Book Review

Brush with Death: A Social History of Lead Poisoning

N Engl J Med 2001; 344:313January 25, 2001

Article

Brush with Death: A Social History of Lead Poisoning
By Christian Warren. 362 pp., illustrated. Baltimore, Johns Hopkins University Press, 2000. $45. ISBN: 0-8018-6289-2

Brush with Death: A Social History of Lead Poisoning is engrossing to read, despite some faults. Although the author attempts to portray it as an objective history of lead poisoning in the United States in the 20th century, the book has an “attitude”: the transgressions of the producers and industrial users of lead are cast in an angry light, in contrast with those affected and their advocates, who are rendered as virtuous. For many readers, this attitude will be cheered or jeered, but in either case it will impair the objectivity with which the book is read. Many will share Warren's view and forgive the rhetoric, whereas others will stop reading, to their loss. Though the tone and passion of this book do not fit well with the typical scholarly treatise, it is nevertheless fascinating and stimulating.

Brush with Death examines in an interesting and parallel fashion the evolution of thought and actions regarding occupational exposure to lead, lead poisoning during childhood, and the main population-wide risk of exposure to airborne lead from automobiles. Warren's description of the development of the lead industry and the production of lead pigments for paint, with its attendant risk to workers, is fascinating, heavily referenced, and very well written. As a reference source, the book contains much material that is difficult to find, reflecting considerable scholarly effort in the writing of the work. Particularly interesting are Warren's descriptions of the processes of lead-pigment protection, the efforts of reformists such as Alice Hamilton, and the growth of the field of occupational health in the United States as compared with European countries. Likewise, the description of early efforts to understand and control lead poisoning among children is instructive and engrossing. Here again, the scholarly effort is evident and noteworthy.

As Warren traces our understanding of the effects of lead on humans, he describes the evolution of social, industrial, and governmental attitudes toward lead as a toxicant and the prevention of lead poisoning. He is particularly astute in delineating the self-interest of industrial entities in preventing occupational lead poisoning as understanding of the problem evolved. He shows the conflict between industrial interests (profits) and public health interests that attended the elimination of lead from gasoline. In recounting the history of lead poisoning among children, Warren clearly demonstrates the shifting self-interest of the lead industry, ranging from impassioned promotion of lead-based paints to the later removal of lead from paints, which was based primarily on business interests and not concern about public health. The contrast between the rates of use of lead-based paints in the United States and the lower rates in the rest of the industrialized world is clearly documented. Warren also accurately documents the shift in the funding and locus of power in research on the toxicity of lead from the industrial sector to the public sector as a result of governmental funding, and the effect this shift apparently had on the type of research conducted and the interpretation of the resulting data.

Throughout the fascinating, scholarly description of the way in which thought and action regarding the toxicity of lead have evolved, the medical reader will be disturbed by some scientific errors. These range from the merely annoying use of “toxin” rather than the correct term “toxicant” as a descriptor for lead to substantial errors in allusions to the biology and epidemiology of lead.

The early parts of this book are sound, reasonably accurate, and fascinating to read. However, the last chapters, which primarily review the past 20 years of efforts to prevent lead poisoning among children, display a highly selective and slanted view of the most recent efforts. For instance, although acknowledging that the new guidelines of the Centers for Disease Control and Prevention “are sensible, sound, and well reasoned, based as they are on credible epidemiological data, humane principles, and sophisticated cost-benefits,” Warren rejects these guidelines because of the belief that they turn “the clock back to the early 1980's.” Only anecdotal evidence and personal assertions support this rejection. The book proposes that only efforts at secondary prevention, such as the screening of all children, can eradicate the remaining problem posed by lead-based paints and dismisses efforts at primary prevention. The review of the enormously complex history of the prevention of lead poisoning during the past 20 years ignores many of the events, personalities, and organizations that have shaped this battle. It is a shame that the excellent scholarship evident in the early parts of the book gets lost in this section.

Despite these and other defects, Brush with Death is well written and absorbing, and I was delighted to have had the opportunity to read it. I recommend it to anyone interested in the history of lead poisoning in the United States.

J. Routt Reigart, M.D.
Medical University of South Carolina, Charleston, SC 29464