill-health in the local population. However, within 9 months of the study starting, and before the Secretary of State had reached a decision on the planning application for an electricity generating station at the Coking Works, the company suddenly announced the closure of the Monkton Works, on economic grounds.
STUDY DESIGN AND APPROACH
The epidemiological study was designed to integrate data on different aspects of health: drawing together evidence from routine health statistics (post-coded mortality, cancer registration and birth information), the patient records of General Practitioners, a population survey, and tests of lung function, and analysing these data alongside air quality data derived both from local authority monitoring sites and also from the computer modelling of stack emissions [3]. In geographical terms, the analysis was built around a three-way comparison. A 'study area' was defined in terms of proximity to the Coking Works. Study areas of different size were adopted for different parts of the study, being widest where routine statistics were available for analysis and narrowest where original data collection was involved. In each case, however, a further distinction was made, dividing the designated study area into an 'inner' and 'outer' portion. These areas were compared with a single 'control area' made up of several adjoining housing estates located 6-10 km east of the works. Identifying a suitable matching
population and housing environment for comparison was aided by the remarkable similarity in the social and economic character of many parts of South Tyneside [11]. The sudden ending of production at Monkton, less than 1 month after closure was announced, forced us to rethink several aspects of the design. In particular, a postal survey of a random sample of the population had to be mounted at short notice, as this was the only way to collect information directly from those living in the vicinity of the Coking Works while it was still a continuing feature of their lives. At the same time, this unexpected turn of events presented certain opportunities. The timing of the survey allowed us to gather information on people's views of the expected health consequences of the ending of coking operations. Moreover, while recognising that we could not study perceptions of the health effects of pollution in depth using a postal questionnaire, we did not want the limitations of the method forced on us to dissuade us from taking the opportunity to explore any recurring themes in local concerns. Several studies of disputes between communities affected by industrial pollution, the firms whose emissions are the cause of complaint, and government agencies, have illustrated the importance of direct communication with the affected public in the U.S.A. [12-15]. Indeed, environmental researchers at the U.S. Environmental Communication Research Program now recommend at the start of any investigation "paying (as much) attention to the community's perception of the risk and to the community's concerns, as to scientific variables" [16]. Our approach led us in the same direction. From the outset we opened a dialogue with all the parties involved: partly to establish the 'open' and unconstrained nature of the research; and partly because each group held information which was useful or essential for the successful completion of the research. While our approach with each party inevitably differed, the same basic principle of open communication was followed. An academic protocol was developed and circulated for discussion to the industry, Local Authority and HMIP. Public meetings were held with local residents to outline the proposed research and to hear residents' views and suggestions. Approaches to the workforce, via their Union, were delayed initially but then became irrelevant following closure. At public meetings there was overwhelming support for the study from the total of 200 or so local residents who attended. People present expressed concern about the possibility of ill-health caused by pollution, especially among children, the elderly and those with respiratory conditions. Where critics expressed a view, it was generally to argue that research was an expensive way for local government and industry to 'buy time', not to deny the impact of air pollution on their lives. These meetings paved the way for periodic dialogue with the Residents Action Group at a number
Industrial pollution in north-east England of informal meetings. This h a d the a d v a n t a g e of showing our c o n t i n u e d involvement with the study, a n d m a y have helped to increase participation in the p o p u l a t i o n survey t h a t we undertook. Perhaps more importantly, we h o p e d t h a t the dialogue would emphasise to residents t h a t their concerns were being listened to and t a k e n seriously, a n d that the research was not a closed debate a m o n g supposed experts from which they were excluded. In u n d e r t a k i n g this study, our task was to retain a dispassionate stance. Classically, in epidemiological research this has been done by separating the observers from all possible influences which might vitiate the reliability of the observation. Yet in a case such as that described here, that stance would a m o u n t to pretending t h a t the study was taking place in a vacuum. It was far more defensible, in our view, to recognise t h a t the local controversy was an inescapable part of the study, requiring the researchers to listen to a variety of different u n d e r s t a n d i n g s of the problem. F r o m this perspective, the voice of the people most affected becomes a crucial element of the study, not a peripheral distraction [16-19].
SELECTED EMPIRICAL FINDINGS The empirical data presented here relate to certain parts only of the overall study: namely, some o f the findings from the postal survey m e n t i o n e d above. This survey produced a 6 9 % response ( N = 3015), with little divergence between inner, outer a n d control areas. R e s p o n d e n t s also exhibited very similar social and economic characteristics, as anticipated, apart from a small but statistically significant excess of smokers in the control area (sample details are described elsewhere [3, 20]). Two kinds of evidence will be d r a w n on in this section o f the paper. To start with, salient quantitative findings on perceptions o f
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the causes of stress, a n d the distribution o f symptoms, will be summarised, based on pre-coded categories in the questionnaire. We then amplify our t r e a t m e n t of individual experience of air pollution a n d health by using v e r b a t i m extracts from c o m m e n t s respondents m a d e in a n open section concluding the questionnaire. Table 1 brings together a variety o f j u d g e m e n t s a b o u t health in the populations compared. A m o n g adults, few differences emerge in response to a question a b o u t 'your general health' (drawn from the G e n e r a l H o u s e h o l d Survey), a l t h o u g h when children's general health was assessed a discrepancy between study a n d control areas was a p p a r e n t [Table l(a)]. Yet w h e n respondents were asked a b o u t the effects of coking emissions on health (or emissions from local industry more generally in the control area), a sharp gradient emerges, with the outer area mid-way between inner and control areas [Table l(b)]. M o r e t h a n 4 0 % of adults in the inner area reported t h a t their health h a d been adversely affected to some degree by coking emissions, with a corresponding figure for children o f 34%. W h e n adults were asked to assess the impact o f coking pollution on the health of others they knew well, the figure rose higher still. The p r o b l e m s attributed to coking emissions were relatively specific, with upper and lower respiratory tract disorders featuring prominently, followed by wider concern a b o u t a dirty e n v i r o n m e n t [Table 1(c)]. M o r e t h a n half the adults in the inner area expected their health to improve following closure of the coking works [Table l(d)]--interestingly this figure is s o m e w h a t greater t h a n those reporting a n effect from air pollution o n their own health [Table l(b)]. Against that b a c k g r o u n d , the next two tables assess the relative importance of a range of factors, pre-specified from a checklist, in creating stress or anxiety (Table 2), or putting health at risk (Table 3),
Table 1. Views on health and expected changes in health due to the closure of Monkton Coking Works (MCW)/local industry Adults Children Inner Outer Control Inner Outer Control (N=725) (N=812) (N=793) X-~for (N = 231) (N = 233) (N = 221) ;(2 for (%) (%) (%) trend P value (%) (%) (%) trend P value (a) General health Excellent/good 63 65 68 85.1 83.5 92.8 Fair/poor 37 35 32 3.35 0.08 14.9 16.5 7.2 5.77 0.02 (b) MCW (inner and outer)/ or local industry (control)/ has had an effect 1. On my health 42 20 13 166 < 0.00001 34 21 5 58.2 < 0.00001 2. On the health of people I know well 64 40 29 150 < 0.00001 56 37 22 51.1 < 0.00001 (c) Problems due to MCW/ local industry 1. Upper respiratory tract disorder 17 6 1 151 < 0.00001 17 10 1 43.7 < 0.00001 2. Lower respiratory tract disorder 14 8 2 95.2 < 0.00001 15 9 I 28.8 < 0.00001 3. Non-health problems 11 6 1 89.1 < 0.00001 0.002 4 1 0 9.48 (d) Expect a health change due to MCW/local/ industry closure 52 30 22 142 < 0.00001 48 33 20 38 < 0.00001
