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Technogenic disease: The price of progress?
PREVENTIVE
MEDICINE
The potential the development mental health
1,
222-230
(1972)
risks of technological progress to the quality of life require of a balanced and rational public policy directed at environhazards.
Technogenic
Surgeon
General,
Disease:
The Price
JESSE L.
STEINFELD
U. S. Public
Health
Service,
of Progress?
Washington,
D. C.
Modern man creates most of his own environment today-buildings and cities, food and clothing, industrial processes and products, transportation, social order and institutions. In the process of developing the unprecedented technological achievement of modern life, man has inadvertently created many of the most significant hazards to his physical and mental health. Thus we now have the concept of “technogenic” diseases, diseases which stem from advancing civilization and its technologies. Dr. Jerome Weisner, a former Presidential science advisor, expressed the thought that troubles us: “We are engaged in a race between catastrophe and the intelligent use of technology and it’s not at all clear we are going to win.” It is a privilege for me to present this communication on technogenic diseases, since the subject is of particular personal interest. The fundamental underlying concept of technogenic diseases is not a new one. As Rem5 Dubos has said: It is no longer permissible to take comfort in the belief that various types of vascular diseases, of cancers, of chronic ailments of the respiratory tract, have become more prevalent simply because people live longer in affluent societies. The increase in chronic and degenerative diseases is due in part at least, and probably in a very large part, to the environmental and behavioral changes that have resulted from industrialization and urbanization.
What may be new is that our society is just now developing an appreciation of the magnitude of diseases and conditions whose origins lie in the progress that has made our civilization great. Technogenic diseases span the spectrum of human conditions. The filth in our rivers, the smoke and fumes in our ambient air, the sounds of progress which shatter our nerves, mountains of waste in city and country alike - in these and many other ways technology insults as well as assists us. Of course, it is a credit to technology that we can today concern ourselves with technogenic diseases, since sanitation and vaccination technology made possible the conquest of the infectious diseases which were once our all-consuming health focus. Technology has brought us access to a higher quality of life, leisure to reflect on that quality, and aspiration for its enhancement. We are constantly learning more about the legion of potential health hazards in the environment. We need only recall the major public concerns in 222 @ 1972 by Academic
Press,
Inc.
TECHNOGENIC
DISEASE
223
environmental health over the past year or two: pesticides-DDT, 2,4,5-T, aldrin, dieldrin, mirex; heavy metals including mercury in tuna and swordfish; smoking; phosphates and NTA as detergent additives; cyclamates and saccharin, as well as the whole list of food additives generally recognized as “safe.” The occupational environment has taught us much about environmental problems by serving unwittingly as a laboratory of concentrated human exposure to a wide variety of environmental factors-uranium mining and the manufacture of radium watch dials have taught us harsh lessons about radiation; pneumoconiosis has taught us lessons about mining, as lung cancer has taught us about certain industrial processes involving asbestos, chromium, and coke production. Studies of occupational environments have also demonstrated physiological and psychological responses to the stress of long periods of required concentration and to kinds and levels of noise. Also rife in our environment are product and consumer hazards which now account annually for at least 1.6 million injuries and as many as 75,000 deaths, primarily from automobile and home accidents. So too with iatrogenic disease, science and technology have provided new treatments and cures for some human disease, but have also brought us a whole new category of disease -that caused unintentionally as a result of a physician’s intervention. Technogenic diseases of this category include adverse effects of diagnostic tools and procedures such as radiopaque media and such medical devices as X-ray equipment, catheters, and gastroscopes. Also included are the many adverse reactions to therapeutic intervention with drugs, radiation, artificial organs, organ transplantation, cardiac pacemakers, blood transfusions-and I could continue. To illustrate the present magnitude of just one form of iatrogenic disease, it has been estimated that 5% of all general hospital admissions are related to adverse drug reactions, and that as many as 20% of hospitalized patients experience adverse drug reactions during their hospital stay. But beyond our recognition of the technogenic bases of many diseases, what may also be new is our developing commitment to learn from the past to try to improve the future, if not the present. The decisions that society is called upon to make are not easy ones. It would not be sensible to block technological progress or to seek to restore the earth entirely to a previous condition. To make rational judgments, we need to know what price we’re paying for what progress. Our traditional laissez-faire philosophy of life has unfortunately not often prepared us very well to answer today’s question, “What price for what progress?” The development of balanced public policy which considers the benefits and risks of technological advances is an exceptionally difficult matter. Great public fear of the possible implications for man has followed reports of .harm in laboratory animal tests. And yet frequently it is not known with certainty what laboratory animal tests may mean for man. We are obligated to make decisions of great health and economic importance on the basis of very limited evidence of potential hazard; prudence allows no other course. We are aware that both good and bad consequences may result from our actions. To avoid simplistic solutions to complex problems, we must all keep in
224
STEINFELD
