Book Review

Cancer Factories: America's Tragic Quest for Uranium Self-Sufficiency

N Engl J Med 1994; 330:442February 10, 1994

Article

Cancer Factories: America's Tragic Quest for Uranium Self-Sufficiency
(Contributions in Medical Studies. No. 37.) By Howard Ball. 188 pp. Westport, Conn., Greenwood Press, 1993. $49.95. ISBN: 0-313-27566-1

Cancer Factories traces the effect of our government's conscious policy decision to promote nuclear self-sufficiency at the expense of U.S. uranium miners immediately after World War II and throughout the 1950s and 1960s. The Atomic Energy Commission was responsible for crafting this policy and for overseeing every aspect of it, including health and safety considerations. The entire process took place in the context of grave concern about national security, in utter secrecy, and without the remotest shred of accountability. The result was predictably grim: an epidemic of lung cancer among Mormon and Native American workers otherwise at very low risk. A tortuous quest for recognition and compensation led these men or, more often, their survivors, through the courts and into Congress, where the fourth attempt at legislative redress finally passed only in 1990.

There is more than enough blame to go around, but a major portion lands squarely on the medical community, as is apparent throughout the book and, most compellingly, in a heart-stopping appendix, which is far and away the highlight of the book. What unfolds is essentially a morality play, where suspension of conscience (as well as of science, not incidentally) inevitably leads to unequivocal evil.

Because of the overriding need to produce uranium, the Atomic Energy Commission decided essentially to ignore health and safety considerations. Not only was effective mine ventilation available, it was relatively inexpensive and known to be necessary to lower the extraordinarily high radiation levels encountered in uranium mines, as the Public Health Service told the Atomic Energy Commission over and over again. Mine owners and operators were not to be “burdened” with this kind of regulation, however, and mine workers were not to be told of the known risks for fear that such knowledge would make it harder to keep them at their jobs, thereby interrupting production. Public Health Service physicians were permitted to study the miners as an occupational cohort, but not to inform them of either hazards or results. Although several physicians resigned, most accepted this pact as the only means of gaining access to the mines and the miners. Not surprisingly, given the tenor of the times, no one blew the whistle. This, however, was not the only or even the most egregious example of the effect of secrecy on medical and scientific ethics.

In 1986 a House of Representatives staff subcommittee issued a report entitled “American Nuclear Guinea Pigs: Three Decades of Radiation Experiments on U.S. Citizens,” which is reproduced in its entirety as an appendix. This is the topic that has been covered so heavily by the national media lately. It is fascinating both to read the report and to wonder why it took the media seven years to pay it any attention. From 1945 to 1947, for example, physicians at Strong Memorial Hospital, in Rochester, New York, Billings Hospital at the University of Chicago, and the University of California, San Francisco, injected plutonium into 18 patients thought to have short life expectancies to determine its rates of retention and excretion. Although most of the subjects were older, one was 18 years old and one was 5. Four of the patients survived for more than 20 years. The University of Rochester also conducted a separate experiment during this time in which six subjects with normal renal function were injected with progressively larger doses of uranium nitrite enriched with ²³⁴U and ²³⁵U to determine the dose at which renal injury occurred. At the Massachusetts Institute of Technology, 20 subjects who thought they had volunteered for a study on normal aging were instead injected with or fed radioactive material, again so that researchers could obtain information on uptake and distribution.

The ethics of these studies is not shaded in gray regardless of the prevailing medical paternalism of the era or of any risk of nuclear incineration. How were our “best and brightest” led into this type of research, and how do we avoid having the whole thing happen again? The book does not really raise this issue and does not really address itself to a medical audience. Such a context would have been useful, not for excusing, but for understanding, what occurred. This was an era when research scientists included themselves and their spouses in experiments of radiation uptake and when physicians routinely proposed mutilating procedures to patients even as they withheld diagnoses (as a house officer I tried to explain the rationale for a proposed orchiectomy to treat the lymphangitic spread of prostatic carcinoma to a patient whose family did not want him to know the diagnosis). Identifying and addressing these contributing factors help keep us from crossing the line.

Despite the author's use of the word “context” twice in chapter titles, a striking lack of context is provided in terms of the overall abysmal state of occupational health and safety in this country and in particular in the mining industry. From a medical standpoint, this lack of context represents a lack of rigor. Although some important medical papers are cited, it is frustrating to search for references for death rates or pathological descriptions and find legal depositions, newspaper articles, and other nonscientific works as sources. These documents are much less accessible to physicians and much less satisfying than primary sources of information. Citing these sources, the author states that miners in the centuries-old Joachimstal silver mines of Czechoslovakia (source of the “Joachimsthaler,” shortened to “thaler” and then to “dollar”) had a 50 percent mortality rate from lung cancer long before uranium mining started in this country. By contrast, the 1983 Encyclopedia of Occupational Health and Safety (Luigi Parmeggiani, ed. Geneva: International Labour Organisation, 1983) states that “[radiation] exposure may occur in the course of mining uranium ores, although the silicosis hazard to which the uranium miner is exposed is more severe than the radiation hazard.” In fact, miners face enormous health and safety hazards, and federal regulations for hard-rock mining were nonexistent into the 1970s.

The title clearly expresses the tenor of the book and its attempt to reach a wide audience. It resembles a public-television special report or a series in the New Yorker: a thoughtful expose aimed at the educated lay audience. The topic is extremely important, but for the price of this book you could become a member of your local public-television station or pay for half a year of the Sunday New York Times.

The author, Howard Ball, is dean of the College of Arts and Sciences of the University of Vermont and a political scientist. This would appear to account for both the strengths and the weaknesses of the book. It takes a particular instance of fundamental policy gone terribly wrong and reminds us that our activities as scientists and physicians are inextricably linked to our basic political freedoms. Unfortunately, it also treats those clinical and scientific aspects in a superficial, unsatisfying way.

Rosemary K. Sokas, M.D., M.O.H.
George Washington University, Washington, DC 20052