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HEALTH - " Health Policy Advisory Center Volume 14, Number fl 5 PAC Great Expectations: BULLETIN the Biotechnology politics of INSIDE Great Expectations: The Politics of Biotechnology P. 7 ? Peer Review To the Editor: I want to thank you for the most in- cisive review by Carl Blumenthal of my book Missing Pieces in the Health / PAC Bulletin (March - April 1983). It is clear from his last com- ment i.e. (my omissions) that I may have made an error in judgement. During the last 18 months I have published four books - one deals very explicitly with the Independent Liv- ing Movement, Independent Living for Physically Disabled People (Jossey - Bass, 1983), and one with sociopolitical issues, Socio Medical - Inquiries: Recollections, Reflections and Considerations (Temple Univ. Press, 1983). As a result, I thought it was enough that I treated the matters mentioned Helsewhere Helsewhere. In the eyes of at least one reviewer I was mistaken. Irving Kenneth Zola, Ph.D. Professor and Chair, Department of Sociology, Brandeis University United nations officials are declar- ing the current African drought more widespread and potentially far more devastating than the disastrous - 1973-74 dry spell. The area suffering most may well be the Horn of Africa, where the i Ethiopian government is engaged in a long, bitter war with guerrilla movements in Eritrea and Tigre. - In 1952 Ethiopia, then ruled by American ally Emperor Haile Selas- sie, won UN approval for a federation with Eritrea. In 1962 the emperor unilaterally abrogated the treaty and annexed Eritrea. The guerrilla movement, which had actually been founded the year before, grew rapidly. Ethiopia's continued on page 4 Health / PAC Bulletin October November -, 1983 Board of Editors Tony Bale Howard Berliner Carl Blumenthal Pamela Brier Robb Burlage Michael E. Clark Barbara Ehrenreich Sally Guttmacher Louanne Kennedy David Kotelchuck Ronda Kotelchuck Arthur Levin Nonceba Lubanga Steven Meister Patricia Moccia Kate Pfordresher Marlene Price Virginia Reath Hila Richardson David Rosner Hal Strelnick Sarah Santana Richard Younge Richard Zall Editor: Jon Steinberg Staff: Roxanne Cruiz, Debra De Palma, Loretta Wavra Associates: Des Callan, Madge Cohen, Kathy Conway, Doug Dorman, Cindy Driver, Dan Feshbach, Marsha Hurst, Mark Kleiman, Thomas Leventhal, Alan Levine. Joanne Lukomnik, Peter Medoff, Robin Omata, Doreen Rappaport, Susan Reverby, Len Rodberg, Alex Rosen, Ken Rosenberg, Gel Stevenson, Rick Surpin, Ann Umemoto. MANUSCRIPTS, COMMENTS, LETTERS TO THE EDITOR AND SUBSCRIPTION ORDERS should be addressed to Health / PAC, 17 Murray St., New York, N.Y. 10007. Subscription rates are $ 17.50 for individuals, $ 35 for institutions. ISSN 0017-9051 1983 Health / PAC. The Health / PAC Bulletin is published bimonthly. Second class postage paid at New York, N.Y. and at additional mailing offices. Design: Three to Make Ready Graphics / 1983 Cover from a 19th century photogravure Pickwick Papers illustration / New York Public Library. Typeset by Kells Typography, Inc. Articles in the Bulletin are indexed in the Health Planning and Administration data base of the National Library of Medicine and the Alternative Press Index. Table of Contents Peer Review Notes & Comment 23 t Letter from the Editor Vital Signs 5 Great Expectations 7 " Our Goal is Prevention " 19 Bulletin Board Media Scan 22327 2 5 (Body English will be back next issue.) 2 Health / PAC Bulletin Notes & Comment Over 40 percent of all U.S. workers are women, with married women the fastest growing group among them (at least before the Reagan Recession). By 1981, both spouses were employed in 52 percent of all married - couple families, with and without children. What do such people do for childcare in the absence of any comprehensive state or national programs? Increas- ingly, apparently, many husbands and wives work different shifts so that at least one parent is with the child almost all the time. This is the surprising finding of a recent study by two sociologists at the University of Maryland, reported in Science magazine last February. About 18 percent of all U.S. workers are on shiftwork. that is, they work in the evening, through the night, or on a rotating shift. But, the study found, among married couples in which both spouses work, at least one spouse is on shiftwork in 34 percent of the households. Ten per- cent of the dual earner couples with children work com- pletely different hours with no overlap. A 1977 study found that the husbands of mothers on shift work frequently - employed as nurses, waitresses, and telephone operators - were the principal caretakers for their children 30 percent of the time. Such arrangements " solve " the childcare problem tem- porarily, but the social and emotional cost to both parents is often heavy. Children feel that cost, and they might also miss seeing their family together the way it appears in elementary school readers. If the Moral Majority is worried about the disintegration of the family, providing daycare and eliminating poverty would be a good place to begin shoring it up. Letter from the Editor The response to our reader survey has been gratifying, both in numbers and in praise. Those who have answered are, of course, a highly self selected - group; they not only subscribe, they took the trouble to tell us what they think. But we like to believe their answers are at least somewhat indicative of general reader attitudes toward the Bulletiin. More people read the major article first, with shorter ar- ticles and Vital Signs a close second. More than half go through the magazine cover to cover (we were quite pleased with that; People magazine has larger print and smaller words and most of its readers aren't so engrossed). The most common criticism was that the major article is too long. We will keep this in mind, and we are already soliciting more short pieces (those who write the longer ones have a lot to say, however, so we have to work on them too).. A number of readers found the prose glib or strident or both. A number of readers found the prose excellent. We will try to please all of them. The Bulletin is used frequently in classrooms, as we suspected, and also in community, union, health education newsletters and advocacy work. We found this variety very encouraging, since our intention is to offer a publication which is of value to health professionals, activists, and con- sumers. This is not as easy as it might seem. The variety of topics suggested for the magazine is vast; it would take us several years to cover them all even if we did nothing else, but we will certainly examine the list carefully when seeking out and selecting new material. More respondents by far became acquainted with the Bulletin through friends than by any other means. This isn't surprising, given our limited resources for publicity. If you haven't shown the Bulletin to some of your friends who might subscribe, we hope you will. If every one of our sub- scribers gets us one more (or half an institution), the Bulletin will be self supporting - . If you can get two or three and bring the average up, that would be wonderful. Our sincere thanks to those who have sent in the ques- tionaire. If you haven't yet, we would still welcome any responses. Jon Steinberg Health / PAC Bulletin 3 continued from page 2 American and Israeli military ad- visers are gone, replaced by Soviet and Cuban personnel, but its war with the Marxist guerrillas for control of Eritrea's 3.5 million people and Ethiopia's only outlet to the sea drags on. The following letter by one of the top medical officers of the Eritrean Peoples Liberation Front (EPLF), provides a revealing picture of how a grossly outgunned revolutionary movement attempts to improve health care to desperately poor people while fighting a guerrilla war. Eritrea As you know, we're a Third World country. Most of our problems are re- lated to malnutrition, and in the background of course is the war. Plus in the past four, five years we've had drought, which has really com- pounded the health problems. To deal with these we have a health system with three sections. The first one dealing with casualties of the war, the second with general medical ser- vices, and the third with medical education. We've been providing services for ten years, and right now we have be- tween two and three million people under our care. In 1978 we had con- trol of most urban centers, but since our withdrawal we've been in the rural areas only. The infant mortality rate had been cut greatly but it's still one of the highest in the world: one out of three children dies before the first birthday, one out of two before the fifth birth- day. Probably after the drought in Eritrea and other East African coun- tries is over it will drop considerably, but right now what we're trying to do first of all is give people