mind that we are still feeling our way along toward a balanced public policy concerning hazards to our personal or general environmentwe are having to crawl before we walk. While we are in this circumstance, the precedent of previous actions taken can only be illustrativebut not controllingto us. Each case must be examined on its own merits, on the basis of risks and benefits, and a decision reached., Each of these situations-pesticides, food additives, heavy metals, detergent additives -has been a learning experience for the decision makers, for the affected businesses and industries, and for the public, and each has made all of us aware of additional facets of hazard assessment. We have learned that there are no nonhazardous substances; there are only nonhazardous ways to use substances. : While benefit-to-risk judgments in medicine are enormously complex, they are generally limited in the sense that the risk is borne by the intended beneficiary. In therapy, even extremely toxic agents are appropriate for use in serious illnesses, since the physician can attempt to tailor the benefit-risk ratio for the individual patient situation. It is a very different matter to impose a potential risk on the society in general when not all of society may benefit, and when those who do benefit may not be those who bear the risk. Pesticides provide a classic example of the complexity of judgments of relative benefit and risk in the society at large (1). A full economic analysis of the benefits of pesticides has not been made, but, clearly, benefits have been considerable. Control of insect disease vectors, and bountiful agricultural productivity are foremost among these benefits. Also lacking is a full economic analysis of the costs of pesticides-comparative economic costs of various methods of control, of environmental costs, and health costs. Our lack of critical data on relative increases in agricultural productivity from the use of pesticides, and relative risks fromtheir use, forces us to move slowly on the basis of gross estimates of costs versus benefits. Let us consider the controversy surrounding the use of DDT. DDT is a persistent pesticide used extensively since World War II to control a wide variety of pests, including pests of public health significance. It successfully halted a typhus epidemic in Italy in 1943. DDT has been demonstrated to be harmful to certain species’of birds, and to be persistent and widespread in the environment and in the food chain as well as in human fat tissue; Following widespread use of DDT, many pests developed resistance to it and thus, domestic DDT use has been gradually declining, in light of the availability of other pesticides, and in light of hazards identified with its use. Many people believe that the use of and production of DDT should be halted immediately. However, the problem is not a simple one. While some informed scientists report that all disease vectors which are susceptible to DDT can be controlled by a substitute, the World Health Organization reports that control of many of the most important vectors of human :diseases is still entirely dependent on insecticides, among which DDT is prominent, and that no effective or economically feasible alternatives are’available inmuch of the world. It has been stated that enforcement of a zero tolerance for DDT in food would necessitate the destruction of the bulk of the nation’s food supply.
TECHNOGENIC
DISEASE
225
Here we have the elements of a dilemma. We want an abundant food supply, we want a safe and healthful food supply, we want disease eradicated, and we want a safe and healthful environment for man and for other forms of life. The challenge is to balance these sometimes conflicting goals in such a way that man wins. The evaluation of balanced public policy for pesticides includes phasing out use of the most persistent pesticides, it includes the substitution of less hazardous pesticides wherever possible, and it includes careful review and action on the registered uses of pesticides to reduce potential hazards to human health and to the environment. Much as it might be wished, there is no easy, one-step solution to these complex problems. Adding to the complexity of weighing benefits and risks is the problem of extrapolating animal data to man. Long-term animal studies are presently our only reliable method for detecting potential hazards to man. But animal studies have inherent limits to their relevance for man-especially species differences in susceptibility to various stimulae. Principally man is not a carefully inbred strain of laboratory animal whose diet and environment are controlled. The human race is genetically heterogeneous and this genetic variety is compounded by widely differing environmental experiences. The possibilities for combination, potentiation, or neutralization of factors in man are clearly enormous. Thus, in extrapolating animal data to man, the judgment could be that the hazard for man is nonexistent, less than, equal to, or greater than the effects in animals -all depending on the complex interaction of environmental factors, exposure levels, individual susceptibility, and interactions of factors. Human judgment is and will continue to be the crucial determinant in extrapolating the significance of animal studies for man. Existing regulatory mechanisms also contribute to the complexity of devising rational public policy for environmental health. The principal deficiency of present mechanisms for the control of environmental hazards is their “all-or-nothing” approach to problems which are inherently “some-andsome” rather than “all-or-nothing.” Most of these mechanisms were designed long before judgments of hazards had reached today’s complexity. In pesticide regulation, for example, one level of action results from a determination of a health hazard, and more stringent regulatory action follows a determination of an “imminent” hazard to health. However, since the primary regulatory control is over pesticide registration rather than use of sale, determination of a health hazard or an “imminent” health hazard may not have a dramatic effect on human exposure. To fill this important gap, the Administration has requested legislation to control the sale and to strengthen labeling of pesticides and other toxic substances determined to be hazardous. In a field where change is the rule rather than the exception, we need regulatory authority which is flexible and responsive to informed judgment, in order to carry out the balanced public policy that we are trying to develop. Another complex, little-understood, and often-overlooked phenomenon is the role of our social environment as a determinant of technogenic disease. We have only the most general sense of the deleterious effects on physical and mental health which results from our social order, from economic and social class inequities and ethnic group discrimination, with associated problems
226
STEINFELD