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Table 2. Adults" views on causes of stress or anxiety in the past year (in rank order of frequency in the inner area). Q: Have any of these things been a cause of stress or anxiety for you in the last year? (figures are percentages saying yes)
Unpleasant smells from outside the home Air pollution Money problems Dirt Other people's health problems Own health problems Work problems Always being in a hurry Family problems Noise Unemployment Problems with neighbours Housing problems
Inner (N = 725) (%)
Outer (N = 812) (%)
Control (N = 793) (%)
43 34 23 20 19 19 16 15 14 14 12 5 4
23 12 26 7 19 18 16 13 15 6 12 4 6
4 3 26 1 18 17 14 14 18 3 14 5 4
T w o p o i n t s n e e d to be m a d e a b o u t t h e s e tables. First, t h e t h r e e g r o u p s o f r e s p o n d e n t s were v e r y s i m i l a r in t h e levels o f stress s e e n to be c a u s e d b y m o n e y p r o b l e m s , o n e ' s o w n o r s o m e o n e else's h e a l t h p r o b l e m s , w o r k , housing or neighbour problems. Differences between t h e s e p o p u l a t i o n s r e v o l v e d crucially a r o u n d p o l l u t i o n c o n c e r n s - - a i r p o l l u t i o n a n d smell, d u s t a n d dirt, noise, a n d i n t e r e s t i n g l y traffic p o l l u t i o n - - a n d t h e s e a l o n e . B u t in T a b l e 3, so p r e d o m i n a n t w a s t h e e m p h a s i s o n external sources of pollution--whether from industry o r t r a f f i c - - i n t h e i n n e r a r e a t h a t s m o k i n g h a b i t s , diet, working conditions and even money problems a s s u m e d slightly less i m p o r t a n c e in r e s p o n d e n t s ' j u d g e m e n t as f a c t o r s e n d a n g e r i n g h e a l t h . More qualitative data, from respondents' comm e n t s , r e i n f o r c e t h e s e differences in t h e m a i n c o n c e r n s a b o u t c a u s e s o f stress a n d ill-health b e t w e e n t h e p o p u l a t i o n s o f t h e t h r e e areas. R e s p o n s e s were grouped into certain broad categories, the most c o m m o n b e i n g listed in T a b l e 4. I n b o t h t h e s t u d y areas, c o m m e n t s m o s t f r e q u e n t l y r e l a t e d to u n e a s e o r w o r r y a b o u t p o s s i b l e h e a l t h effects o f t h e M o n k t o n e m i s s i o n s . U n c e r t a i n t y , n o t c o n v i c t i o n , is t h e h a l l m a r k
X2 for trend 322 265 1.27 173 0.59 1.19 1.37 0.23 5.12 70 2.02 0.03 0.007
P value < 0.00001 < 0.00001 0.26 < 0.00001 0.44 0.28 0.24 0.63 0.024 < 0.00001 0.16 0.87 0.93
of these statements, expressed with observations about s m o k e a n d d u s t i n h a l a t i o n . A selection o f s t a t e m e n t s is p r e s e n t e d below. W o m a n aged 31, Surely this black smoke must be getting on people's chests causing breathing problems. M a n aged 28, I can't believe that the fumes and dust spewing from the coke works can be taken into a h u m a n ' s lungs and have no effect whatsoever. Parent of a 12 year old, If we have been inhaling what I clean off my windows and paint work, we should all feel better. Some respondents linked observed environmental effects w i t h p o t e n t i a l h e a l t h effects: W o m a n aged 52, If the plants and trees were dying, the air pollution couldn't have done me much good. F e w e r r e s p o n d e n t s held t h e view t h a t t h e W o r k s h a d definitely affected their h e a l t h . H o w e v e r , a l m o s t all s u c h c o m m e n t s were g i v e n w i t h ' e v i d e n c e ' to j u s t i f y this view: 42 year old woman, I have always believed that the cokeworks were to blame for all my sinus problems as I never had any symptoms before I exchanged houses to my present address. I lived at my previous home for seven years without any sinus problems.
Table 3. Views on what puts health at risk (in rank order of frequency in the inner area). Q: Do you feel that any of these things have put your health at risk in recent years? (figures are percentages saying yes) Adults Industrial pollution Dust in/around home Traffic pollution Smoking habits Money worries Work conditions Nearby noise Poor diet Drinking habits Poor housing
Inner (N = 725) (%)
Outer (N = 812) (%)
Control (N = 793) (%)
Z-' for trend
P value
60 33 19 18 15 14 13 11 6 2
38 16 18 20 16 17 5 17 5 3
10 4 14 26 18 18 3 17 7 3
431 227 8.07 13.4 3.01 5.60 57 10.6 1.43 0.16
< 0.00001 <0.00001 0.0045 0.00025 0.08 0.018 < 0.00001 0.0011 0.23 0.69
Inner (N = 231) (%)
Outer (N = 233) (%)
Control (N = 221) (%)
X-' for trend
P value
71 37 20 19 6 6 5
48 15 25 28 6 4 9
10 6 23 21 1 5 11
170 67 0.35 0.28 5.89 0.11 4.84
< 0.00001 < 0.00001 0.55 0.60 0.015 0.74 0.027
Children
Air pollution Dust in/around home Traffic pollution Smoking Nearby noise Poor housing Poor diet
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Industrial pollution in north-east England Table 4. Type and frequency of adults' comments Inner area 56 Percentage of adults who commented 158 Worry about possible health effects 109 Improvement to the environment on closure 74 Definite view that there has been a health effect/health improvement on works' closure 60 Nuisance or damage caused by pollution from Coke Works/local industry 30 Definite view of no health effect or improvement 18 Concern about unemployment caused by closure/demise of industry 0 Good health 0 Poor health Other factors affecting health 10 Smoking (inc. passive smoking) 0 Alcohol 0 Diet 0 Stress
63 year old man, When the weather is foggy the smoke from the coke ovens holds the smell and smoke down and this can cause my wife to wheeze. A m o n g those closest to the Works, there were more c o m m e n t s emphasising t h a n denying a health effect. However, a m o n g outer area residents, equal n u m b e r s c o m m e n t e d t h a t there was a n d was not a health effect. O f those who said there was no health effect, 23 residents also stated t h a t this was because they lived some distance from the Works. Second only to past experience o f pollution t h r o u g h o u t the study area was a n expectation of a n i m p r o v e m e n t to the e n v i r o n m e n t after closure. M a n y of these c o m m e n t s vividly illustrate h o w u n p l e a s a n t it was living close to the works: 53 year old woman, We have lived for many years with polluted air, the smell of sulphur carried with the wind, smoke billowing out day and night and window sills and cars covered with soot and grit. This has been a constant menace to the area, described by the Council as a'Smokeless Zone'. I hope we will never have to live in such conditions again. 29 year old woman, There was always dust around in the house. The worst problem I found, however, was the dust it left on newly washed clothes while hanging on the line. By contrast, the most frequent c o m m e n t from b o t h w o m e n a n d m e n in the control area concerned being in good health. Stress featured quite highly as a factor affecting health, this was related usually to job, m o n e y or family difficulties. Occupational conditions, either past or present were cited most c o m m o n l y by men. Few c o m m e n t s , however, referred to the e n v i r o n m e n t in general. This section has highlighted the perceptions of the impact o f coking pollution on the lives a n d health o f those living in the vicinity, a n d has e n d e a v o u r e d to place such subjective judgements a b o u t the stressfulness of living alongside a polluting industrial site in the context o f a range of other stresses experienced in daily life. We end this section by returning to certain o f the m o r e detailed epidemiological data o n s y m p t o m s of ill-health collected in the same postal survey a n d discussed in detail elsewhere [3]. The p a t t e r n of ill-health which emerged for b o t h adults a n d children showed a statistically significant excess of some, but n o t all, respiratory conditions. A s t h m a - - i n adults or c h i l d r e n - - a n d bronchitis reveal no more
Outer area 43 97 69 45 60 45 26 5 0
Control area 29 11 0 2 2 1 8 70 27
14 2 0 0
19 l 9 37
t h a n trivial differences between groups. However, excesses of chronic phlegm, sinus trouble, glue ear, allergies a n d headache were apparent. As predicted a gradient from inner area to control area was f o u n d for these conditions, e.g. the p r o p o r t i o n s o f adults reporting chronic phlegm in the inner, outer a n d control areas was, respectively, 19, 16 a n d 14% (g'- = 9.40; P = 0.002) sinus trouble a m o n g children in the same areas was 13, 7 a n d 6 % (X2 = 8.11, P = 0.004). The inferences t h a t such a differentiated pattern suggests will be discussed below.