enough food to ensure their survival. We also show them how to grow crops which are most effective in combating malnutrition - vegetables like carrots, tomatoes, and green vegetables. People near the towns have grown them in the past as cash crops for sale in the towns; what we're trying to do is convince them that if they're good enough for the towns- people, they're good enough for them. Traditionally for themselves they've just grown buckwheat, wheat, corn, millet, and peas, made the cereals into bread and mixed it with a soup made from the peas. Second, we are trying to deal with infections and infestations by prevent- ing them and treating them. The health workers go around to instruct people in sanitation, particularly how to construct simple latrines, and work with the regular education system to provide basic health education. Because of the drought the water is on average three to five miles away. Still, because we think there will be enough to dig wells once the drought is over, we're educating people now in washing habits. We're also working on a prototype latrine with some peo- ple from Australia which we think will be acceptable to the people. Each village has an assembly which has grown up in the struggle and I think that because of their mass participa- tion they will be able to spread the use of the latrines. Again, the only prob- lem is the drought. We're using a Swedish type with two compart- ments. When one is filled up it can be used for compost while the other is filling. The most severe problem in the Third World and in Eritrea and the rest of East Africa particularly is schistosomiasis, an intestinal para- site. In a survey we did it was second only the diarrhea as the most com- mon disease. And that wasn't a very sophisticated study; probably it is first. That is why I'm not so enthu- siastic about the Swedish model. We have others which utilize flowing water that breaks down the excreta, and we're modifying these to meet our conditions. There is a wood common in Eritrea called min which the Australians think is very good for latrines, and we've sent it there for study. We have some clever people who are saying that using materials common in the lowlands we can produce a cheap cement. The village assembly is basically the local government. Villages in Eritrea generally have between 1000 and 10,000 people, so they're quite large communities. Each of them chooses one, two, or three people. depending on the village size, which they send to us for training for three months. Then we send him or her back to the village with basic equip- ment needles - , syringes, a boiler, some materials for first aid, and drugs. After that we're responsible for visiting him or her every week or at most every two weeks to provide supervision and on the spot training. The community can dismiss any worker for poor behavior, and shares part of the expense. Obviously because of the drought many com- munities can't afford very much, so we currently bear 60 or 70 percent of the cost, but we feel its very impor- tant for the local population to con- tribute to the extent possible. If the village is really spread out we have two centers. In the three month training we pro- vide education on the common diseases, how to identify the symp- toms, and how to treat them. We also give them some education in preven- tive medicine, particularly general sanitation, latrines. If it's a swampy area where there is malaria, we ex- plain the problem so that they can en- courage the village to take action. We also teach them how to par- ticipate in the care of the newborn. Usually the village prefers the tradi- tional midwife, and in that case the health worker cooperates with her. In the beginning we thought that anyone with common sense could be brought in for training, but now we say that people must have basic literacy so they can record births and deaths and disease. Grade four or five would be acceptable. We give a mini- mal amount of biology and anatomy in the program. There are some slides continued on page 30 4 Health / PAC Bulletin Vital Signs oefi dents caused by jets hitting birds. Maj. Dennis Funnemark said the device, called a chicken gun, was a converted foot 20 - cannon that This Competition Has Few Buyers shoots 4 pound - chickens into engines, windshields and landing gear to determine how much damage such collisions can cause. Although the Reagan Administra- tion doesn't believe in throwing money at domestic problems, it obviously has Although Business Week (October 24) is announcing the profits investors can reap from the new national health maintenance organization chains, workers appear are less enthusiastic about them. Since 1973 all employers with 25 or more workers who offer a health in- surance plan have been obliged under law to have an HMO option. Right now only three percent of the 21 million workers enrolled in plans take the opportunity to join one, according to a recent study by the Bureau of Na- tional Affairs. The major reason may be cost. In 1981 the average monthly HMO pay- ment when employee contribution was required totaled $ 12.77; for other health plans it was $ 7.21. With dependents the differential jumped even higher, $ 27.21 versus $ 18.96. Despite relatively greater benefits in HMO plans, this extra payment may be too much for many workers to af- ford, particularly in a time of wage cuts and a serious threat of unem- ployment. Murder Most Fowl no such reservations about throwing chickens at military problems. Since the above article appeared, Health / PAC has plucked information from high government officials indicating that U.S. intelligence agency reports are ruffling feathers in the White House. The U.S., they say, is already behind the Soviet Union in the key chicken missile field and the poultry gap is widening. According to them the Soviets have developed anti missile - chickens which are particularly threatening because they cannot be picked up by U.S. radar units. This also creates considerable confusion. Satellite photos detected what intelligence analysts thought was a giant new Soviet base outside Kransnopolsk, but after careful research it turned out to be a collective farm. " This means that any Soviet chicken coop could be a cover for a missile base and vice versa, " warned on Reagan Administration official who opposes all arms control agree- ments on grounds that they are unverifiable. The top secret - CIA study also says that the latest Soviet models have a throw weight - capacity sufficient to launch a two - ton The following article appeared on page A24 of the New York Times last June 9:, Langley, Va., June 8.- Officials at Langley Air Force Base said to- day that a cannon that hurls dead chickens at airplanes at 700 miles an hour is helping to reduce acci- chicken, should Soviet experts come up with one. Egged on by these reports, Secre- tary of Defense Weinberger has ap- parently asked the President for $ 20 billion (Not " exactly chickenfeed, " noted one Pentagon analyst) to develop a superior American weapon as well as an anti missile- - anti - chicken, code named - Fox. A Warning to Hospital Workers The Occupational Health and Safety Letter reports that several Virginia hospital workers have devel- oped respiratory disorders from shampooing carpets with concen- trated commercial cleaners, accord- ing to state officials. These shampoos contain many toxic substances, including trichloro- ethylene, perchloroethylene, naph- tha, kerosene, and other petroleum solvents. They must be diluted as directed before use and adequate ven- tilation must be provided. Wasting Away Representative John Dingell of the House Committee on Energy and Commerce has published a new report entitled Hazardous Waste En- forcement. It comes to what Ex- posure, the monthly publication of the Environmental Action Founda- tion's Waste and Toxic Substances Project, notes is a not very surprising conclusion, that " a strong, effective enforcement program " is the only way to stop illegal or improper dumping. The committee report comes out of a two year investigation of hazardous waste disposal in New Jersey where, it says, organized crime is " in control of both solid waste carting " and the " illegal dumping " which continues to be rampant throughout the state. The Environmental Protection Admini- stration's efforts to control mob in- volvement and to regulate the dis- posal industry have been ineffectual, the report charges, and the EPA's new " confrontational non - , voluntaristic " p Health / PAC Bulletin 5 approach doesn't have a chance of succeeding. - The committee's chairman is James Florio, a Democrat from New Jersey. He issued a related General Account- ing Office report on hazardous waste sites around the country saying, " We were shocked to learn that the laws and regulations are in large part being ignored or are not being enforced at all. " The GAO reported that 