of poor surroundings, inadequate income, educational barriers, and unequal occupational opportunities. Nor do we understand much of the effects of an individual’s inability to cope with the problems of living in a complex, technological society without adequate education or the opportunity for meaningful work. And all of these problems are intensified in the face of widespread, rapidly increasing expectations for significant social change. What’s more, its not just the disadvantaged in our society who suffer from the impact of technology on our social environment. Every one of us is experiencing the stresses of modern life, in the way we’ve arranged our life style-from the microcosm of the family, to the macrocosm of a city such as this, or the nation, or the world. Furthermore, we all now face the potential prospect of a majority of our youth, our hope for the future, disaffected from the basic values and institutions of our society. Society is changing rapidly, technologically and socially. The majority of us live in urban areas where personal human contacts are reduced, and impersonal, secondary contacts comprise the bulk of our interaction with other people, and where the opportunities to develop mutual concern and understanding are dramatically reduced. A classic example of the results of these phenomena is the nice, thoughtful person who, when he gets behind the wheel of a car, drives with a homicidal bent for the destruction of everything barring his path, because he no longer relates personally to anything outside his car. I mention these things not to propose solutions-for we are still in an early infancy in much research into such social problems, but rather to stress that the problems of the future of our environment are not just the problems of air pollution, oil spills or pesticides. Our environment must be totally livable, not just breathable and drinkable. Such a totally livable environment may require drastic changes in the way we arrange our lives -from the relocation of population centers and “new towns” to a new concept of an acceptable impact of “progress” on the whole spectrum of our lives. And let me also mention, very quietly, the problem of noise in our environment, a source of more technogenic diseases. We have a limited base of knowledge from which to begin: specifically, we know that excessive noise exposure causes hearing loss; we know that hearing acuity of selected groups of exposed workers is significantly poorer than that of nonexposed comparable groups; we know also, on the basis of surveys, that many of the machines in industrial use produce noise levels intense enough to pose a hazard to the hearing of exposed workers. In addition to hearing loss, it has been demonstrated that noise can cause physiological changes. These include cardiovascular, glandular, and respiratory effects reflective of a generalized stress reaction. These changes are typically produced by intense sounds of sudden onset-the sonic boom is the most frequently cited examplebut can also occur under sustained high level, or even moderately high level, noise conditions. Such environmental stresses have been demonstrated to contribute to the development of chronic diseases. Still to be explored, of course, are many questions underlying and sur-
TECHNOGENIC
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rounding these observations. We need to know more about the mechanisms whereby noise damages hearing. We need to know more about the effects of noise on performance and work efficiency in the job setting. And, of course, we need to extend our knowledge outward into the community where people live-to the world of jack-hammers, power mowers, booming stereos, and screeching airplanes that we call home. It seems to me that there are two important elements which could assist the development of the kind of balanced public policy we all seek. The first of these is improved mechanisms for technology forecasting and assessment. The need for such forecasting and assessment has grown with the pace of technological and community change. The ability to forecast the potential for future problems, based either on existing scientific and technical knowledge or on projections of possible technologies, are difficult, but increasingly important because of the speed with which scientific concepts can be converted into practical, marketable uses. For example, only a few years passed between the first suggestion of the possibility of microwave amplification of stimulated radiation emission to the first commercial microwave device, and even fewer years for microwave devices to become a $1.5 billion dollar annual business. Lasers represent another area of rapidly developing technology, burgeoning quickly from laboratory and military uses to commercial and possible home uses; as many as 15,000 gas laser welding machines may already be in commercial operation. Beryllium, titanium, and transuranium are examples of natural materials whose use patterns are expected to change and grow dramatically in the coming years. Forecasting techniques vary from inspired guesses, through extrapolations of existing trends and complex matrix-analysis of the future trends of many events, to mathematical modeling and computer simulation. Adequate forecasts of health effects depend on prediction of the new technology as well as the environmental levels and health effects of its products and by-products; these estimates must be integrated with demographic and behavioral forecasts in order to define populations at risk and the intensity of expected exposures. Present forecasting techniques require further development to grapple effectively with the complexities of health, but have nevertheless proved useful in the assessment of potential health effects. Extrapolations of existing trends have permitted the prediction of emission levels of conventional pollutants such as sulfur dioxide. Based on varying control schedules, judgment of potential health and environmental effects can then be related to predicted emission levels. Extrapolation techniques also permit the identification of hypothetical “worst case” situations which can serve as standards of judgment for future technologies being considered. Los Angeles and New York City as locations with special conditions for air inversions, have become a kind of “worst case” standard for assessing air pollution hazards, while the Great Lakes and Suffolk County, New York, have become similar potential “worst case” standards for certain water pollution problems. Extrapolation of present trends is probably the most accurate form of forecasting, and one which has had dramatic influence on public policy for the control of air pollution. Awareness of the predictable consequences of a par-
228