DISCUSSION H o w do we interpret the kind o f evidence summarised here? We shall end this p a p e r by exploring the pros and cons o f alternative readings of such data. F r o m one perspective, the M o n k t o n study echoes other work o n c o m m u n i t y exposure to e n v i r o n m e n t a l pollution, showing how anxiety a b o u t possible health problems contributes to stress, which in turn m a y itself u n d e r m i n e health [21]. The stressfulness o f living in close proximity to an industrial operation which continually released dirt a n d noxious fumes into the air comes across time a n d again from the survey we conducted. We found t h a t stress and anxiety a b o u t pollution was experienced by a sizeable p r o p o r t i o n o f the c o m m u n i t y a n d was believed to place health at risk by the majority o f those living nearby. The H e b b u r n Residents Action G r o u p and subsequent c a m p a i g n can be viewed as a positive response to coping with the stress of living with pollution a n d the uncertainty of its effects. F o r example, adults in o u r control area were more likely t h a n their c o u n t e r p a r t s in the study area to view smoking habits, diet a n d material factors as those posing the greatest risk to health (Tables 2, 3 a n d 4). C u r r e n t smokers in the control a n d outer areas r a n k e d smoking as the greatest risk to health; a m o n g inner area current smokers, this position was reserved for industrial pollution. E n v i r o n m e n t a l factors (associated with air pollution from the W o r k s ) were the overriding concern in relation to health risk a m o n g study area residents. Full discussion o f these particular finding are b e y o n d the scope of this paper, but have implications for health p r o m o t i o n .
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Moreover, the strongly held suspicion that toxic emissions from the Works have damaged health seems to be confirmed by evidence on symptoms and health problems. In data presented previously, we also showed that consultations with a general practitioner for respiratory complaints were strongly correlated with air quality, as measured at three nearby monitoring sites, in the study but not the control area, while no such association was observed for non-respiratory problems [3, 20]. On this reading, local anxieties are shown to have been at least partially borne out, with confirmation that certain specific kinds of respiratory ill-health were closely correlated with and attributable to emissions from the coking process. Yet for many epidemiologists the big difficulty with such an interpretation is likely to be the prior public concern and anxiety about possible health effects that led to the study being proposed in the first place. On this argument, a population already predisposed to anticipate adverse health effects from pollution episodes is so 'sensitised' as to be an unreliable vehicle for the testing of a hypothesis which seeks to measure any underlying cause-and-effect relationship. Biased data are seen as the inescapable result. Whether people report their opinions about health, their symptoms, or their experience of ill-health, such statements are compromised by their prior anxiety about a possible causal association between pollution and health. Even evidence about consultations with a general practitioner is vulnerable to the same scepticism, for people's behaviour in seeking a consultation is potentially as readily coloured by pre-existing anxieties as are their statements. A good example of this general approach comes in a recent piece in The Lancet [22] reviewing the main epidemiological findings from the Monkton study. While adopting a broadly sympathetic line, Malmberg states that: The conclusions seem plausible and the researchers and residents may have arrived at the correct conclusion regarding health hazards ... Overall, the arguments for refuting awareness bias are not entirely convincing [22] (p. 632). We recognise that such concerns are legitimate products of any scientific claim that apparent evidence is not taken simply at face value. Yet there remains a real danger that such well honed scepticism results in potentially damaging impacts on health being overlooked, because the voices of those with the most immediate experience, through direct exposure, are ignored [13]. As we stated in the Introduction, the further studies of health are removed from the laboratory, the more difficult it is to screen off the intrusions of an array of potential social influences-whether confounding (to the epidemiologist) or compounding (to the sociologist). And the more that such supposedly extraneous influences are removed from an analysis, the more the measurement and meaning of data are compromised through the removal of context.
In our judgement, however, there are persuasive grounds both for recognising public concerns as data, and not as a barrier to data, and also for concluding in this particular case that these concerns were in certain respects well-founded. Five points may be singled out in this connection. First, respondents were generally consistent in their descriptions of pollution effects and the symptoms likely to ensue. Second, self-reports of symptoms and health problems revealed a pattern of raised levels of certain kinds of respiratory ill-health, but not generalised respiratory ill-health. This specificity in itself strengthens the conclusion that we are not faced here with a population predisposed to anticipate ill-health from coking pollution. Third, the evidence from general practice consultation patterns points to a very clear association between rising incidence of respiratory consultations with rising levels of sulphur dioxide (where sulphur dioxide is also seen as a marker for a range of unmeasured pollutants [3]). Fourth, the pattern of air pollution was consistent with no other source in the vicinity apart from the Coking Works [20]. And finally, recent computer modelling analysis of emissions indicates that very short-term releases from various sites in the coking plant close to ground level produced gas concentrations far greater than had previously been appreciated in those housing areas closest to the coking works [23]. The significance of this last point is considerable, for it challenges many of the toxicological assumptions about likely exposure levels, and the levels below which clinical symptoms are implausible, which have been used to dismiss local claims as baseless or even hysterical [24, 25]. In the final analysis, there is no way of answering completely the doubts of sceptics in a case such as this, unless there existed conclusive evidence on mortality or the incidence of cancers, both lacking in the present context. Because illness (or morbidity) is a complex phenomenon--part biological, part social and part psychological--any attempt to disentangle a purely physiological bedrock of clinically confirmable ill-health is on many occasions doomed to failure. It is perhaps easier to make the case for the incorporation of public understanding of environmental health dangers, both as a guide to analysis and also as data in its own right, where in the end it is shown that the public were justified in their concerns. If, however, epidemiological findings turn out to lend little or no support to the concerns of a local population, what conclusions are to be drawn? Mainstream epidemiology, with its roots in bio-medicine, would surely conclude that--for whatever reason--the public were wrong or mistaken in their views. Clinical data provide the touchstone against which other data, if they are admitted as data in the first place, must be judged. By contrast, a more social approach to these kinds of health issues would be reluctant to grant such privileged status to clinical definitions in the depiction of patterns of illness. The absence of clinically confirmable ill-health would not
Industrial pollution in north-east England in itself be sufficient to reject p o p u l a r concerns as u n w a r r a n t e d . In fact, public responses to e n v i r o n m e n tal health controversies suggests that these two contrasting perspectives are not confined to academics. Medical a n d social models of health j ostle side by side in local accounts of health causation a n d the i n t e r p r e t a t i o n of available evidence. F u r t h e r m o r e , some of these abstract issues have surfaced in the M o n k t o n context. While this p a p e r has been in preparation, the m a i n epidemiological findings have been published [3], to a mixed reception from m e m b e r s o f the now d i s b a n d e d Residents A c t i o n G r o u p . R a t h e r t h a n seeing their concerns a b o u t acute episodes o f respiratory illness justified by two separate sources o f m o r b i d i t y data, one reaction was t h a t our interpretation o f d a t a o n mortality a n d the incidence of cancers was flawed because it failed to conclude that there were d e m o n s t r a b l e long-term health effects from the coking works' pollution*. The wider response to the findings highlighted the i m p o r t a n c e of raised cancer and mortality as the m a r k e r o f 'true' or 'serious' ill-health. F o r example, some local councillors felt the study was a waste o f m o n e y because the findings related to ' m i n o r illnesses'; local television, who h a d covered the story from the beginning, did not b r o a d c a s t the findings, a n d instead showed a piece on a new study into c h i l d h o o d a s t h m a a n d industrial air pollution. There are no simple solutions to problems like this. But the more that epidemiology tries to do justice to a social model of health, the more these difficulties in i n t e r p r e t a t i o n will continue to arise. In spite of difficulties in interpretation or conflicts following research publication, it remains our view that local viewpoints a n d u n d e r s t a n d i n g s o f illness a n d its causes must inform epidemiological research o n public health topics. Acknowledgements--We are grateful to South Tyneside Metropolitan Borough Council and Hebburn Residents Action Group for their involvement with the study. We are also indebted to Simon Kingham, for his help coding comments, Anne Rooke for constructing maps and Tanja Pless-Mulloli, Martin White and Jacqui Tate for their comments on earlier drafts. REFERENCES
1. Wood C. Planning Pollution Prevention: Anticipatory Controls Over Air Pollution Sources. Heinemann Newnes, Oxford, 1989. *At public meetings held to disseminate the research findings to local residents, there was considerable scepticism directed at the cancer and mortality results by those involved in the Residents Action Group. The increased morbidity was viewed by many present as, 'just proving what they had always said', and of much less importance than raised cancer or mortality. It was not possible to gauge the opinion of the majority of non-active, but concerned local residents towards the results.
