ENVIRONMENTAL HEALTH CONTROVERSIES CANCER Significant increases in cancer rates recently (20% from 1973 to 1991), 2/5 Canadians

will get cancer Environmental Focus - Cancer caused by carcinogen exposure - Focus on reducing exposure Lifestyle Focus - Cancer is caused by unhealthy lifestyles (diet, exercise) - Problem: healthy also get cancer Biomedical Focus - Cancer is genetic, focus on cure - Problem: genetics cannot account for increase, adopted children rates

Methodological barriers: 1. Time lag (exposure-disease) 2. People move around 3. Inadequate toxicological knowledge (very few chemicals have actually been tested) 4. Only short term effects are studied one chemical at a time 5. Multiple exposure to carcinogens 6. Double blind cancer studies = unethical 7. Many studies required for certainty Political, Economic, Ideological Barriers: - Biomedical approach to illness is hegemonic o Focus on: ind. Responsibility, treatment, and lifestyle prevention o Little focus on environment - Research is focused on treatment/detection o Money to be made in cancer drugs/technologies o Little funding for environmental causes/prevention - Economic Interests of government/corps/industry o Polluting industries keep focus from environment Rachel Carson Biologist who brought attention to DDT safety Silent Spring: book, focused on harmful effects of pesticides on environment - Pesticide companies launched PR campaign o Highlighted safety importance of pesticides/threatened to sue/attacked Carsons character Carson hid the fact she had breast cancer, or the industry would use it against her Died in 1964 Cancer charities heavily controlled b biomedical researchers, funds go to treatment Chasing the Cancer Answer Wendy Mesley diagnosed with cancer, begins a journey to find why more Canadians are getting sick Thought she was doing everything right; Canadian Cancer Society touts its 7 steps to health Mesley followed these, but was still diagnosed, she figured there is more to it Blood test found many carcinogens in her body: lifetime exposure to industrial chemicals, pollutants and pesticides Industry puts blame on individuals, doesnt give public tools to avoid cancer Ex. Birth control pills may increase risks of breast cancer, many cosmetics also include carcinogens

OCCUPATIONAL HEALTH Industrial revolution (1800s) - Rise of factory labour - Increased urbanization/pollution/workpace - Low wages, no safety, long hours, exploitation of children/women Struggles: - Trade unions fight for the worker - Marxism o Class struggle; capitalism is exploitative o Wealthy profit at the expense of the poor - Organization of work o Employer decisions often based on maximum return (cheaper materials, safety/equipment, number of breaks) - Rise of social benefits and Workmans Compensation Workplace Injury in Canada - Workplace injury is on the decline, though since 1990s, workplace fatality has increased 45% since 1993 - Increase due to high number of primary industry jobs o Mining, logging, fishing, agriculture, construction Asbestos - 70% of increased worker fatality due to asbestos exposure - Canada was 2nd largest world producer - Asbestos generally accepted as dangerous, industry argues o It is safe when used properly, and creates scientific uncertainty Ship Breaking - Taking apart ships, mostly in developing countries - Little safety equipment/regulation, high risk of injury - Exposure to mercury, asbestos, PCBs, etc. - Workers underpaid RACISM Certain people have disproportionate exposure to harmful chemicals leading to illness Hispanic and African Americans live near a hazardous waste site in the US LA Map: extremely high numbers of toxic waste sites in Hispanic dominated neighborhoods - Toxic areas are cheaper to live on - Financial incentives for poor/racialized communities - Poor racialized communities are less informed/have less resources to fight/take longer to clean Grassy Narrows Ojibwa: 1959s hydro dam is constructed, grassy narrows peoples moved - Relocated again, prone to flooding, mercury dumped in river, game & fish poisoned - 1990s: logging in grassy narrows territory - 2002-2008: natives protest

POPULAR EPIDEMIOLOGY Controversy: government/industry hesitant to address emerging community environmental health problems Love Canal 1890s: William Love builds a 7 mile canal near Niagara River, abandoned project. Left a trench 1900s: Land sold to Niagara Falls (used as nuclear waste site), land bought by company that fills canal with more waste (covered with clay). Land sold to school board, company is absolved of liability 1950s-70s: school built, homes built, homeowners not informed of chemical wastes Residents complain of symptoms, city conducts a study, finds high waste levels. Nothing done Newspaper article prompts NYSDOH to conduct a study and finds love canal families are prone to health problems Schools/homes closed, 1st ring residents evacuated, others told they are safe Love Canal Home Owners Association Formed to document contamination/illness & lobby government for evacuation Began epidemiological survey of illness among residents, found increased chronic health disorders - illness was clustered along paths of underground stream; contaminants carried by ground water - State authorities dismissed study as useless housewife data 1980: US Environmental Protection Agency prompted to do own study, finds outer ring residents are susceptible to health effects. LCHOA takes 2 EPA members hostage; all residents relocated later that year Today: love canal is still contaminated, new housing development begins in 1990s, playground made Popular Epidemiology Laypersons using scientific data to understand epidemiology Challenges scientific hegemony (science is not always objective, citizens can do scientific studies, gov does not always protect public interest) Affected communities: pool resources to enforce accountability, create public pressure Traditional Epidemiology Distribution of disease and factors affecting it Practiced by scientists