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ticular technological course has permitted our society to select alternative technologies -for example, emission control devices for automobiles and smoke stacks, desulfurization of fossil fuels, and indeed, emphasis on mass transit-all represent technologies more consonant with our goal of a livable environment. Other forecasting devices could also become convincing mechanisms for facilitating constructive social action concerning proposed technologies. For example, new applications of metals such as titanium and beryllium, chemicals for use in weather modiification, detergent additives, new pesticides, and various food additives are promising areas for forecasting future effects. Such forecasts should make it possible to build control processes into initial production to reduce hazards to acceptable levels, or to prevent investment in costly production facilities should too great a hazard be forecast. These forecasts should also aid the development of a total approach to the environment so that we do not transfer pollution from one medium of the environment to another, as in removing pollution from the air in a manner that contributes to water pollution or solid wastes. We should not kid ourselves about the imminence of our expertise at this kind of forecasting of the future, nor should we think that matters of this complexity will ever be reduced to some simple formula. Judgment will be as critical when we are expert at forecasting as it is now; forecasting will only give us more sophisticated predictions on which to base that judgment. The public plays a critical role in any effort to harness technology for the benefit of man. But the results of public involvement in environmental health policy can be either good or bad. Thus, in my view, the second important element which could dramatically assist the development of balanced public policy is an informed public. The public needs to be informed about the complexities of benefit and risk analyses, of the gaps in present scientific knowledge, and of the limitations of animal or other models as predictors of effects in man. The public needs to know about these problems in order to use its powerful influence rationally and constructively. A useful example of the significance of informed public opinion is the controversy surrounding the use of phosphates as detergent additives. Phosphates have been added to detergents to enhance their cleaning effectiveness through several mechanisms. The controversy surrounding phosphates is based on the finding that phosphates accelerate the aging or eutrophication of surface waters; thus phosphates are said to be “killing” our lakes and streams. Evidence of the effectiveness of the environmental education campaign on the effects of phosphates is to be found in the number of phosphate-free detergents which were developed and heavily advertised on that basis. Until recently, most of these phosphate-free detergents used nitrilotriacetic acid as a substitute for phosphates. Production of detergents containing this material was halted early this year based on studies which suggested possible long-term health hazards. Tests conducted thus far indicate that other effective substitutes for phosphates are potentially dangerous to health, largely because they pose serious accident hazards to children. Thus our society finds
TECHNOGENIC
DISEASE
229
itself on at least two horns of a dilemma. We want clean clothes and we want to stop accelerated eutrophication; we don’t want to poison our children and we don’t want to risk long-term health hazards. The present phosphate controversy has already resulted in numerous local ordinances prohibiting phosphate-containing detergents. The danger evident to me in this controversy, is that public concern over phosphates will become so great as to obscure the health or environmental impact of alternatives to phosphates. The ill effects of phosphates on the environment-serious as they are - should not be allowed to drive us to ill-considered, hasty action. We should not leap out of the phosphate “frying pan” and “into the fire.” Rather, we should move with all reasonable speed to adopt well-considered alternatives. Balanced public policy involves development of substitutes for phosphates which are not more toxic or caustic and are not more hazardous to health or the environment; careful examination of ways to minimize the use of phosphates while achieving their intended purposes; and consideration of all reasonable and feasible means of extracting phosphates from the sewage discharged into our surface waters. Many basic scientists have individually joined, as private citizens, the ranks of those who have expressed their deep concern about environmental threats to our health. Yet some of them are reluctant to let such considerations enter into the ivory tower atmosphere of their laboratories. It is certainly essential that no external concern interfere with the scientific quality and rigorous methodology that are the best guarantees for continuing growth of our basic knowledge of biology. Yet the tasks that face us in the field of environmental health are so great that they need the contribution of all those who can help. The scientist has the most powerful tool that can be used for the defense of man from environmental hazards: his own laboratory. By asking himself what he can do as a research worker for the cause he is already concerned with as a citizen, he will discover the importance his contribution can have in correlating different levels of research into an effective program of disease prevention (2). In addition to involvement in these pressing scientific problems, scientists are being called upon to exhibit statesmanship with respect to issues at the interface of science and public policy. It is absolutely essential that scientists bring the same careful reasoning and judgment to their public statements as they bring to their scientific research, since scientists must help the public understand the relevance of scientific studies. As long as our scientific understanding of environmental hazards is as imperfect as it is today-with the formidable problems of extrapolating animal data to man-scientists have a responsibility to the public neither to understate nor overrate scientific evidence which emerges about such hazards. The development of balanced and rational public policy concerning health hazards in the environment is too important to become a partisan political issue. The evolution of such public policy requires fundamental scientific knowledge, an informed public, and the highest personal integrity from scientists, public officials, and citizens alike.
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1. Report of the Secretary’s Commission on Pesticides and Their Relationship to Environmental Health, U. S. Department of Health, Education, and Welfare, Washington, D. C., 1969. 2. Man’s Health and the Environment-Some Research Needs (Report of the Task Force on Research Planning in Environmental Health Science), U. S. Department of Health, Education, and Welfare, Washington, D. C., 1970.