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2. Bhopal R. S. The impact of industry on the health of surrounding communities: an analysis ofepidemiological and public health challenges. In Proceedings. The Role of the ASAIHL in Combating Health Hazards of Em, ironmental Pollution (Edited by Hedley A. J. et al.), pp. 65-73. University of Hong Kong, Hong Kong, 1992. 3. Bhopal R. S., Phillimore P., Moffatt S. and Foy C. Is living near a coking works harmful to health? J. Epid. Commun. Hlth. 48, 237, 1994. 4. Pope A. C., Schwartz J. and Ransom H. R. Daily mortality and PM ~°pollution in Utah Valley. Arch. envir. Hlth 47, 121, 1993. 5. Dales R. E. S., Suissa S., Schechter M. T., Tousignant P. and Steinmetz N. Respiratory health of a population living downwind from natural gas refineries. Am. Rev. Respir. Disord. 139, 595, 1989. 6. Lloyd O. L., Williams F. L. R. and Gailey F. A. Y. Is the Armadale epidemic over? Air pollution and mortality from lung cancer and other diseases, 1961-1982. Br. J. lndustr. Med. 42, 815, 1995. 7. Calnan M. Maintaining health and preventing illness: a comparison of the perceptions of women from different social classes. Hlth Promotion 1, 167, 1986. 8. Williams R. G. A. Concepts of health: an analysis of lay logic. Sociology 17, 185, 1983. 9. Cornwell J. Hard-earned Lives. Tavistock, London, 1984. 10. Herzlich C. Health and Illness: a Social Psychological Analysis. Academic Press, London, 1973. 11. Townsend P., Phillimore P. and Beattie A. Health and Deprivation: Inequality and the North. Croom Helm, London, 1988. 12. Paigen B. Controversy at Love Canal. The Hasting Center Report 12, 29, 1982. 13. Brown P. Popular epidemiology and toxic waste contamination: lay and professional ways of knowing. J. Hlth Soc. Behav. 33, 267, 1992. 14. Levine A. Love Canal: Science, Politics and People. Lexington Books, Lexington, 1982. 15. Nash J. and Kirsch M. Polychlorinated biphenyls in the electrical machinery industry: an ethnological study of community action and corporate responsibility. Soc. Sci. Med. 23, 131, 1986. 16. Hance B. J., Chess C. and Sandman P. M. Setting a context for explaining risk. Risk Analysis 9, 113, 1989. 17. Martin C. J. Researching the obvious and influencing the influentials. Local Government Policy Making 16(December), 47, 1989. 18. Platt S. D., Martin C. J., Hunt S.M. and Lewis C. W. Damp housing, mould growth, and symptomatic health state. Br. reed. J. 298, 1673, 1989. 19. Seymour J. Science for the people. New Scient. 1798, 50, 1991. 20. Bhopal R. S., Moffatt S., Phillimore P. and Foy C. The impact of an industry on the health of a community: the Monkton Coking Works Study. A report to South Tyneside MBC, University of Newcastle upon Tyne, 1992. 21. Hallman W. K. and Wandersman A. Attribution of responsibility and individual and collective coping with environmental threats. J. Soc. Issues 48, 101, 1992. 22. Malmberg P. Coking to death? Lancet 344, 3 September, 632, 1994. 23. Personal communication, from Dr Ivan Vince, 1994. 24. Goldsmith J. R. Environmental Epidemiology: Epidemiological Investigation of Community Environmental Health Problems. CRC Press, Boca Raton, FL, 1986. 25. Anonymous. Environmental pollution: it kills trees, but does it kill people? Lancet 340, 3 October, 821, 1992.