51 of the 65 sites it examined were in direct viola- tion of Federal and state laws. In Illi- TASTEE FOODS Bido Bido A.SUBSIDIARY OF MULTI- CHEM INDUSTRIAL ' WASTE REPROCESSING CORP. nois, managers of 33 of 38 dumps checked were not complying with Federal requirements " that they monitor underground water near the . dumps to assure there was no seepage into the drinking water. " Of the 8000 dump sites in the > country, the GAO noted, only 24 have received final Federal approval. Representative Florio proposed an amendment to the Federal hazardous waste law which would require dump operators to " certify they were in compliance with the Federal require- ments of their permits or shut down. A fraudulent certification would be grounds for criminal prosecution. " Clearly, even if such an amendment were to be passed- an unlikely pro- spect, since corporations want to dump their waste now, not when facilities are upgraded at considerable cost which would be passed on to them - to be really meaningful it would require much tougher policing of the 8000 dumpsites than the Dingell report indicates the EPA is wont to provide. ISISIT M }} Pavemnt cent greater than among all women workers. Ronald Katz of the Depart- ment of Preventive Medicine at the University of Illinois Medical Center reported in the October issue of the Journal of Occupational Medicine that of 2,157 female registered nurses in his study who died between 1963 and 1977, 41 committed suicide; the expected number for women workers would have been 27. The excessively high rate was largely due to suicides among nurses over age 50. No other cause of death was significantly higher among the RN's. These findings are benign com- pared to those of a recent study of women doctors, which found that their suicide rate is four times that of all American women, greater than the rate for male doctors. Nurses in Danger Healthcare workers are well aware that stress is one of their profession's occupational hazards. Recently pub- lic health researchers have been pro- viding data which corroborates this assumption. One of the most extreme manifesta- tions of stress is suicide, and a new study has found that the rate among nurses is exceptionally high, 50 per- As Maine Goes... Who Knows? Until last July nursing costs in Maine, as in most hospitals else- where, were buried in " inpatient routine care costs ", a category that in- cludes a patient's room and board, medical and surgical supplies, and rental of hospital equipment. Now, thanks to a comprehensive, well- organized Maine State Nurses As- sociation campaign over many months, patients will know what part of the hospital bill went to nursing care. Increasing consumer awareness of why they " rang for hours for a nurse who never came " is part of a national campaign by nursing organizations to promote their members'professional autonomy, dignity, and accountabil- ity. The American Nursing Associa- tion favors legislation to break out the cost of nursing services to reveal variations in intensity of care. demon- strate that these service generate revenue, and protect the nursing budget from slashing expected under the new Federal diagnostically related groups (DRG) system, which reim- burses hospitals a set amount for each medical problem covered by Medi- care regardless of the treatment given. The Maine nurses association, tak- ing advantage of its new sophistica- tion in flexing nurses " power, " is pressing for passage of another bill removing a major irritant. Like other state nursing associations and unions of hospital and health care employees. the MSNA has long been outraged that hospital administrators can use Federal funds to pay for consultation on how to beat back employee demands. Last year Congress banned the use of Medicare monies for such purposes. The MSNA and other Maine groups are pressing for state legislation that bars such funding under both Medicare and Medicaid and mandates fines and forfeitures of payments for any hospital found in violation of this rule. The Chips Are Down in Silicon Valley A strike by 1200 San Jose, CA nurses at four hospitals over compar- able worth issues has ended. Some of the nurses had spent more than a year continued on page 30 6 Health / PAC Bulletin Great Expectations The Politics of Biotechnology by Eric Holtzman Most critical public discussion of " genetic engineering " and of other biotechnological matters, has focused on ob- vious " hot " issues - public and environmental safety, poss- ible ethical problems in applications to humans, and the peculiarities of patenting living organisms and life processes. Fueled largely by the momentum of the environmental and antinuclear movements, and the resurgence of religion, a vague undertone of disquiet has developed. Much of the debate, however, has centered on peripheral and short term questions. This is unfortunate, since bio- technology has potentially explosive economic and political aspects - far from all of which are necessarily to be feared or opposed. Agricultural and medical practices are likely to be dramatically changed and important new productive capacities unleashed with major consequences, perhaps especially for the Third World. Concrete questions about who is to control biotechnology and how this control is to be exercised are already looming, promising struggles and shake - ups. The discussion that follows is written from the vantage- point of a university - based cell biologist. Inevitably its perspective develops out of experience with biology in the U.S. I am aware of the ambiguities of technology and of the evils attendant upon overrelying on technical solutions to solve social problems. I do, nevertheless, believe that much of biotechnology should be greeted as potentially liberating, and as difficult to assimilate within current economic frameworks. The idea that new technologies are to be resisted, reflex- ively, because the history of the last century teaches us that technologies tend to run out of control is both ahistorical and beside the point. Such positions do simplify matters and help energize opposition. They eliminate the need to weigh benefits and risks; or to evaluate the economic, political and cultural forces that underlie particular developments. But this approach tends to be based too Eric Holtzman is Chairman of the Department of Biological Sciences, Columbia University. heavily on fear, which can disable as well as mobilize. Moreover, many of the most important issues raised in terms of risks are really forms of fundamental questions about how economic and political power is exercised and who, legitimately, has the right to make decisions with potentially broad social effects. I believe such questions are more fruitfully posed as such, rather than in the more mysti- fying terms of technologies running out of control. What's new Our vision of biotechnology is dominated by news of pro- gress in sophisticated genetic manipulation. In fact, recent advances are much broader - based and include many less spectacular, but still very useful, improvements in our understanding of cells and organisms and in our capacity to work with them.'With increasing ease, rational ap- proaches can be constructed to deal directly with diverse problems that researchers hitherto grappled with clumsily or in hit miss - and - fashion. The combination of versatility, relative simplicity, and potential low costs is the basis for the promise of biotechnology. These attributes also generate the growing pressures on current practices in research, the control and transfer of information, and structures of pro- duction and distribution. Modern biotechnology draws heavily on longstanding, sometimes quite ancient, methods of agriculture, medicine, and industry. Selective breeding and related procedures, based on an increasingly refined understanding of hered- ity, have been fundamental to the establishment of present- day food crops and herd animals. Medicine has applied biotechnological approaches to produce vaccines and antibiotics for decades; medical personnel also use bio- logically based diagnostic procedures and extract drugs and hormones from biological sources. The production of alcoholic beverages is only the most widespread of a varied group of microbiologically based industries; sewage treat- ment is another. As would be expected, the recent upsurge in biotech- nology has largely flowed within agendas and production methods originating in this long history. This " conserva- Health / PAC Bulletin 7 Orhan Abdulah tivism " is likely to diminish as the possibilities arising from recent research are explored and exploited. What is new intellectually is the sophistication of tech- niques for manipulating biological material directly at the genetic level and the capacity to engineer particularly convenient cell populations - principally microbes and cell cultures -- to produce materials that