MEDICINE
The potential the development mental health
1,
222-230
(1972)
risks of technological progress to the quality of life require of a balanced and rational public policy directed at environhazards.
Technogenic
Surgeon
General,
Disease:
The Price
JESSE L.
STEINFELD
U. S. Public
Health
Service,
of Progress?
Washington,
D. C.
Modern man creates most of his own environment today-buildings and cities, food and clothing, industrial processes and products, transportation, social order and institutions. In the process of developing the unprecedented technological achievement of modern life, man has inadvertently created many of the most significant hazards to his physical and mental health. Thus we now have the concept of “technogenic” diseases, diseases which stem from advancing civilization and its technologies. Dr. Jerome Weisner, a former Presidential science advisor, expressed the thought that troubles us: “We are engaged in a race between catastrophe and the intelligent use of technology and it’s not at all clear we are going to win.” It is a privilege for me to present this communication on technogenic diseases, since the subject is of particular personal interest. The fundamental underlying concept of technogenic diseases is not a new one. As Rem5 Dubos has said: It is no longer permissible to take comfort in the belief that various types of vascular diseases, of cancers, of chronic ailments of the respiratory tract, have become more prevalent simply because people live longer in affluent societies. The increase in chronic and degenerative diseases is due in part at least, and probably in a very large part, to the environmental and behavioral changes that have resulted from industrialization and urbanization.
What may be new is that our society is just now developing an appreciation of the magnitude of diseases and conditions whose origins lie in the progress that has made our civilization great. Technogenic diseases span the spectrum of human conditions. The filth in our rivers, the smoke and fumes in our ambient air, the sounds of progress which shatter our nerves, mountains of waste in city and country alike - in these and many other ways technology insults as well as assists us. Of course, it is a credit to technology that we can today concern ourselves with technogenic diseases, since sanitation and vaccination technology made possible the conquest of the infectious diseases which were once our all-consuming health focus. Technology has brought us access to a higher quality of life, leisure to reflect on that quality, and aspiration for its enhancement. We are constantly learning more about the legion of potential health hazards in the environment. We need only recall the major public concerns in 222 @ 1972 by Academic
Press,
Inc.
TECHNOGENIC
DISEASE
223
environmental health over the past year or two: pesticides-DDT, 2,4,5-T, aldrin, dieldrin, mirex; heavy metals including mercury in tuna and swordfish; smoking; phosphates and NTA as detergent additives; cyclamates and saccharin, as well as the whole list of food additives generally recognized as “safe.” The occupational environment has taught us much about environmental problems by serving unwittingly as a laboratory of concentrated human exposure to a wide variety of environmental factors-uranium mining and the manufacture of radium watch dials have taught us harsh lessons about radiation; pneumoconiosis has taught us lessons about mining, as lung cancer has taught us about certain industrial processes involving asbestos, chromium, and coke production. Studies of occupational environments have also demonstrated physiological and psychological responses to the stress of long periods of required concentration and to kinds and levels of noise. Also rife in our environment are product and consumer hazards which now account annually for at least 1.6 million injuries and as many as 75,000 deaths, primarily from automobile and home accidents. So too with iatrogenic disease, science and technology have provided new treatments and cures for some human disease, but have also brought us a whole new category of disease -that caused unintentionally as a result of a physician’s intervention. Technogenic diseases of this category include adverse effects of diagnostic tools and procedures such as radiopaque media and such medical devices as X-ray equipment, catheters, and gastroscopes. Also included are the many adverse reactions to therapeutic intervention with drugs, radiation, artificial organs, organ transplantation, cardiac pacemakers, blood transfusions-and I could continue. To illustrate the present magnitude of just one form of iatrogenic disease, it has been estimated that 5% of all general hospital admissions are related to adverse drug reactions, and that as many as 20% of hospitalized patients experience adverse drug reactions during their hospital stay. But beyond our recognition of the technogenic bases of many diseases, what may also be new is our developing commitment to learn from the past to try to improve the future, if not the present. The decisions that society is called upon to make are not easy ones. It would not be sensible to block technological progress or to seek to restore the earth entirely to a previous condition. To make rational judgments, we need to know what price we’re paying for what progress. Our traditional laissez-faire philosophy of life has unfortunately not often prepared us very well to answer today’s question, “What price for what progress?” The development of balanced public policy which considers the benefits and risks of technological advances is an exceptionally difficult matter. Great public fear of the possible implications for man has followed reports of .harm in laboratory animal tests. And yet frequently it is not known with certainty what laboratory animal tests may mean for man. We are obligated to make decisions of great health and economic importance on the basis of very limited evidence of potential hazard; prudence allows no other course. We are aware that both good and bad consequences may result from our actions. To avoid simplistic solutions to complex problems, we must all keep in
224
STEINFELD