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'IF THIS IS WHAT IT'S D O I N G TO O U R WASHING, WHAT IS IT D O I N G TO O U R LUNGS?' I N D U S T R I A L P O L L U T I O N A N D PUBLIC U N D E R S T A N D I N G IN N O R T H - E A S T ENGLAND
SUZANNEM O F F A T T ,
P E T E R P H I L L I M O R E , R A J B H O P A L and CHRISTOPHER FOY Departments of Epidemiology and Public Health and Social Policy, University of Newcastle upon Tyne, Newcastle upon Tyne NE2 4HH, England Abstract--An epidemiological study of the impact of industrial pollution from a coking works in north-east England on the health of a population resident nearby uncovered strong but localised public concern about the possible dangers of air pollution. This paper discusses these popular concerns in the context of empirical findings from the study which examined evidence of ill-health alongside evidence on air quality levels. The substantive issues this paper examines relate to local variations in popular beliefs about health risks, and the relation between such beliefs and measurable differences in health states and status. The methodological issues addressed centre on the difficulties of interpreting this relationship between popular beliefs and concerns, on the one hand, and health experience, or apparent health experience, on the other. Key words--environmental controversy, public views, health status, health risk
INTRODUCTION
nearby, they are suffering the perceived disadvantages, which may be viewed in terms of health or the environment. This paper arises out of an epidemiological study of the impact of industrial pollution from a coking works in north-east England on the health of a population resident nearby, the main findings are summarised elsewhere [3]. The research was undertaken in response to strong but localised public concern about the possible dangers of air pollution from this site. Evidence gathered as a by-product of the main study reinforced our awareness as researchers of the extent of public concern about coking emissions. We shall discuss these popular concerns in the context of empirical findings from the study which examined evidence of ill-health alongside evidence on air quality levels. The substantive issues this paper examines relate to local variations in popular beliefs about health risks from coking pollution, using survey data, and the relationship between such beliefs and measurable differences in health states and status. The methodological issues addressed centre on the difficulties of interpreting this relationship between popular beliefs and concerns, on the one hand, and health experience, or apparent health experience, on the other. There has been a tendency in the literature for epidemiological studies investigating the health effects of particular industries on surrounding populations to ignore studies of 'lay beliefs'* [4-6], while those interested in such beliefs have not generally been interested in how they modify our understanding of
Over the last few years, it has become increasingly common for groups and communities in the richer countries of the world to voice concerns about industrial pollution, emphasising in local campaigns unease about damage to health and environmental degradation [1]. This new wave of concern has coincided with the disappearance of much of the old industrial landscape, as coal and steel industries in particular have contracted to a fraction of the size they were barely one generation ago. But even where heavy industries survive, a bond which often existed in the past between an industry and its neighbouring population has been greatly weakened in the last 20-30 years. Local residents are less and less likely to be the workforce: the workforce are less and less likely to be local residents. Influences are various, but include: new technologies and the resultant decline in manual jobs; improved transport, making possible the geographical separation of home and work; and raised public expectations about the quality of life and the environment [2]. Not only are decreasing numbers of people gaining whatever are perceived to be the direct benefits of living close to industry; but by remaining *The term 'lay beliefs' is itself an interesting one, that only has currency in the context of an explicit contrast with the views of a more powerful group who can claim expert or authoritative status--scientists, the medical profession, the legal profession, or of course the church. Thus, views of 'lay' people by definition lack authority--and the term qay beliefs' can easily function as a euphemism for 'popular misconceptions'. 883
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health patterns [7-10]. The measurement of health differences within the population presupposes the application of standardised criteria to enable comparison of 'like with like' to take place. Popular beliefs about health, and the impact that such beliefs have on the ways that ill-health manifests itself, tend to be seen as disconcerting obstacles to epidemiological investigation, rather than as inherently relevant facets of it. Case control methodology, the cornerstone of epidemiological research, assumes that factors other than those which are the focus of investigation can be held constant• In contrast, the study of popular beliefs assumes a diversity that is the antithesis of holding variables constant. Exploration of the varied ways in which ill-health is acknowledged and enacted and finally treated, lends itself to an amplification of what is atypical and distinctive. Clarity in 'case definition' is central to the epidemiological project in this regard. Yet the further removed from the clinical setting and bio-chemical procedures that research on health moves, the more elusive and chimerical a notion case definition can become.
al.
Moreover, where questions of disease prevalence and uneven distribution have disputed or potentially controversial causes, the more likely it is that popular beliefs will be regarded not simply as an irrelevance but as an obstacle to scientific enquiry• In such contexts, beliefs are liable to be seen as the reflection of a 'sensitised' population, distorting clarification of 'real' levels of ill-health. This paper is written against such a stance, using our research on the health impact of the Monkton Coking Works as a case study. We shall argue that there is a need to bring together these two facets of health. On the one hand, epidemiological research that attempts to put to one side local concerns and popular beliefs thereby distorts the very reality it so assiduously seeks to describe. On the other hand, because illness strikes unevenly and unequally a focus on the ways that people think about and experience illness without reference to the causation of that illness is incomplete, because it ignores the contrasting material conditions and constraints shaping people's lives.
AREA AROUND MONKTONCOKINGWORKS 1937 SHOWING CONTEMPORARYHOUSING ~ ~_,~ :.. /./,./
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Industrial pollution in north-east England We begin, however, by sketching the background to concerns about the contribution of the Monkton Coking Works to ill-health in the surrounding population. BACKGROUND
The controversy which led to the study described here goes back not to the commissioning of the Monkton Coking Works in 1937, but to the completion of a housing estate in the early 1950s which at its closest point was just 250 m from the works. At the time of Monkton Coking Works' construction, the nearest housing was approx 1.5 km north (Fig. 1). With the exception of a few farms, no housing existed to the south and west for several kilometres. This particular location offered considerable advantages: proximity to raw materials; easy distribution of coke via railway, road and sea; and it was sufficiently distant from built-up areas to minimise any adverse effects from the pollution caused by the coking process.
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After the Second World War, slum clearances took place on a large scale in Hebburn and Jarrow (the relevant local authorities prior to 1974), with a correspondingly large programme of new house building throughout the 1950s, 1960s and early 1970s. A good deal of new housing was built within 2.5 km of the Works (Fig. 2). All except one of the estates surrounding the Works are council-owned and the estates to the east and south whose boundaries lay within 0.75 and 1.0 km of the Works were the last to be completed in the early 1970s. In 1968, Hebburn and Jarrow became smokeless zones. The Coking Works may have been built before the wave of post-war housing estates were created, but the prevailing expectation among local residents by the later 1970s seems to have been that the plant was in the later stages of its useful life. However, in 1980, the Works returned to two-battery production (66 ovens) after a period of 20 years in which only one battery had been in operation (with the exception of a few months in 1972). In the same year, a Residents Action Group was formed to campaign about the pollution from the
AREA AROUND MONKTON COKING WORKS 1967 SHOWING CONTEMPORARY HOUSING
Fig. 2
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works. Numerous complants were lodged with the Local Authority Environmental Health Department. Their authority was limited, for as a scheduled industrial process the Monkton Coking Works came under the jurisdiction of Her Majesty's Inspectorate of Pollution (HMIP), an organisation with no requirement to respond to the concerns of individual residents. The Works was closed during the 1984-85 Miners' Strike, and was not reopened until January 1986. By this time, only about 4% of the workforce came from the locality (about 10 men). The residents resumed their campaign after production restarted, focusing by this time particularly on the potential health effects of air pollution. In 1987, however, a planning application by the company to use flared gas to generate electricity galvanised local opposition to the Works and escalated this long-running dispute in which the company, the local community and the Local Authority were by this stage all at loggerheads. Local residents continued registering complaints with the Environmental Health Department, and repeatedly called for a health study. In the end, in 1989, the Residents Action Group carried out their own health survey, covering some 1400 households. This survey helped persuade South Tyneside MBC that an independent study was required, in the hope that it would answer once and for all whether or not pollution from coking production caused or contributed to ill-health in the local population. However, within 9 months of the study starting, and before the Secretary of State had reached a decision on the planning application for an electricity generating station at the Coking Works, the company suddenly announced the closure of the Monkton Works, on economic grounds.