were previously avail- able primarily from markedly less convenient, or inherently limited sources. In the laboratory genetic engineering of bacteria has produced hormones and other medically or industrially valuable proteins of higher organisms. Hybrid cell lines, produced by fusing different cell types, have been used to generate monoclonal antibodies useful in diagnosis and therapy. Animal embryos, including those of humans, have been transfered and stored. The study of the cell and molecular biology of plants have come of age. All this has excited enthusiasm which has carried over to a range of other activities in search of strains of organisms, enzymes, and other biological materials for in- dustrial, medical, and agricultural use. This enthusiasm and the confidence that biological approaches have tremendous potential are probably the most important products generated thus far. Many people, however, are convinced that this potential is primarily for disaster. Public doubts have centered on the possibility that laboratories might accidentally create microbial " gypsy moths " which would escape, propagate. and wreak havoc - cause cancer, an exotic plague, or devour oil fields. This concern has been raised in the scientific commun- ity as well. When recombinant DNA techniques (the foun- dation of genetic engineering) were first developed as research tools, a broad and highly influential body of biological researchers imposed its own system of precau- tions and controls. Under the auspices of the National Institutes of Health (NIH), these restrictions by and large held sway for several years. Some communities, including Cambridge, Massachusetts - an early center of genetic engineering - attempted to develop their own regulations for research and applications of the emerging technologies. The Decline of Regulation No disasters occurred. Recombinant DNA techniques proved to be immensely powerful research tools. A few studies evaluating potential dangers produced reassuring results. Soon the scientific community decided that the fears were exaggerated and that all but a few of the usual applica- tions of the techniques were safe. In the space of a few years virtually all the controls that had been imposed were effec- tively lifted. (The NIH did retain a review panel, one of whose jobs is to regulate field tests of engineered organisms; more will be said about this below.) At this point those few individuals in the scientific community who still argue in favor of controls must endure heavy opprobrium from their colleagues. In truth, most applications of the procedures are as safe as more familiar industrial techniques, few laboratory uses pose much danger, and the possibilities of accidentally pro- ducing a monster are very low. But it should also be recognized that the regulatory structure was razed so quickly in part because people were impatient to get on with research. Competition heightened the urgency. There were fears that some states, localities, and nations would gain a signifi.. cant edge in attracting researchers by promising much laxer regulation. As the commercial potential of the new methods became increasingly real, this was no longer an academic question. Another factor was the strong, not entirely groundless, fear of regulation in our society. This history has had several important consequences. One is that although the issues of regulation were debated primarily in terms of laboratory research, the outcome, a system of minimal regulation, may well be carried over to regulation of commercial activities despite the very impor tant differences in scale and spirit between research 8 Health / PAC Bulletin laboratories and commercial enterprises. The NIH is encouraging private genetic engineering cor- porations to seek approval voluntarily from the NIH field- test panel before testing engineered organisms outside the laboratory. However, the NIH panel is already facing familiar company demands that significant portions of the proceedings be conducted in secret, as well as charges of conflict of interest. Congress is eager to step in, but its major concerns are stimulating investment, opening foreign markets, emulating aspects of Japanese government - industry cooperation, and taking up issues which carry political mileage such as pos- sible " engineering " of humans. The Environmental Pro- tection Agency's view of its responsibilities is not yet known. Another legacy of the history of regulation is that the issues were framed and resolved in terms of accidents and exotic laboratory creations. It is, however, not genetic accidents that should concern us most, but deliberate misuse of the new techniques and more mundane matters such as disposal of wastes and occupational safety. During the recent period relying on self discipline - , there have been a few publicized (and probably a few more unpublicized) violations of the rules by scientists whose only likely rewards were the ability to publish research findings a few months earlier. Temptation to cut corners and bend the rules will multiply with the addition of potential commercial ad- vantages in speed in getting to market and minimization of costs. Recent history is not reassuring when such stakes are involved, especially when production is shrouded under the argument that irreplaceable " trade secrets " are at stake. Dangers could, of course, be premeditated. Biological agents designed to devastate crops, herds, or humans can be created more readily than ever. It would be naive not to believe that this has played a role in both the Reagan Administration's drive to relegitimize the Pentagon's chemical warfare programs and its claims that our " enemies " are using biological weapons - with the clear implication that we must rid ourselves of awkward and restrictive treaties so we can increase our own capabilities. Another quite serious negative consequence of the history of regulation was that the embryonic experiments in modi- fying relations between the public and research scientists were terminated just when they were beginning to produce valuable results. The regulations were formulated and im- posed at the Federal level, essentially administratively, and they were relaxed in similar manner. In the discussions of local legislation and regulation it was evident, in at least some cases, that laypeople in local government were quite capable of weighing expert advice and making well- reasoned judgements. This experience, which might well have turned into an exceptionally creative two way - inter- play between science and society, was rendered irrelevant. The overblown notion that scientific matters re particu- larly difficult for legislators and the public to understand has been perpetuated. In addition, the precedent was set for minimizing local regulation of biotechnology. Finally, this history gave scientists the sense - partly false, but with some real substance -- that the emerging technology is truly theirs to control and dispose of. This, I believe, colored subsequent events - especially the auction of scien- tists and research departments that followed court decisions establishing that products and procedures of the new biology can be patented. The Rise of Commercial Exploitation During the past few decades, virtually all of the signifi- cant frontier research now being applied as biotechnology has been funded by the Federal government through the NIH and the National Science Foundation. The fruits of this research represent a remarkable collective effort, involv- ing major contributions from tens, perhaps hundreds, of laboratories and thousands of people in several countries. Even though these laboratories and scientists were profess- ing traditional competitive and individualistic attitudes and often engaged in frantic races to be first with a new finding, the structure and practices of research were highly cooperative operationally: information, organisms, and biochemicals were shared to an extraordinary degree. Furthermore, through peer review and related practices the scientific community held considerable control over the directions research took; within understandable limits this control was exercised reasonably democratically. Commercial exploitation of biotechnology, on the other hand, involves a rapidly growing number of competing private corporations. Some are well established pharma- ceutical and agricultural giants. Others are new research and production companies, many of which sprung up in the giddy investment period of 1981-82, when it seemed that Vogel Helmut Health / PAC Bulletin In 1972 a research microbiologist for the General Electric Company, Ananda M. Chakra- barty, developed a strain of bacteria that could degrade and digest four of the major components of crude oil. The special strain of bacteria had been'designed'by Chakrabarty to eat the oil in a spill and break it down into harmless by products - . When the oil slick was gone, the bacteria would disappear for lack of food. His strain of bacteria was developed using four naturally occurring plasmids small, circular lengths of DNA that are not a part of a cell's chromosomes -each -each of which gave its parent bacterium the ability to degrade one component of crude oil. Using techniques that antedated current'gene splicing,'all four plasmids were introduced into one strain of bacteria. Because the microbe itself would be the product sold, Chakrabarty applied for a patent on his " in- vention "; without it, others could secure and reproduce the organism for their own use at will. The U.S. Patent and Trademark Office granted him a patent on the process by which the strain was developed and on the combination of the car- rier and the bacterium, but it refused to grant pa- tent protection on the organism itself, contending that living things other than plants specifically ( covered by the Plant Patent act of 1930 and the Plant Variety Protection Act of 1970) could not be A CLONE TO CALL YOUR OWN: patented. On appeal the Court of Customs and Patent Ap- peals reversed the Patent Office's decision; this reversal was affirmed in 1980 by the Supreme Court's 5 to 4 decision in Diamond v. Chakrabarty. The Court, led by conservative justices Warren Burger and William Rehnquist, made a narrow ruling, interpreting Congressional intent in the patent statutes to distinguish not between living and non living - but between " products of nature, whether living or not, and human - made inventions. " " The patentee has produced a new bacterium with markedly different characteristics from any found in nature and one having potential for sig- nificant utility, " the Court said, " His discovery is not nature's handiwork, but his own; accordingly it is patentable subject matter under [the law]. " According to Monroe Price, dean of Yeshiva University's Cardozo Law School, the narrow statutory decision reflects the dilemma posed by a choice of either adapting outdated patent law (first written in 1793 and last revised in 1952) to present circumstances or awaiting further Con- gressional directives. Dean Price noted that the patent laws were written to protect property rights that otherwise would have to be protected in the form of trade secrets and at the same time to max- millions of dollars in venture capital were available to anyone who wished to incorporate for genetic research. This explosion of private investment fulfilled the theory under which the government supported basic research: public funding would ultimately bring practical benefits, with the private sector developing their commercial poten- tial and reaping the profits. There has been a bit of concern that the increased inter- penetration of the academic world and the commercial sphere will unduly distort university life, subject graduate students to new forms of exploitation, perhaps choke off some of the openness and cooperation through which biology has thrived, and diminish government funding. There has also been some discussion in Congress about the degree to which government funds for basic research should be available directly to private, profit making - , high- technology enterprises, as well as about existing legislation aimed at providing research funds to relatively small businesses. Still, it is remarkable how little scientists and the public at large have been disquieted by the appropria- tion of a body of knowledge produced by a large scientific community, with public funding, for private economic advantage benefiting only a very few scientists and institutions. The lack of concern with such issues in the scientific community has multiple roots. In some measure it reflects the involvement, actual or hoped for, of significant numbers of the intellectual leaders of modern biology in commer- cial ventures. Another factor is the lack of obvious, available alternatives to commercialization through private corpora- tions and the numerous precedents for this route. But equally important is the traditions of science itself. especially the pattern of competition, publication, recogni- tion, and reward. The history of progress in lines of research fades rapidly from view as the latest results and interpre- tations accumulate. In publications and grant applications the sense of building on past accomplishments of others is much less evident than the stress on what is new and what disagrees with past viewpoints. Access to publicity via the proper journals, meetings, and connections plays a very im- portant role in deciding who gets credit for what. Small wonder then that it appears natural when scientists who take the most recent step in a line of research scram- ble, successfully, to establish claims to commercial profits 10 Health / PAC Bulletin PATENTING LIFE FORMS imize wealth through property - based incentives. " How, " he asked, " will property law change as the nature of wealth and property changes with the new information technologies? " Clearly, other genetically engineered micro- organisms may be patented under the Court's rul- ing. Indeed, about 200 applications had been made at the time of its decision in 1980. Whether other living organisms can be patented once they have been genetically altered remains to be decided. In December 1980, President Carter signed the Government Patent Policy Act that sets Federal policy for patents developed under Federally sup- ported research by universities, nonprofit organizations, and small businesses. The Act is designed to promote utilization of inventions resulting from Federally funded research and development, allowing universities or firms to pa- tent discoveries and license them, subject to cer- tain provisions to protect the public interest. Before the Act, each Federal agency had its own policy regarding ownership of inventions developed under its auspices; some permited private, nonprofit institutions to own patents (sub- ject to conditions to protect the public interest), while others retained the title, permitting anyone in the private sector to develop them for commer- cial use. Of the 28,000 patents that the Federal govern- ment owns (and makes available nonexclusively), only four percent have been licensed for commer- cialization; in contrast, universities that issue ex- clusive rights have licensed one third of their patents. Stanford, the University of California- San Francisco and Columbia have secured patents for the Federally sponsored research in recombi- nant DNA techniques that are now used in gene splicing and genetic engineering, and stand to pro- fit from licenses they may grant. Patents, however, do not always lead to the use of inventions. For example, take Professor Chakrabarty's bacterium. According to Chakra- barty, now a professor at the University of Illinois, G.E. " has been sitting on it, " an assertion the com- pany does not deny. " We're not in the business of cleaning up oil spills, " explained a spokesperson. So much for G.E.'s current advertising slogan, We " bring good things to life. " Hal Strelnick Hal Strelnick is a physician teaching in the Social Medicine pro- gram at Montefiore Hospital in the Bronx and a member of the Health / PAC Board. that are actually derived from the entire chain of research and hence the accumulated effort of many other people. Furthermore, for all the effective cooperation among laboratories and the widespread networks of communica- tion upon which progress has depended, biologists, like other scientists, lack organizations or other means for ef- fectively promoting or even debating their common political and economic interests and concerns. Professional societies are grossly underdeveloped in this area and relatively powerful and influential groups such as the National Academy of Sciences are both too non representative - and too self selecting - to create a sense of actual operational community. The American Association for the Advance- ment of Science has more potential along these lines, but it is not regarded in the research community, at least its natural scientist component, as a " spokesperson. " The fragmentation of the scientific community reflects, in part, strong traditions of individualism and scepticism toward anything that smacks of trade unionism, and the widespread. conviction that the present system is reasonably just in rewarding merit. Such judgements have long been recogniz- ed as major determinants of the attitudes of intellectuals in societies like ours. It is also true that relative to sectors of society hard hit in recent years science, especially branches with military applications, has been well treated. This creates a feeling that those who speak for science are do- ing as well as can be hoped in influencing decisions. The Distortion of Academic Life The rush by private corporations to develop biotech- nology has led them to establish