mind that we are still feeling our way along toward a balanced public policy concerning hazards to our personal or general environmentwe are having to crawl before we walk. While we are in this circumstance, the precedent of previous actions taken can only be illustrativebut not controllingto us. Each case must be examined on its own merits, on the basis of risks and benefits, and a decision reached., Each of these situations-pesticides, food additives, heavy metals, detergent additives -has been a learning experience for the decision makers, for the affected businesses and industries, and for the public, and each has made all of us aware of additional facets of hazard assessment. We have learned that there are no nonhazardous substances; there are only nonhazardous ways to use substances. : While benefit-to-risk judgments in medicine are enormously complex, they are generally limited in the sense that the risk is borne by the intended beneficiary. In therapy, even extremely toxic agents are appropriate for use in serious illnesses, since the physician can attempt to tailor the benefit-risk ratio for the individual patient situation. It is a very different matter to impose a potential risk on the society in general when not all of society may benefit, and when those who do benefit may not be those who bear the risk. Pesticides provide a classic example of the complexity of judgments of relative benefit and risk in the society at large (1). A full economic analysis of the benefits of pesticides has not been made, but, clearly, benefits have been considerable. Control of insect disease vectors, and bountiful agricultural productivity are foremost among these benefits. Also lacking is a full economic analysis of the costs of pesticides-comparative economic costs of various methods of control, of environmental costs, and health costs. Our lack of critical data on relative increases in agricultural productivity from the use of pesticides, and relative risks fromtheir use, forces us to move slowly on the basis of gross estimates of costs versus benefits. Let us consider the controversy surrounding the use of DDT. DDT is a persistent pesticide used extensively since World War II to control a wide variety of pests, including pests of public health significance. It successfully halted a typhus epidemic in Italy in 1943. DDT has been demonstrated to be harmful to certain species’of birds, and to be persistent and widespread in the environment and in the food chain as well as in human fat tissue; Following widespread use of DDT, many pests developed resistance to it and thus, domestic DDT use has been gradually declining, in light of the availability of other pesticides, and in light of hazards identified with its use. Many people believe that the use of and production of DDT should be halted immediately. However, the problem is not a simple one. While some informed scientists report that all disease vectors which are susceptible to DDT can be controlled by a substitute, the World Health Organization reports that control of many of the most important vectors of human :diseases is still entirely dependent on insecticides, among which DDT is prominent, and that no effective or economically feasible alternatives are’available inmuch of the world. It has been stated that enforcement of a zero tolerance for DDT in food would necessitate the destruction of the bulk of the nation’s food supply.
TECHNOGENIC
DISEASE
225
Here we have the elements of a dilemma. We want an abundant food supply, we want a safe and healthful food supply, we want disease eradicated, and we want a safe and healthful environment for man and for other forms of life. The challenge is to balance these sometimes conflicting goals in such a way that man wins. The evaluation of balanced public policy for pesticides includes phasing out use of the most persistent pesticides, it includes the substitution of less hazardous pesticides wherever possible, and it includes careful review and action on the registered uses of pesticides to reduce potential hazards to human health and to the environment. Much as it might be wished, there is no easy, one-step solution to these complex problems. Adding to the complexity of weighing benefits and risks is the problem of extrapolating animal data to man. Long-term animal studies are presently our only reliable method for detecting potential hazards to man. But animal studies have inherent limits to their relevance for man-especially species differences in susceptibility to various stimulae. Principally man is not a carefully inbred strain of laboratory animal whose diet and environment are controlled. The human race is genetically heterogeneous and this genetic variety is compounded by widely differing environmental experiences. The possibilities for combination, potentiation, or neutralization of factors in man are clearly enormous. Thus, in extrapolating animal data to man, the judgment could be that the hazard for man is nonexistent, less than, equal to, or greater than the effects in animals -all depending on the complex interaction of environmental factors, exposure levels, individual susceptibility, and interactions of factors. Human judgment is and will continue to be the crucial determinant in extrapolating the significance of animal studies for man. Existing regulatory mechanisms also contribute to the complexity of devising rational public policy for environmental health. The principal deficiency of present mechanisms for the control of environmental hazards is their “all-or-nothing” approach to problems which are inherently “some-andsome” rather than “all-or-nothing.” Most of these mechanisms were designed long before judgments of hazards had reached today’s complexity. In pesticide regulation, for example, one level of action results from a determination of a health hazard, and more stringent regulatory action follows a determination of an “imminent” hazard to health. However, since the primary regulatory control is over pesticide registration rather than use of sale, determination of a health hazard or an “imminent” health hazard may not have a dramatic effect on human exposure. To fill this important gap, the Administration has requested legislation to control the sale and to strengthen labeling of pesticides and other toxic substances determined to be hazardous. In a field where change is the rule rather than the exception, we need regulatory authority which is flexible and responsive to informed judgment, in order to carry out the balanced public policy that we are trying to develop. Another complex, little-understood, and often-overlooked phenomenon is the role of our social environment as a determinant of technogenic disease. We have only the most general sense of the deleterious effects on physical and mental health which results from our social order, from economic and social class inequities and ethnic group discrimination, with associated problems
