Correspondence
More on Critical Condition: Human Health and the Environment
N Engl J Med 1994; 330:1161-1162April 21, 1994
- Article
To the Editor:
Dr. Eisenbud's unrelievedly negative review (Dec. 2 issue)1 of our book Critical Condition: Human Health and the Environment is inaccurate, incomplete, and misleading. The evaluation centers on a critique of one table in the chapter on occupational health. What is particularly inexcusable is Eisenbud's disregard for evidence of changes in the global environment that ominously threaten humanity. He has no comment on nine other chapters on the effects on human health of air, water, and food pollution; radiation; war; population growth; stratospheric ozone depletion; climate change; and the loss of biodiversity. His only reference to the remainder of the book is that “there are many factual errors, and most of the chapters tend to be biased and sensationalized.” We strongly object to this unsubstantiated evaluation.
Dr. Eisenbud makes several factual errors. He takes issue with our use of the concept of the sentinel health event, developed by the late David Rutstein and colleagues at Harvard Medical School, which has been very valuable in preventive and occupational medicine2. Dr. Eisenbud picks at the listing of sentinel health events in a table we used. And his picking is quite inaccurate -- not, we hope, because of his commercial connections.
For example, Dr. Eisenbud states that beryllium disease is a condition not seen in nuclear-reactor workers. This is not accurate. The paper describing sentinel health events clearly refers to nuclear-reactor workers as a group at risk for chronic beryllium disease of the lung2. Dr. Eisenbud further states that aplastic anemia is not caused by ionizing radiation. This statement is also inaccurate. Rutstein et al. cite work by Genevieve Matanoski3 and W.M. Court Brown and Sir Richard Doll4 (see also the paper by Seed et al.5).
In addition, Dr. Eisenbud states that osteogenic sarcoma caused by radium is of historical interest only and is not important to physicians in occupational medicine today. That is simply not true. Radium is used today -- in Kansas, for example, where workers still paint the dials of aircraft instruments with radium and still wet the tips of the brushes in their mouths, as women painting watch dials did years ago in New Jersey. We suspect that radium may very well be used today in other parts of the world.
Finally, Dr. Eisenbud lists his affiliation as Duke University Medical Center, but he fails to note his long-standing role as a consultant to the beryllium and nuclear-power industries. Eisenbud is the chairman of the Beryllium Industry Scientific Advisory Committee.
We wrote Critical Condition because we wanted physicians, scientists, policy makers, and the general public to have access to the best information available on the effects of the degradation of the global environment on human health. We believe readers of the Journal deserve, but did not get, an objective and unbiased review of our book.
5 ReferencesMichael McCally, M.D., Ph.D.
Chicago Community Trust, Chicago, IL 60601Eric Chivian, M.D.
Massachusetts Institute of Technology, Cambridge, MA 02139Philip Landrigan, M.D.
Mount Sinai School of Medicine, New York, NY 100291
Eisenbud M . Review of: Critical condition: human health and the environment. N Engl J Med 1993;329:1749-1750
Full Text2
Rutstein DD ,Mullan RJ ,Frazier TM ,Halperin WE ,Melius JM ,Sestito JP . Sentinel Health Events (occupational): a basis for physician recognition and public health surveillance. Am J Public Health 1983;73:1054-1062
CrossRef | Web of Science | Medline3
Matanoski GM ,Seltser R ,Sartwell PE ,Diamond EL ,Elliott EA . The current mortality rates of radiologists and other physician specialists: deaths from all causes and from cancer. Am J Epidemiol 1975;101:188-198
Web of Science | Medline4
Brown WMC ,Doll R . Mortality from cancer and other causes after radiotherapy for ankylosing spondylitis. BMJ 1965;2:1327-1332
CrossRef | Web of Science | Medline5
Seed TM ,Carnes BA ,Tolle DV ,Fritz TE . Blood responses under chronic low daily dose gamma irradiation. I. Differential preclinical responses of irradiated male dogs in progression to either aplastic anemia or myeloproliferative disease. Leuk Res 1989;13:1069-1084
CrossRef | Web of Science | Medline
Author/Editor Response
Dr. Eisenbud replies:
To the Editor: My review of Critical Condition did deal mainly with the chapter on occupational health, at the expense of the other chapters. Unfortunately, this was necessary because of space limitations. Although some, but not all, of the other chapters would have deserved more favorable comments, the one on occupational health seemed appropriate for special attention, because that is the subject with which the physician is most often involved in dealing with patients about environmental matters. This is certainly more true than is the case with stratospheric ozone depletion, the loss of species diversity, nuclear war, and the possible effects of climate change, important though these subjects may be.
Concerning the specific points made by the authors in their response to my review, I offer the following responses. First, the authors are correct that the studies of Court Brown and Doll demonstrated an excess of aplastic anemia. However, that work was limited to patients undergoing irradiation to treat ankylosing spondylitis. The mean dose they received to bone marrow was about 350 rem -- far higher than the doses received by radiation workers, except in the most severe accidents. The last such accident in this country involved one employee more than 30 years ago.1 The authors also refer to the paper on mortality rates among radiologists by Matanoski et al., but they fail to note that the reported excess of aplastic anemia was observed only in the 1920-1929 cohorts and that “thereafter the excess disappears.” It is well known, of course, that the early radiologists received very high doses. Examples such as these are of historical and scientific interest but have no relevance to the contemporary practice of occupational medicine.
Second, the authors continue to claim that beryllium disease is seen in nuclear-reactor workers. This is simply not so. Cases have been reported in plants and laboratories in which beryllium is used in nuclear-physics research and nuclear-weapons manufacturing, but not among nuclear-reactor workers. Except for rare experimental research, beryllium is not used in reactors, and hence there is no opportunity for occupational exposure. The Beryllium Case Registry maintained by the National Institute for Occupational Safety and Health contains no cases involving reactor workers.
The authors also state that radium “is used today -- in Kansas, for example, where workers still paint the dials of aircraft instruments with radium and still wet the tips of the brushes in their mouths. . . . ” I have been informed by the Kansas Department of Health and Environment (Allen G: personal communication) that the use of radium for new dials in that state was discontinued in the 1940s, although a stockpile of old dials does exist, and from time to time some of them must be repainted. The practice of using the lips to prepare a point on the camel-hair brushes has not been allowed for about 70 years. Between 1936 and about 1949, I visited many dial-painting shops and can testify firsthand about the changes in the industry that had already taken place.
The authors object that the only affiliation listed in my review was Duke University, which happens to be the most active of the three academic appointments I hold in my semiretirement. They are troubled by the fact that I have served as a paid consultant to industry, in particular as chairman of the Beryllium Industry Scientific Advisory Committee. This seemed relevant to them because of my statement that beryllium disease has not been seen in reactor workers. Since this was a statement of easily verifiable fact, rather than opinion, I did not think there was a real or perceivable conflict of interest.
1 ReferencesMerril Eisenbud, Sc.D.
Duke University Medical Center, Durham, NC 27710