STUDY DESIGN AND APPROACH
The epidemiological study was designed to integrate data on different aspects of health: drawing together evidence from routine health statistics (post-coded mortality, cancer registration and birth information), the patient records of General Practitioners, a population survey, and tests of lung function, and analysing these data alongside air quality data derived both from local authority monitoring sites and also from the computer modelling of stack emissions [3]. In geographical terms, the analysis was built around a three-way comparison. A 'study area' was defined in terms of proximity to the Coking Works. Study areas of different size were adopted for different parts of the study, being widest where routine statistics were available for analysis and narrowest where original data collection was involved. In each case, however, a further distinction was made, dividing the designated study area into an 'inner' and 'outer' portion. These areas were compared with a single 'control area' made up of several adjoining housing estates located 6-10 km east of the works. Identifying a suitable matching
population and housing environment for comparison was aided by the remarkable similarity in the social and economic character of many parts of South Tyneside [11]. The sudden ending of production at Monkton, less than 1 month after closure was announced, forced us to rethink several aspects of the design. In particular, a postal survey of a random sample of the population had to be mounted at short notice, as this was the only way to collect information directly from those living in the vicinity of the Coking Works while it was still a continuing feature of their lives. At the same time, this unexpected turn of events presented certain opportunities. The timing of the survey allowed us to gather information on people's views of the expected health consequences of the ending of coking operations. Moreover, while recognising that we could not study perceptions of the health effects of pollution in depth using a postal questionnaire, we did not want the limitations of the method forced on us to dissuade us from taking the opportunity to explore any recurring themes in local concerns. Several studies of disputes between communities affected by industrial pollution, the firms whose emissions are the cause of complaint, and government agencies, have illustrated the importance of direct communication with the affected public in the U.S.A. [12-15]. Indeed, environmental researchers at the U.S. Environmental Communication Research Program now recommend at the start of any investigation "paying (as much) attention to the community's perception of the risk and to the community's concerns, as to scientific variables" [16]. Our approach led us in the same direction. From the outset we opened a dialogue with all the parties involved: partly to establish the 'open' and unconstrained nature of the research; and partly because each group held information which was useful or essential for the successful completion of the research. While our approach with each party inevitably differed, the same basic principle of open communication was followed. An academic protocol was developed and circulated for discussion to the industry, Local Authority and HMIP. Public meetings were held with local residents to outline the proposed research and to hear residents' views and suggestions. Approaches to the workforce, via their Union, were delayed initially but then became irrelevant following closure. At public meetings there was overwhelming support for the study from the total of 200 or so local residents who attended. People present expressed concern about the possibility of ill-health caused by pollution, especially among children, the elderly and those with respiratory conditions. Where critics expressed a view, it was generally to argue that research was an expensive way for local government and industry to 'buy time', not to deny the impact of air pollution on their lives. These meetings paved the way for periodic dialogue with the Residents Action Group at a number
Industrial pollution in north-east England of informal meetings. This h a d the a d v a n t a g e of showing our c o n t i n u e d involvement with the study, a n d m a y have helped to increase participation in the p o p u l a t i o n survey t h a t we undertook. Perhaps more importantly, we h o p e d t h a t the dialogue would emphasise to residents t h a t their concerns were being listened to and t a k e n seriously, a n d that the research was not a closed debate a m o n g supposed experts from which they were excluded. In u n d e r t a k i n g this study, our task was to retain a dispassionate stance. Classically, in epidemiological research this has been done by separating the observers from all possible influences which might vitiate the reliability of the observation. Yet in a case such as that described here, that stance would a m o u n t to pretending t h a t the study was taking place in a vacuum. It was far more defensible, in our view, to recognise t h a t the local controversy was an inescapable part of the study, requiring the researchers to listen to a variety of different u n d e r s t a n d i n g s of the problem. F r o m this perspective, the voice of the people most affected becomes a crucial element of the study, not a peripheral distraction [16-19].
SELECTED EMPIRICAL FINDINGS The empirical data presented here relate to certain parts only of the overall study: namely, some o f the findings from the postal survey m e n t i o n e d above. This survey produced a 6 9 % response ( N = 3015), with little divergence between inner, outer a n d control areas. R e s p o n d e n t s also exhibited very similar social and economic characteristics, as anticipated, apart from a small but statistically significant excess of smokers in the control area (sample details are described elsewhere [3, 20]). Two kinds of evidence will be d r a w n on in this section o f the paper. To start with, salient quantitative findings on perceptions o f
887
the causes of stress, a n d the distribution o f symptoms, will be summarised, based on pre-coded categories in the questionnaire. We then amplify our t r e a t m e n t of individual experience of air pollution a n d health by using v e r b a t i m extracts from c o m m e n t s respondents m a d e in a n open section concluding the questionnaire. Table 1 brings together a variety o f j u d g e m e n t s a b o u t health in the populations compared. A m o n g adults, few differences emerge in response to a question a b o u t 'your general health' (drawn from the G e n e r a l H o u s e h o l d Survey), a l t h o u g h when children's general health was assessed a discrepancy between study a n d control areas was a p p a r e n t [Table l(a)]. Yet w h e n respondents were asked a b o u t the effects of coking emissions on health (or emissions from local industry more generally in the control area), a sharp gradient emerges, with the outer area mid-way between inner and control areas [Table l(b)]. M o r e t h a n 4 0 % of adults in the inner area reported t h a t their health h a d been adversely affected to some degree by coking emissions, with a corresponding figure for children o f 34%. W h e n adults were asked to assess the impact o f coking pollution on the health of others they knew well, the figure rose higher still. The p r o b l e m s attributed to coking emissions were relatively specific, with upper and lower respiratory tract disorders featuring prominently, followed by wider concern a b o u t a dirty e n v i r o n m e n t [Table 1(c)]. M o r e t h a n half the adults in the inner area expected their health to improve following closure of the coking works [Table l(d)]--interestingly this figure is s o m e w h a t greater t h a n those reporting a n effect from air pollution o n their own health [Table l(b)]. Against that b a c k g r o u n d , the next two tables assess the relative importance of a range of factors, pre-specified from a checklist, in creating stress or anxiety (Table 2), or putting health at risk (Table 3),
Table 1. Views on health and expected changes in health due to the closure of Monkton Coking Works (MCW)/local industry Adults Children Inner Outer Control Inner Outer Control (N=725) (N=812) (N=793) X-~for (N = 231) (N = 233) (N = 221) ;(2 for (%) (%) (%) trend P value (%) (%) (%) trend P value (a) General health Excellent/good 63 65 68 85.1 83.5 92.8 Fair/poor 37 35 32 3.35 0.08 14.9 16.5 7.2 5.77 0.02 (b) MCW (inner and outer)/ or local industry (control)/ has had an effect 1. On my health 42 20 13 166 < 0.00001 34 21 5 58.2 < 0.00001 2. On the health of people I know well 64 40 29 150 < 0.00001 56 37 22 51.1 < 0.00001 (c) Problems due to MCW/ local industry 1. Upper respiratory tract disorder 17 6 1 151 < 0.00001 17 10 1 43.7 < 0.00001 2. Lower respiratory tract disorder 14 8 2 95.2 < 0.00001 15 9 I 28.8 < 0.00001 3. Non-health problems 11 6 1 89.1 < 0.00001 0.002 4 1 0 9.48 (d) Expect a health change due to MCW/local/ industry closure 52 30 22 142 < 0.00001 48 33 20 38 < 0.00001