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of poor surroundings, inadequate income, educational barriers, and unequal occupational opportunities. Nor do we understand much of the effects of an individual’s inability to cope with the problems of living in a complex, technological society without adequate education or the opportunity for meaningful work. And all of these problems are intensified in the face of widespread, rapidly increasing expectations for significant social change. What’s more, its not just the disadvantaged in our society who suffer from the impact of technology on our social environment. Every one of us is experiencing the stresses of modern life, in the way we’ve arranged our life style-from the microcosm of the family, to the macrocosm of a city such as this, or the nation, or the world. Furthermore, we all now face the potential prospect of a majority of our youth, our hope for the future, disaffected from the basic values and institutions of our society. Society is changing rapidly, technologically and socially. The majority of us live in urban areas where personal human contacts are reduced, and impersonal, secondary contacts comprise the bulk of our interaction with other people, and where the opportunities to develop mutual concern and understanding are dramatically reduced. A classic example of the results of these phenomena is the nice, thoughtful person who, when he gets behind the wheel of a car, drives with a homicidal bent for the destruction of everything barring his path, because he no longer relates personally to anything outside his car. I mention these things not to propose solutions-for we are still in an early infancy in much research into such social problems, but rather to stress that the problems of the future of our environment are not just the problems of air pollution, oil spills or pesticides. Our environment must be totally livable, not just breathable and drinkable. Such a totally livable environment may require drastic changes in the way we arrange our lives -from the relocation of population centers and “new towns” to a new concept of an acceptable impact of “progress” on the whole spectrum of our lives. And let me also mention, very quietly, the problem of noise in our environment, a source of more technogenic diseases. We have a limited base of knowledge from which to begin: specifically, we know that excessive noise exposure causes hearing loss; we know that hearing acuity of selected groups of exposed workers is significantly poorer than that of nonexposed comparable groups; we know also, on the basis of surveys, that many of the machines in industrial use produce noise levels intense enough to pose a hazard to the hearing of exposed workers. In addition to hearing loss, it has been demonstrated that noise can cause physiological changes. These include cardiovascular, glandular, and respiratory effects reflective of a generalized stress reaction. These changes are typically produced by intense sounds of sudden onset-the sonic boom is the most frequently cited examplebut can also occur under sustained high level, or even moderately high level, noise conditions. Such environmental stresses have been demonstrated to contribute to the development of chronic diseases. Still to be explored, of course, are many questions underlying and sur-
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rounding these observations. We need to know more about the mechanisms whereby noise damages hearing. We need to know more about the effects of noise on performance and work efficiency in the job setting. And, of course, we need to extend our knowledge outward into the community where people live-to the world of jack-hammers, power mowers, booming stereos, and screeching airplanes that we call home. It seems to me that there are two important elements which could assist the development of the kind of balanced public policy we all seek. The first of these is improved mechanisms for technology forecasting and assessment. The need for such forecasting and assessment has grown with the pace of technological and community change. The ability to forecast the potential for future problems, based either on existing scientific and technical knowledge or on projections of possible technologies, are difficult, but increasingly important because of the speed with which scientific concepts can be converted into practical, marketable uses. For example, only a few years passed between the first suggestion of the possibility of microwave amplification of stimulated radiation emission to the first commercial microwave device, and even fewer years for microwave devices to become a $1.5 billion dollar annual business. Lasers represent another area of rapidly developing technology, burgeoning quickly from laboratory and military uses to commercial and possible home uses; as many as 15,000 gas laser welding machines may already be in commercial operation. Beryllium, titanium, and transuranium are examples of natural materials whose use patterns are expected to change and grow dramatically in the coming years. Forecasting techniques vary from inspired guesses, through extrapolations of existing trends and complex matrix-analysis of the future trends of many events, to mathematical modeling and computer simulation. Adequate forecasts of health effects depend on prediction of the new technology as well as the environmental levels and health effects of its products and by-products; these estimates must be integrated with demographic and behavioral forecasts in order to define populations at risk and the intensity of expected exposures. Present forecasting techniques require further development to grapple effectively with the complexities of health, but have nevertheless proved useful in the assessment of potential health effects. Extrapolations of existing trends have permitted the prediction of emission levels of conventional pollutants such as sulfur dioxide. Based on varying control schedules, judgment of potential health and environmental effects can then be related to predicted emission levels. Extrapolation techniques also permit the identification of hypothetical “worst case” situations which can serve as standards of judgment for future technologies being considered. Los Angeles and New York City as locations with special conditions for air inversions, have become a kind of “worst case” standard for assessing air pollution hazards, while the Great Lakes and Suffolk County, New York, have become similar potential “worst case” standards for certain water pollution problems. Extrapolation of present trends is probably the most accurate form of forecasting, and one which has had dramatic influence on public policy for the control of air pollution. Awareness of the predictable consequences of a par-