Industry/Gov: use power to avoid accountability

HEALTH CARE CONTROVERSIES PUBLIC VS PRIVATE HEALTH CARE Great depression: most could not pay for health care Tommy Douglas: lobbied Saskatchewan to implement universal hospital insurance funded through provincial tax Opposition: most medical professional associations (CMA), private insurance companies, pharmaceutical companies due to limits in profits The Hall Commission (1961-1964): study options for improving health care. Recommends: - National universal health plan, covering all health related services - Government pays - Physicians keep private practice and fee-for-service model National Medicare implemented in 1968 Canadian Health Care Today Single payer system: funding shared equally by provinces and federal government Service delivery is public and private - 75% of services are privately delivered, fees regulated by government - 10% GDP spent on health care per year in Canada - First Nations reserve based health facilities lag in quality and quantity compared to provincial Only physician, diagnostic and hospital services covered - Non-insured services are paid through private insurance or out of pocket (dental, vision, etc.) Privatization: Two-Tier Model Allowing public and private financing Proponents argue: - Preventing people from paying for health care infringes human rights - Decreased demand for public services - More doctors would stay in Canada, reducing wait times - Competition = increased efficiency and quality Opponents argue: - Health care not a commodity - Growth of private system would be at the expense of public system, integrity of public system would be lost, less investment, doctors would go private, etc. - 86.2% of Canadians support public health care Passive Privatization Result of declining government funding - Delisting not medically necessary health services (enlisting private insurance for NIHBs) - Earlier discharge from hospitals Leads to active privatization

ALTERNATIVE HEALTH CARE AND BIOMEDICAL HEGEMONY Controversy: CAM is becoming popular, but how effective/safe are they? Opinions on CAMs are shaped by biomedical hegemony rather than demand/efficacy Hegemony Dominance of one social group over others Cultural values of dominant group are normalized Scientific hegemony - Science is the best way to discover the objective truth - Unscientific knowledge cant be trusted Biomedical hegemony - Biomedical doctors are most authoritative - Based on scientific nature of biomedicine

Biomedical Practitioners argue: - Need RCTs to evaluate efficacy of CAMs, current evidence is flawed/unscientific - Natural does not mean safe - Unregulated and non-standardized supplements can be dangerous Biomedical perspectives have political/economic interests RCTs not always appropriate 1. Science is unable to examine anything beyond the physical nature of things as a fundamental preset 2. A 3. RCTs rely on standardized treatments: many CAMs must be tailored Most funding for studying CAMs goes to biomedical practitioners. CAM practitioners denied access to resources. Chiropractic - Biomedicine was not hegemonic end of 19th Centry (unpleasant treatments, inconsistent effectiveness) - CAMs (magnetism, chiropractic, naturopathy) offered pleasant, cheaper treatment 1985: DD Palmer performs first chiropractic adjustment in Iowa - Combination of religion & science was appealing to the public - All disease can be treated by manipulating the spine and allowing the body to heal itself Opposition to Chiropractics - AMA regards chiropractics as a threat to biomedicine - 20th century, chiropractics are labeled as unscientific, ineffective, and unsafe Today - Recognized as effective for neuro muscular problems - Education is as scientific as biomedicine - Still marginalized from hospitals and some biomedical practitioners - Still not taught at public universities

HEALTH CARE CONTROVERSIES MEDICALIZATION AND SOCIAL CONTROL Controversy: some health conditions are controversial as there is a debate about whether they are real conditions that should e treated biomedically Medicalization: process by which certain life behaviours and stages become defined as medical issues Ex. ADHD, alcoholism, pregnancy, depression Medicalization and Stigma Medicalization legitimizes problematic/abnormal behaviours (ex. Obesity as moral weakness, ADHD as bad parenting/behaviour) - Reduces associated stigma as beyond individual control - Allows access to social benefits Medicalization and Social Control Medicalization can act as a social control mechanism 1. Redefines social/political/economic problems as individual ones 2. Emphasizes individual treatment rather than social/political/economic causes 3. Reinforces status quo Ex. Treating cancer as a genetic disorder (vs. environmental), polluters can continue without penalty Demedicalization Some suggest we are seeing demedicalization - Increase in chronic diseases not easily fixed via biomedicine (diabetes, arthritis, Alzheimers) - Increased use/acceptance of CAMs - Increased patient education, activism (lots of information via mass media) Medicating Kids - More and more children in the US are being diagnosed and prescribed medication for issues that had been previously classified as behavioural issues - Ritalin was helping NOEL - NOEL was persuaded to try CAM by friends mom, stepped off Ritalin, behaviours went bad again - Is school intolerant of kids who are hyperactive?