various arrangements with academic institutions. These arrangements are initiated, most often, to obtain some form of privileged access to new findings, or sometimes to personnel. They provide signifi- cant amounts of money for basic research at the institutions in areas of general interest to the sponsoring corporations. In addition, new private research enterprises have been intensively recruiting well established scientists and new graduates to work on lines of research with potential for profit. Inevitably, these developments will alter the structure of scientific research. They do have some quite positive facets: formidable intellectural resources are being focused on important practical problems, redressing biases in favor of Health / PAC Bulletin 11 Langer Heinz CANGER basic purer aspects of science. Nice as it is to think of universities as truly independent havens of seekers after intellectual beauty, this is belied by their history. While traditions of academic freedom and the degree of univer- sity independence that does exist are very worth preserv- ing, they are not inevitably threatened by vigorous concern with the needs of the broader society. Still, the relatively rosy view of commercialization ig- nores the overarching problems arising from the roles and power of large corporations. More narrowly, there is cer- tainly need to brake the intrusion of the corporate drive for profit or control into the academic world, and to protect the endangered public investments, which have been essential to maintaining diversity of activities and viewpoints in academia. Most directly threatened is the long - run health of biological research and the traditions of open exchange of information and open sharing of materials. For the time being, corporations have been satisfied with relatively unrestrictive arrangements in their support of basic research at universities; limitations on publication or discussion are modest. Because the fundamental informa- tion is so widely available and the general nature of the problems most immediately challenging is so widely known, commercial control of research and information poses complex difficulties for the private sector. Moreover industry and the new research enterprises need ready ac- cess to fundamental research underway around the world and would hesitate to disrupt the flow by raising their own barriers. The new research enterprises have constituted themselves with large enough groups of scientists to ensure vigorous interchange in house - . Some arrange extensive programs of seminars and visits from outside as well to keep abreast of the latest findings. However even with the most optimistic assumptions about corporate self interest - in not killing the goose that lays the golden eggs, it is inevitable that much information and research material of the kind hitherto freely circulated among scientists will be sequestered entirely or enter public circulation at a much slower pace. This may occur mini- mally with respect to fundamental information about the nature of genes, but clearly it will apply to precisely the sort of details about convenient short cuts, tricks in pro- cedure, useful materials, and the like that can be crucial to the success or speed of research. Much of biotechnology will be very difficult to " protect " with patents or comparable legal devices - too much information is already broadly available, there are too many alternative routes to the same goal, and too much of the most difficult fundamental work has already been done. Thus commercial success will de- pend largely on corralling talent and on relative speed in getting to market and maneuvering once there. This is already true in sectors of agriculture and the pharmaceutical industry. It is hard to imagine that niceties such as open- ness about tricks of the trade or sharing helpful mutant cell lines will survive such pressures indefinitely. The future role of the Federal government is also in doubt. The Reagan Administration has been very concerned with keeping technology and information under wraps to maintain the American superiority considered vital to pro- fits. It has already made several classification and secrecy forays into the academic world, purportedly to protect militarily sensitive technology. Given the importance of agricultural and medical exports to the national economy and American influence abroad, it is not surprising that government and corporate policymakers are obsessed with our supposedly slipping world supremacy in generating new ideas in such fields. Their temptation to " protect " discover- ies by restricting the extensive international communica- tion and cooperation that has characterized biological research will be very strong. Prospects in Underdeveloped Countries Given the centrality of agriculture in much of the Third World, biotechnology offers considerable promise for aiding in economic development and in the solution of health problems. Many of the most important applications are relatively simple and inexpensive and do not require detailed mastery of all the most recent advances or elegant solution of re- maining problems at the fundamental level; there are already plenty of scientists in many of these countries capable of doing much of the work if given the resources. Cuba, for example, is very actively pursuing a host of agri- cultural and medical projects; some of these, such as work to improve animal feeds and livestock breeding, are already paying off. For Third World countries to succeed with reasonable efficiency, however, they must have access to precisely the kind of information most likely to be increas- ingly restricted - practical details about the handling of economically important organisms. Subtler problems also hinder their efforts. Too often the most experienced and best equipped scientists in the Third World received their training in industrialized nations and imbibed the perspectives and interests prevailing there. As a consequence they lack the motivation and the orientation necessary to tackle unglamorous but vital local problems. In addition, since so much of genetic engineering is 12 Health / PAC Bulletin BOOM AND BUST AMONG THE BIOTECH BLUE (AND RED) CHIPS Those who wish to follow the growth and development of biotechnology are better served by a subscription to the Wall Street Journal than one to the New England Journal of Medicine (Science and Nature, it is true, are required reading). Speculation scientific, journalistic, and financial is fast overwhelming the healthy scep- ticism of traditional medicine. Gene green - fever began seriously in October 1980 when Genentech, the San Francisco gene splicing firm, opened its first public stock offer- ing at $ 35 per share and watched the price leap to $ 89 the first day. The company got $ 36 million in new capital. Five months later the Cetus Corporation of Berkeley, CA raised $ 115 million in the largest in- itial public stock offering in U.S. corporate history. Other biotech companies, including Enzo Bio- chem, Genetic Systems, Biotechnics, Ribi Im- muno Chem, Biotech Research, Bio Response, and Genetic Engineering have enjoyed similar meteoric rises in their stock prices; as a group they outpaced the bullish 1983 market by some 40 percent. ; But all that splices and clones is not green and gold. Southern Biotech, a Tampa, FL firm, filed for protection under Chapter 11 of the Federal Bankruptcy Act in June 1982 with $ 1.4 million in liabilities. This despite a successful blood compo- nent and interferon business. Toronto's Bio Logicals lost almost $ 1 million in 1980. The brokerage firm E.F. Hutton also spoke too soon. DNA Science, its biotech holding company venture that was supposed to spawn subsidiary corporations wherever the hunted scientists were, spent two years getting organized and recruiting the prestigious Weizmann Institute of Science in Israel, the Battelle Memorial Institute of Colum- bus, OH, UC San Francisco's Dr. John Baxter, and Nobel laureate Christian B. Anfinson. The entire project then collapsed when Johnson & Johnson entered as a major investor and in exchange for its $ 5 million demanded exclusive marketing rights for any products developed. Other investors and the researchers involved weren't interested on that basis. WHO'S WHO AMONG THE BIOTECH COMPANIES Company Biogen (Geneva, Switzerland) Cetus (Berkeley, CA) Collaborative Research (Lexington, MA) Genentech Genex Leading Scientist (s) Major Shareholders Walter Gilbert Phillip Sharp Schering Plough, Inco (Int'l Nickel) Peter J. Farley Stanley Cohen Standard Oil of Indiana, Standard Oil of California, Nat'l Distillers & Chemicals David Baltimore Dow Chemical, Green Cross (Japan) Herbert Boyer J. Leslie Glick Lubrizol Koppers Co. - Hal Strelnick Health / PAC Bulletin 13 publicized in terms of success in being first with the most elegant solutions to the most basic problems, it is