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Table 2. Adults" views on causes of stress or anxiety in the past year (in rank order of frequency in the inner area). Q: Have any of these things been a cause of stress or anxiety for you in the last year? (figures are percentages saying yes)
Unpleasant smells from outside the home Air pollution Money problems Dirt Other people's health problems Own health problems Work problems Always being in a hurry Family problems Noise Unemployment Problems with neighbours Housing problems
Inner (N = 725) (%)
Outer (N = 812) (%)
Control (N = 793) (%)
43 34 23 20 19 19 16 15 14 14 12 5 4
23 12 26 7 19 18 16 13 15 6 12 4 6
4 3 26 1 18 17 14 14 18 3 14 5 4
T w o p o i n t s n e e d to be m a d e a b o u t t h e s e tables. First, t h e t h r e e g r o u p s o f r e s p o n d e n t s were v e r y s i m i l a r in t h e levels o f stress s e e n to be c a u s e d b y m o n e y p r o b l e m s , o n e ' s o w n o r s o m e o n e else's h e a l t h p r o b l e m s , w o r k , housing or neighbour problems. Differences between t h e s e p o p u l a t i o n s r e v o l v e d crucially a r o u n d p o l l u t i o n c o n c e r n s - - a i r p o l l u t i o n a n d smell, d u s t a n d dirt, noise, a n d i n t e r e s t i n g l y traffic p o l l u t i o n - - a n d t h e s e a l o n e . B u t in T a b l e 3, so p r e d o m i n a n t w a s t h e e m p h a s i s o n external sources of pollution--whether from industry o r t r a f f i c - - i n t h e i n n e r a r e a t h a t s m o k i n g h a b i t s , diet, working conditions and even money problems a s s u m e d slightly less i m p o r t a n c e in r e s p o n d e n t s ' j u d g e m e n t as f a c t o r s e n d a n g e r i n g h e a l t h . More qualitative data, from respondents' comm e n t s , r e i n f o r c e t h e s e differences in t h e m a i n c o n c e r n s a b o u t c a u s e s o f stress a n d ill-health b e t w e e n t h e p o p u l a t i o n s o f t h e t h r e e areas. R e s p o n s e s were grouped into certain broad categories, the most c o m m o n b e i n g listed in T a b l e 4. I n b o t h t h e s t u d y areas, c o m m e n t s m o s t f r e q u e n t l y r e l a t e d to u n e a s e o r w o r r y a b o u t p o s s i b l e h e a l t h effects o f t h e M o n k t o n e m i s s i o n s . U n c e r t a i n t y , n o t c o n v i c t i o n , is t h e h a l l m a r k
X2 for trend 322 265 1.27 173 0.59 1.19 1.37 0.23 5.12 70 2.02 0.03 0.007
P value < 0.00001 < 0.00001 0.26 < 0.00001 0.44 0.28 0.24 0.63 0.024 < 0.00001 0.16 0.87 0.93
of these statements, expressed with observations about s m o k e a n d d u s t i n h a l a t i o n . A selection o f s t a t e m e n t s is p r e s e n t e d below. W o m a n aged 31, Surely this black smoke must be getting on people's chests causing breathing problems. M a n aged 28, I can't believe that the fumes and dust spewing from the coke works can be taken into a h u m a n ' s lungs and have no effect whatsoever. Parent of a 12 year old, If we have been inhaling what I clean off my windows and paint work, we should all feel better. Some respondents linked observed environmental effects w i t h p o t e n t i a l h e a l t h effects: W o m a n aged 52, If the plants and trees were dying, the air pollution couldn't have done me much good. F e w e r r e s p o n d e n t s held t h e view t h a t t h e W o r k s h a d definitely affected their h e a l t h . H o w e v e r , a l m o s t all s u c h c o m m e n t s were g i v e n w i t h ' e v i d e n c e ' to j u s t i f y this view: 42 year old woman, I have always believed that the cokeworks were to blame for all my sinus problems as I never had any symptoms before I exchanged houses to my present address. I lived at my previous home for seven years without any sinus problems.
Table 3. Views on what puts health at risk (in rank order of frequency in the inner area). Q: Do you feel that any of these things have put your health at risk in recent years? (figures are percentages saying yes) Adults Industrial pollution Dust in/around home Traffic pollution Smoking habits Money worries Work conditions Nearby noise Poor diet Drinking habits Poor housing
Inner (N = 725) (%)
Outer (N = 812) (%)
Control (N = 793) (%)
Z-' for trend
P value
60 33 19 18 15 14 13 11 6 2
38 16 18 20 16 17 5 17 5 3
10 4 14 26 18 18 3 17 7 3
431 227 8.07 13.4 3.01 5.60 57 10.6 1.43 0.16
< 0.00001 <0.00001 0.0045 0.00025 0.08 0.018 < 0.00001 0.0011 0.23 0.69
Inner (N = 231) (%)
Outer (N = 233) (%)
Control (N = 221) (%)
X-' for trend
P value
71 37 20 19 6 6 5
48 15 25 28 6 4 9
10 6 23 21 1 5 11
170 67 0.35 0.28 5.89 0.11 4.84
< 0.00001 < 0.00001 0.55 0.60 0.015 0.74 0.027
Children
Air pollution Dust in/around home Traffic pollution Smoking Nearby noise Poor housing Poor diet
889
Industrial pollution in north-east England Table 4. Type and frequency of adults' comments Inner area 56 Percentage of adults who commented 158 Worry about possible health effects 109 Improvement to the environment on closure 74 Definite view that there has been a health effect/health improvement on works' closure 60 Nuisance or damage caused by pollution from Coke Works/local industry 30 Definite view of no health effect or improvement 18 Concern about unemployment caused by closure/demise of industry 0 Good health 0 Poor health Other factors affecting health 10 Smoking (inc. passive smoking) 0 Alcohol 0 Diet 0 Stress
63 year old man, When the weather is foggy the smoke from the coke ovens holds the smell and smoke down and this can cause my wife to wheeze. A m o n g those closest to the Works, there were more c o m m e n t s emphasising t h a n denying a health effect. However, a m o n g outer area residents, equal n u m b e r s c o m m e n t e d t h a t there was a n d was not a health effect. O f those who said there was no health effect, 23 residents also stated t h a t this was because they lived some distance from the Works. Second only to past experience o f pollution t h r o u g h o u t the study area was a n expectation of a n i m p r o v e m e n t to the e n v i r o n m e n t after closure. M a n y of these c o m m e n t s vividly illustrate h o w u n p l e a s a n t it was living close to the works: 53 year old woman, We have lived for many years with polluted air, the smell of sulphur carried with the wind, smoke billowing out day and night and window sills and cars covered with soot and grit. This has been a constant menace to the area, described by the Council as a'Smokeless Zone'. I hope we will never have to live in such conditions again. 29 year old woman, There was always dust around in the house. The worst problem I found, however, was the dust it left on newly washed clothes while hanging on the line. By contrast, the most frequent c o m m e n t from b o t h w o m e n a n d m e n in the control area concerned being in good health. Stress featured quite highly as a factor affecting health, this was related usually to job, m o n e y or family difficulties. Occupational conditions, either past or present were cited most c o m m o n l y by men. Few c o m m e n t s , however, referred to the e n v i r o n m e n t in general. This section has highlighted the perceptions of the impact o f coking pollution on the lives a n d health o f those living in the vicinity, a n d has e n d e a v o u r e d to place such subjective judgements a b o u t the stressfulness of living alongside a polluting industrial site in the context o f a range of other stresses experienced in daily life. We end this section by returning to certain o f the m o r e detailed epidemiological data o n s y m p t o m s of ill-health collected in the same postal survey a n d discussed in detail elsewhere [3]. The p a t t e r n of ill-health which emerged for b o t h adults a n d children showed a statistically significant excess of some, but n o t all, respiratory conditions. A s t h m a - - i n adults or c h i l d r e n - - a n d bronchitis reveal no more
Outer area 43 97 69 45 60 45 26 5 0
Control area 29 11 0 2 2 1 8 70 27
14 2 0 0
19 l 9 37
t h a n trivial differences between groups. However, excesses of chronic phlegm, sinus trouble, glue ear, allergies a n d headache were apparent. As predicted a gradient from inner area to control area was f o u n d for these conditions, e.g. the p r o p o r t i o n s o f adults reporting chronic phlegm in the inner, outer a n d control areas was, respectively, 19, 16 a n d 14% (g'- = 9.40; P = 0.002) sinus trouble a m o n g children in the same areas was 13, 7 a n d 6 % (X2 = 8.11, P = 0.004). The inferences t h a t such a differentiated pattern suggests will be discussed below.