THE PHARMACEUTICAL INDUSTRY Controversy: Pharma has two missions: help people with safe drugs, and provide profit for their shareholders. Do existing regulations protect public health or pharmaceutical profits? - Pharma companies represent themselves as kind helpers, though profit is the priority 20% profit vs. 8% for other industries Profitability determines which drugs are made - Orphaned diseases: treatment for rare diseases with small markets are not researched - Me too drugs: (78% of new drugs), drugs for conditions with large markets. Recycled, small changes which may actually be riskier than predecessors Patent Protection Pharma companies rush to get new drugs to market first - Patent protection: rights to market and distribute a new drug for 20 years - Industry: patent protection recoups high R&D costs, can sell for whatever May lead to improper safety testing and cutting corners Vioxx Made by Merck for arthritis pain, approved by FDA in 1999 2000: study finds Vioxx 4x higher risk of heart attack than alternatives 2004/05: withdrawn from market, evidence that Merck distorted and hid data Resulted in 28,000 deaths, $30 billion in lawsuits Problematic Marketing Medicalization: new markets for drugs created by marketing of new diseases - These diseases have broad, unspecific symptoms, no clear biological origin, large markets Ex. General Anxiety Disorder DTCA: direct to consumer advertising. Mass advertising of drugs to consumers 1. Product claims (states drug, health condition, and side effects) 2. Reminders (states drug without listing health condition) 3. Help-seeking (describes health condition but no drug) Creates unnecessary hypochondrias - Banned in most countries, illegal in Canada (challenged by media firms) - DTCA is influential (more requests for advertised drugs, 75% of physicians will grant them) Bribing Physicians Pharma companies employ reps to promote drugs to physicians through gifts/information - Downplay side effects - Exaggerate efficacy - Emphasize off label uses After visits, physicians are more likely to prescribe the marketed drugs, yet there are few regulations on the practices of pharmaceutical reps Possible Solutions - Impartial testing of safety and efficacy of drugs - More thorough peer reviewed process for industry sponsored studies - Government subsidies for orphaned disease research - Stronger regulation against DTCA - Stronger guidelines against accepting pharma gifts

DES, HRT AND DIANE-35 Three case studies to illustrate medicalization controversy and problematic pharma/government practices. Early research/approval, marketing and rebranding, troubling evidence and inaction DES 1938: First synthetic estrogen, many papers on potential uses (ex. Gonorrhea, menopause), many also suggest breast cancer in rodents Approved in US and Canada 1940s: research suggests DES may prevent miscarriages, begins off-label use, FDA eventually approves DES during pregnancy (despite no studies on efficacy/safety in pregnancy) - Marketed as healthy pregnancy vitamin 1950S: studies find higher miscarriage/infant mortality, banned for chicken/lambs, allowed for pregnant women 1971: marketed as off label morning after pill. FDA warns against prescribing to pregnant women, physicians continue to prescribe. Pharma continues to sell in 3rd world despite warning 1997: NA manufacture discontinued ERT/HRT 1940s: Premarin approved in US and Canada for menopausal symptoms 1950s-60s: marketed menopause as estrogen deficiency disease - menopausal women were suffering, loss of youth and femininity, treatable with pemarin 1960s-70s: ERT sales up 170%, sales triple. Linked with 4.5x risk of endometrial cancer. FDA warns ERT shouldnt be used for simple nervousness 80s: sales drop 50%, progestin added to estrogen to decrease risk of cancer (ERT renamed to HRT) - studies find HRT may reduce risk of osteoporosis and help heart health, marketed as such 1994: Recommended for all Canadian women Late 80s-early 2000s: studies show HRT increases heart problems and breast cancer rates Diane-35 Oral contraceptive; Berlex applied twice for Canadian approval (1993 and 1996), refused due to liver cancer concerns 1997: Berlex submits uncontrolled study suggesting minimal risk to liver 1998: Approved in Canada as second line therapy for severe acne/hormonal imbalance - Berlex ads heavily suggested that Diane-35 was for both acne and birth control, despite it not being an OC 2002: Berlex funded study reports Diane-35 is an effective OC and report little evidence for negative health effects. - Many doctors begin perscribibg Diane-35 as long-term birth control 2000/1: Studies find over 2x risk of stroke compared with other OCs. No response from health Canada 2002: Health Canada issues warning to physicians Today: still being used as therapy for acne and birth control, 11 deaths as of 2006 in Canada

NRTs AND EUGENICS Controversy: How safe and effective are new reproductive technologies? What limits should there be to NRTs? New Reproductive Technologies: technologies that assist or manipulate reproduction or its products Ex. Fertility drugs, sperm extraction, donor semen/eggs, genetic engineering, cloning In Vitro Fertilization (IVF) Egg development/extraction sperm extraction IVF (fertilization) genetic testing and transfer of embryos pregnancy promotion - Not covered by Medicare, 11% efficacy for women over 40, $25,000 cost - 20X chance of multiple births (can undermine baby health and strain family resources) - IVF drugs have detrimental side effects (higher cancer rate) - Babies have 1.5-4X disability rates - Access restricted from poor/non-heterosexual/disabled couples Limits to NRTs - Debates about who is a parent (surrogacy arrangements can lead to child custody conflicts) - Daughters giving birth to mothers genetic children - Sex selection (parents will usually choose males, leads to social problems) - Selection for or against disability - Creating the ideal designed baby