often hard for Third World researchers to build up their self- confidence. A sense of facing very bright, very rich com- petitors who have all the advantages can be disheartening even if the problem at hand is actually of little or no im- mediate interest to these " rivals. " There are also problems in developing self reliance - among people with habits of pur- chasing " better " solutions from the industrialized world and receiving " aid " of various sorts from foreign agencies. R $ Alvarez Tersa Matters, however, will not stand still. Difficult choices will be forced upon the countries of the Third World. One very probable effect of advances in biotechnology will be exacerbation of several focal imbalances in their relations with the industrialized countries. The Third World con- stitutes a crucial market for precisely the sorts of products and production techniques biotechnology is likely to affect first agricultural - materials such as foods, seeds and fer- tilizers; and pharmaceuticals and related medical materials. The poorer nations are also an essential source of land, labor and raw materials. In the short term, we can expect intensification of phenomena already underway in many of these countries: changes in patterns of landholding and crops, with attendant massive social upheaval; struggles between locally - owned industries and multinationals: com- petition among the industrialized countries; sales of pro- ducts prohibited or restricted in the industrialized countries; and the flight of multinational capital to friendly, low wage - havens. Longer - term prospects depend on the political future - most centrally on the degree to which countries of the Third World achieve governments committed to autonomous na- tional development accompanied by broad social welfare. The prospects also depend on whether some of the more dramatic possibilities of biotechnological agriculture are realized. It is not unimaginable, for example, that products now fundamental to the economies of various Third World countries such as sugar and some petroleum - derived chemicals will some day come to be produced by quasi- industrial microbiological techniques. This would render current production methods and sites increasingly un- necessary, and perhaps even obsolete. More certain is that in the medium term, many of the diseases of humans, livestock, and plants that still afflict the Third World will become much more susceptible to large scale amelioration or eradication, at least insofar as scientific understanding of the responsible organisms and etiology is concerned. It will be increasingly obvious that the major problems are how to mobilize interest in the necessary research and how to overcome political and economic impediments to adequate public health measures, agricultural improvement, and veterinary programs. Possibilities at Home As already mentioned, the recent history of biology pro- vides some interesting lessons concerning how curiosity is constituted and constrained. Our society evolved mechanisms, based on relatively generous support, appreciable autonomy, and relative democratization of op- portunity, which unleashed remarkable scientific capabilities. There is much to learn from this experience of value in oraganizing intellectual work and maintaining high morale and productivity in many sorts of contexts and societies. On the other hand, scientists have effectively been insulated from control over and concern with practical ap- plicatons of their work. Buttressed by the prevailing mechanisms for recruitment, training, and socialization of scientists, this has ensured that the issue of private appro- priation of the collectively - produced, government - funded body of knowledge would not arise with any insistence. It is disconcerting, but instructive for understanding the contradictory psychology of the middle class, that at a time when the very idea of government involvement in society is under heavy attack as inevitably ineffective and waste- ful, almost no one offers in rebuttal the exceptional success of the government - mediated planning and investment that started, in the case of biology, over a century ago. What re- mains to be seen is how scientists will react to a future which 14 Health / PAC Bulletin will bring sharp decreases in autonomy and in funding for many of them, as well as an atmosphere in which suspicion, secrecy, and occasional fraud are apt to increase markedly. There is at least some hope for the development of coun- tervailing movements within the scientific community, which does still retain a strong commitment to cooperation, openness. and international collaboration, and has poten- tial political and economic leverage. It would require implausible levels of conspiracy and con- trol to keep biotechnology completely confined within pre- sent balances of economic and political forces. The experi- ence of the last decade with electronics, especially com- puters, and with copying machines demonstrates how very difficult it is to entrap new technologies within the bounds of the legal devices constructed principally to protect previously dominant commercial interests especially - especially while at the same time supporting " free market " economics and international competition. An intensive effort is under- way to devise patent and copyright formulas that will " pro- S perly " reward innovation in biotechnology. This may help funnel some profits to " deserving " scientists, universities and corporations, but at very least there is likely to be a long period of sustained, international competition which will be only minimally constrained by domestic law. U.S. anti- trust laws are already being reinterpreted and reframed to facilitate cooperation in research among otherwise com- peting companies. Competition is heating up among the U.S., the Western European countries, and Japan - one interesting question that will probably be answered is whether countries like the U.S. which have a " lead " in the research end of biotechnology will be able to translate this into continued economic supremacy. More concrete issues may soon emerge. Given the large social investment in the underlying research, public con- tention could arise over what products are brought to market and at what prices. This debate probably will concern medicine first. A likely harbinger of things to come, with resonant implications for the Third World, is the delay in aggressive development of a potential malaria vaccine caused by disputes over licensing rights. The potentials exist for dramatically lowering production costs for a variety of medical materials, increasing supplies of presently very scarce resources, and evolving effective, inexpensive diagnostic procedures. How these enter and alter medical practice cannot be clearly foreseen yet, but they almost cer- tainly will contribute to the already heated ferment over the costs, organization, accessibility, and effectiveness of modern medicine. In agriculture, the issues concerning Third World coun- tries outlined above will be paralleled in industrialized countries; these are already foreshadowed in discussions of policies about diet, land and water use, natural vs. chemical pest control - , chemical fertilizers, and the like. Differences will probably gradually intensify as it becomes clearer that fewer and fewer choices are dictated by bio- logical necessities and more and more by political and economic decisions. It would be foolhardy to predict how all this will turn out. I started with the conviction that the engineering of organisms could prove an appreciably more versatile, more productive, and less distorting approach to important facets of certain large scale - economic activities when compared with the elaborate interference with environments these ac- tivities entail today. Whether these possibilities are realized depends principally upon the political future, but biological scientists have fewer justifications than ever for pretending that their laboratory life is separable from what goes on out- side in the " real world. " It seems to me that scientists have particularly strong stakes and responsibilities in several of the key issues that will determine the short - term future of biotechnology. Paramount among these are matters of secrecy. Practices that inhibit or close off the flow of information either within national scientific spheres or internationally must be com- bated on grounds of both their practical effects and their violation of longstanding principles. More positively, scientists and their institutions should vigorously support the few efforts now being made to ~~ - f HAKLAR. y) Haklar Health / PAC Bulletin 15 BETTER LIVING THROUGH BIOTECHNOLOGY What are the products promised by genetic cells targeted for diagnosis or treatment. engineering and biotechnology that have Wall University of Minnesota doctors have already