DISCUSSION H o w do we interpret the kind o f evidence summarised here? We shall end this p a p e r by exploring the pros and cons o f alternative readings of such data. F r o m one perspective, the M o n k t o n study echoes other work o n c o m m u n i t y exposure to e n v i r o n m e n t a l pollution, showing how anxiety a b o u t possible health problems contributes to stress, which in turn m a y itself u n d e r m i n e health [21]. The stressfulness o f living in close proximity to an industrial operation which continually released dirt a n d noxious fumes into the air comes across time a n d again from the survey we conducted. We found t h a t stress and anxiety a b o u t pollution was experienced by a sizeable p r o p o r t i o n o f the c o m m u n i t y a n d was believed to place health at risk by the majority o f those living nearby. The H e b b u r n Residents Action G r o u p and subsequent c a m p a i g n can be viewed as a positive response to coping with the stress of living with pollution a n d the uncertainty of its effects. F o r example, adults in o u r control area were more likely t h a n their c o u n t e r p a r t s in the study area to view smoking habits, diet a n d material factors as those posing the greatest risk to health (Tables 2, 3 a n d 4). C u r r e n t smokers in the control a n d outer areas r a n k e d smoking as the greatest risk to health; a m o n g inner area current smokers, this position was reserved for industrial pollution. E n v i r o n m e n t a l factors (associated with air pollution from the W o r k s ) were the overriding concern in relation to health risk a m o n g study area residents. Full discussion o f these particular finding are b e y o n d the scope of this paper, but have implications for health p r o m o t i o n .
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Moreover, the strongly held suspicion that toxic emissions from the Works have damaged health seems to be confirmed by evidence on symptoms and health problems. In data presented previously, we also showed that consultations with a general practitioner for respiratory complaints were strongly correlated with air quality, as measured at three nearby monitoring sites, in the study but not the control area, while no such association was observed for non-respiratory problems [3, 20]. On this reading, local anxieties are shown to have been at least partially borne out, with confirmation that certain specific kinds of respiratory ill-health were closely correlated with and attributable to emissions from the coking process. Yet for many epidemiologists the big difficulty with such an interpretation is likely to be the prior public concern and anxiety about possible health effects that led to the study being proposed in the first place. On this argument, a population already predisposed to anticipate adverse health effects from pollution episodes is so 'sensitised' as to be an unreliable vehicle for the testing of a hypothesis which seeks to measure any underlying cause-and-effect relationship. Biased data are seen as the inescapable result. Whether people report their opinions about health, their symptoms, or their experience of ill-health, such statements are compromised by their prior anxiety about a possible causal association between pollution and health. Even evidence about consultations with a general practitioner is vulnerable to the same scepticism, for people's behaviour in seeking a consultation is potentially as readily coloured by pre-existing anxieties as are their statements. A good example of this general approach comes in a recent piece in The Lancet [22] reviewing the main epidemiological findings from the Monkton study. While adopting a broadly sympathetic line, Malmberg states that: The conclusions seem plausible and the researchers and residents may have arrived at the correct conclusion regarding health hazards ... Overall, the arguments for refuting awareness bias are not entirely convincing [22] (p. 632). We recognise that such concerns are legitimate products of any scientific claim that apparent evidence is not taken simply at face value. Yet there remains a real danger that such well honed scepticism results in potentially damaging impacts on health being overlooked, because the voices of those with the most immediate experience, through direct exposure, are ignored [13]. As we stated in the Introduction, the further studies of health are removed from the laboratory, the more difficult it is to screen off the intrusions of an array of potential social influences-whether confounding (to the epidemiologist) or compounding (to the sociologist). And the more that such supposedly extraneous influences are removed from an analysis, the more the measurement and meaning of data are compromised through the removal of context.
In our judgement, however, there are persuasive grounds both for recognising public concerns as data, and not as a barrier to data, and also for concluding in this particular case that these concerns were in certain respects well-founded. Five points may be singled out in this connection. First, respondents were generally consistent in their descriptions of pollution effects and the symptoms likely to ensue. Second, self-reports of symptoms and health problems revealed a pattern of raised levels of certain kinds of respiratory ill-health, but not generalised respiratory ill-health. This specificity in itself strengthens the conclusion that we are not faced here with a population predisposed to anticipate ill-health from coking pollution. Third, the evidence from general practice consultation patterns points to a very clear association between rising incidence of respiratory consultations with rising levels of sulphur dioxide (where sulphur dioxide is also seen as a marker for a range of unmeasured pollutants [3]). Fourth, the pattern of air pollution was consistent with no other source in the vicinity apart from the Coking Works [20]. And finally, recent computer modelling analysis of emissions indicates that very short-term releases from various sites in the coking plant close to ground level produced gas concentrations far greater than had previously been appreciated in those housing areas closest to the coking works [23]. The significance of this last point is considerable, for it challenges many of the toxicological assumptions about likely exposure levels, and the levels below which clinical symptoms are implausible, which have been used to dismiss local claims as baseless or even hysterical [24, 25]. In the final analysis, there is no way of answering completely the doubts of sceptics in a case such as this, unless there existed conclusive evidence on mortality or the incidence of cancers, both lacking in the present context. Because illness (or morbidity) is a complex phenomenon--part biological, part social and part psychological--any attempt to disentangle a purely physiological bedrock of clinically confirmable ill-health is on many occasions doomed to failure. It is perhaps easier to make the case for the incorporation of public understanding of environmental health dangers, both as a guide to analysis and also as data in its own right, where in the end it is shown that the public were justified in their concerns. If, however, epidemiological findings turn out to lend little or no support to the concerns of a local population, what conclusions are to be drawn? Mainstream epidemiology, with its roots in bio-medicine, would surely conclude that--for whatever reason--the public were wrong or mistaken in their views. Clinical data provide the touchstone against which other data, if they are admitted as data in the first place, must be judged. By contrast, a more social approach to these kinds of health issues would be reluctant to grant such privileged status to clinical definitions in the depiction of patterns of illness. The absence of clinically confirmable ill-health would not
Industrial pollution in north-east England in itself be sufficient to reject p o p u l a r concerns as u n w a r r a n t e d . In fact, public responses to e n v i r o n m e n tal health controversies suggests that these two contrasting perspectives are not confined to academics. Medical a n d social models of health j ostle side by side in local accounts of health causation a n d the i n t e r p r e t a t i o n of available evidence. F u r t h e r m o r e , some of these abstract issues have surfaced in the M o n k t o n context. While this p a p e r has been in preparation, the m a i n epidemiological findings have been published [3], to a mixed reception from m e m b e r s o f the now d i s b a n d e d Residents A c t i o n G r o u p . R a t h e r t h a n seeing their concerns a b o u t acute episodes o f respiratory illness justified by two separate sources o f m o r b i d i t y data, one reaction was t h a t our interpretation o f d a t a o n mortality a n d the incidence of cancers was flawed because it failed to conclude that there were d e m o n s t r a b l e long-term health effects from the coking works' pollution*. The wider response to the findings highlighted the i m p o r t a n c e of raised cancer and mortality as the m a r k e r o f 'true' or 'serious' ill-health. F o r example, some local councillors felt the study was a waste o f m o n e y because the findings related to ' m i n o r illnesses'; local television, who h a d covered the story from the beginning, did not b r o a d c a s t the findings, a n d instead showed a piece on a new study into c h i l d h o o d a s t h m a a n d industrial air pollution. There are no simple solutions to problems like this. But the more that epidemiology tries to do justice to a social model of health, the more these difficulties in i n t e r p r e t a t i o n will continue to arise. In spite of difficulties in interpretation or conflicts following research publication, it remains our view that local viewpoints a n d u n d e r s t a n d i n g s o f illness a n d its causes must inform epidemiological research o n public health topics. Acknowledgements--We are grateful to South Tyneside Metropolitan Borough Council and Hebburn Residents Action Group for their involvement with the study. We are also indebted to Simon Kingham, for his help coding comments, Anne Rooke for constructing maps and Tanja Pless-Mulloli, Martin White and Jacqui Tate for their comments on earlier drafts. REFERENCES
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