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ticular technological course has permitted our society to select alternative technologies -for example, emission control devices for automobiles and smoke stacks, desulfurization of fossil fuels, and indeed, emphasis on mass transit-all represent technologies more consonant with our goal of a livable environment. Other forecasting devices could also become convincing mechanisms for facilitating constructive social action concerning proposed technologies. For example, new applications of metals such as titanium and beryllium, chemicals for use in weather modiification, detergent additives, new pesticides, and various food additives are promising areas for forecasting future effects. Such forecasts should make it possible to build control processes into initial production to reduce hazards to acceptable levels, or to prevent investment in costly production facilities should too great a hazard be forecast. These forecasts should also aid the development of a total approach to the environment so that we do not transfer pollution from one medium of the environment to another, as in removing pollution from the air in a manner that contributes to water pollution or solid wastes. We should not kid ourselves about the imminence of our expertise at this kind of forecasting of the future, nor should we think that matters of this complexity will ever be reduced to some simple formula. Judgment will be as critical when we are expert at forecasting as it is now; forecasting will only give us more sophisticated predictions on which to base that judgment. The public plays a critical role in any effort to harness technology for the benefit of man. But the results of public involvement in environmental health policy can be either good or bad. Thus, in my view, the second important element which could dramatically assist the development of balanced public policy is an informed public. The public needs to be informed about the complexities of benefit and risk analyses, of the gaps in present scientific knowledge, and of the limitations of animal or other models as predictors of effects in man. The public needs to know about these problems in order to use its powerful influence rationally and constructively. A useful example of the significance of informed public opinion is the controversy surrounding the use of phosphates as detergent additives. Phosphates have been added to detergents to enhance their cleaning effectiveness through several mechanisms. The controversy surrounding phosphates is based on the finding that phosphates accelerate the aging or eutrophication of surface waters; thus phosphates are said to be “killing” our lakes and streams. Evidence of the effectiveness of the environmental education campaign on the effects of phosphates is to be found in the number of phosphate-free detergents which were developed and heavily advertised on that basis. Until recently, most of these phosphate-free detergents used nitrilotriacetic acid as a substitute for phosphates. Production of detergents containing this material was halted early this year based on studies which suggested possible long-term health hazards. Tests conducted thus far indicate that other effective substitutes for phosphates are potentially dangerous to health, largely because they pose serious accident hazards to children. Thus our society finds
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itself on at least two horns of a dilemma. We want clean clothes and we want to stop accelerated eutrophication; we don’t want to poison our children and we don’t want to risk long-term health hazards. The present phosphate controversy has already resulted in numerous local ordinances prohibiting phosphate-containing detergents. The danger evident to me in this controversy, is that public concern over phosphates will become so great as to obscure the health or environmental impact of alternatives to phosphates. The ill effects of phosphates on the environment-serious as they are - should not be allowed to drive us to ill-considered, hasty action. We should not leap out of the phosphate “frying pan” and “into the fire.” Rather, we should move with all reasonable speed to adopt well-considered alternatives. Balanced public policy involves development of substitutes for phosphates which are not more toxic or caustic and are not more hazardous to health or the environment; careful examination of ways to minimize the use of phosphates while achieving their intended purposes; and consideration of all reasonable and feasible means of extracting phosphates from the sewage discharged into our surface waters. Many basic scientists have individually joined, as private citizens, the ranks of those who have expressed their deep concern about environmental threats to our health. Yet some of them are reluctant to let such considerations enter into the ivory tower atmosphere of their laboratories. It is certainly essential that no external concern interfere with the scientific quality and rigorous methodology that are the best guarantees for continuing growth of our basic knowledge of biology. Yet the tasks that face us in the field of environmental health are so great that they need the contribution of all those who can help. The scientist has the most powerful tool that can be used for the defense of man from environmental hazards: his own laboratory. By asking himself what he can do as a research worker for the cause he is already concerned with as a citizen, he will discover the importance his contribution can have in correlating different levels of research into an effective program of disease prevention (2). In addition to involvement in these pressing scientific problems, scientists are being called upon to exhibit statesmanship with respect to issues at the interface of science and public policy. It is absolutely essential that scientists bring the same careful reasoning and judgment to their public statements as they bring to their scientific research, since scientists must help the public understand the relevance of scientific studies. As long as our scientific understanding of environmental hazards is as imperfect as it is today-with the formidable problems of extrapolating animal data to man-scientists have a responsibility to the public neither to understate nor overrate scientific evidence which emerges about such hazards. The development of balanced and rational public policy concerning health hazards in the environment is too important to become a partisan political issue. The evolution of such public policy requires fundamental scientific knowledge, an informed public, and the highest personal integrity from scientists, public officials, and citizens alike.
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1. Report of the Secretary’s Commission on Pesticides and Their Relationship to Environmental Health, U. S. Department of Health, Education, and Welfare, Washington, D. C., 1969. 2. Man’s Health and the Environment-Some Research Needs (Report of the Task Force on Research Planning in Environmental Health Science), U. S. Department of Health, Education, and Welfare, Washington, D. C., 1970.