Street and medical science pacing expectantly in tried this approach to protecting leukemia patients the delivery suite waiting room? with bone marrow transplants against rejection of The hope (and hype) embraces almost every the body by the transplants (graft versus host commercially significant organic chemical from disease). Monoclonal antibodies have also been us- methane (a major component of natural gas) to ed in conjunction with radio isotopes - to identify perfume, as well as diverse biological " factories " cancer cells missed by other techniques. such as dioxin - eating and hormone producing - bacteria. Last year the FDA approved distribution Gene splicing may alter existing vaccines, pro- vide new protection against existing infections, and of human insulin produced by a genetically facilitate production of existing pharmaceuticals. engineered bacterium. Biologically active agents A New York State Department of Health scientist such as interferon (naturally produced only in such searching for a vaccine against herpes has just minute quantities that its use in cancer and other developed a technique that might one day lead to treatment is prohibitively expensive) might be a universal vaccine, incorporating into the current similarly " manufactured. " smallpox vaccine (vaccinia) genetic information Design of such " magic bullets " is rapidly moving from the drawing boards to laboratories and which will stimulate e the body's immune reaction ' to a host of viruses bacteria, toxins, and parasites. hospital wards. Among these exciting most interest Below is a list of potential biotechnology pro- are hybridomas, fusion of antibody producing - ducts and their markets, determined by the pro- white blood cells (lymphocytes) with permanently- prietary research of Genex, one of the new . growing white blood tumor cells (myelomas), that _ will indefinitely produce a single, highly specific - biotechnology companies. These data were published in 1981, which is a long time ago in this (monoclonal) antibody that can recognize types of field.: organize international mechanisms which would facilitate the spread of biological information and personnel to Third World nations. These initiatives are being developed through the UN, scientific institutions of individual Third World countries, and internationally funded laboratories.8 There is a longstanding tradition - albeit one mixed with paternalism of small - scale efforts of these sorts. Not sur- prisingly, the official response of the U.S. and other indus- trialized countries towards proposed large scale - projects in spreading knowledge related to biotechnology has been unenthusiastic and dilatory. The projects have also suffered from the usual sorts of disputes among the Third World na- tions themselves over matters such as where new facilities should be sited. Scientists should also lose their inhibitions about publicly defending the benefits of public investment. They may well be driven to do so if they want to save their research pro- grams and the educational and other institutions in which many of them work. If optimistic, one can imagine that this will lead many of them to question the policy of giving away the fruits of decades of biological research to enterprises whose primary interest is their own economic success. One of the few beneficial aspects of the Reagan Adminis- tration's remodelling of the U.S. is likely to be widespread interest in experimenting with new forms of regulation and with new modes of interaction between the public and the private sectors. Despite their relative quiescence, there is a broadly based sense among scientists that what is 16 Health / PAC Bulletin Product Category BIOTECHNOLOGY PRODUCTS Product Lines 20 Year Current Value Projected ($ million) Market Amino acids (food enrichment and flavoring) Vitamins Enzymes (catalysts, drugs) Steroid hormones (e.g. cortisone) Peptide hormones (e.g. insulin) Short peptides (e.g. sweeteners) Nucleotides Miscellaneous proteins (e.g. albumin, interferon) Antibiotics Pesticides Methane Organic chemicals: alephatics aromatics Inorganic chemicals (ammonia and hydrogen) Gene preparations Viral vaccines 9 6 11 6 9 2 2 2 4 (classes) 2 (classes) 1 22044 10 204 2 3 9 $ 1703 668 218 377 264 4 72 300 4240 100 12,572 2738 1251 2681 0 N.A. $ 5110 - - - 1000 2100 _ 1000 1 ~ - - - ~ 100 - Source: Office of Technology Assessment, Impact of Applied Genetics: Micro Organisms - , Plants, and Animals, Washington, DC, Government Printing Office, OTA - HR - 132, April, 1981. happening in their professional life and surroundings is dis- tasteful and threatening; this sense is a potential source of energy. Allowing the market to be the principal determinant of what is produced with the new techniques, and what the products will cost, would have predictably unfortunate con- sequences, but this is not inevitable. There are, after all, major social movements demanding better nutrition, cheaper and more accessible medical care, improvement of the workplace or environment, and the like. As they come to understand that the new biological technologies can con- tribute to the goals they seek, they are very likely to press more constructively for socially responsible use of these technologies. Specific issues where the concerns of such movements parallel those of scientists concerned with the long term - in- tegrity of their fields and institutions have begun to surface. For instance, a recent suit to enjoin the NIH from permit- ting field tests of genetically engineered microorganisms has sharply questioned the capacity of scientists with com- mercial connections or the desire for such connections to disentangle their own self interest - from their judgements about proposed tests, especially when the discussions are carried out in secret. _ Such issues have many contradictory features and, it is unlikely that many scientists will be comfortable allied to movements with tenets and practices that seem unscientific and obstructionist, or to groups so reflexively hostile to Health / PAC Bulletin 17 " scientific progress " as many are at present. 10 But we are only at the beginning of what promises to be a long period of tumult. Just as we hope that scientists will come to understand their roles and possible obligations better, so we can hope that progressive movements will realize that fears of ambiguity and the new can lead to the surrender of what could and should be contested terrain. 1. A helpful brief review is Abelson, P.H., " Biotechnology: an overview, " Science 219: 611, 1983. The entire issue in which this appears (vol 219, no 4585) consists of ar- ticles outlining the range of current biotechnological approaches. 2. Holtzman, E., " Recombinant DNA: Triumph or Trojan Horse, " Man and Medicine 2:83, 1977. 3. Fox, J.L., and Norman, C., " Agricultural Genetics Goes to Court, " Science 221 1355:, 1983; and David, P., " Suit Filed Against NIH, " Naturex 305 262:, 1983. 4. Garmon, L., " How the New Congress Will Legislate Biotech, " Bio technology / 1:27, 1983. 5. For a curious illustration see Kayton, I., " Does Copyright Law Apply to Genetically Engineered Cells, Trends in Biotechnology 1 2:, 1983. 6. David, P., " Antitrust Restraint Is on the Way Out. " Nature 304: 4, 1983. 7. cf. " NYU's Malaria Vaccine: Orphan at Birth?, " Science (News and Views column) 219 466:, 1983. 8. See, e.g. Dickson, D., " UNIDO Hopes for Biotechnology Center, " Science 221 1351:, 1983; and " Nairobi Laboratory Fights More than Disease, " Science 216 500:, 1982. Magazine Magzine Hopkins Johns 18 Health / PAC Bulletin 9. Boffey, P.M., " Plan Gains for First Outdoor Test of Genetically Engineered Plant. " New York Times Sept 23, 1983: B7 p.. 10. See, e.g. the editorial and discussion of the NIH suit in Nature 305: 347, 349, 1983. a " Our Goal is Prevention " An Interview with Nicaragua's Director of Health and Safety Programs by Michael Fairfax I first became aware of occupational health and safety issues in Nicaragua in the summer of 1982, when I met Mario Epelman, a consultant on workers'health with the Nicaraguan Ministry of Labor. Mario was touring Canada to learn of our successes in preventing occupational illness and accidents; he was not very impressed. After viewing a multi milli- odno l-la r worker rehabilita- tion center in British Columbia, he commented, " all the money is being spent to treat diseases, and very little to pre- vent them from happening. " His tour of a nearby univer- sity's occupational research center replete with costly equip- ment to measure workers'tolerance to auditory, respiratory, and tactile assaults of the industrial workplace evoked a more bitter complaint: " They waste more money on this gadgetry in this one place than we have to spend for health and safety in all of Nicaragua. " " What do I tell my comrades when I return to Managua? " Mario concluded with his customary dry humor, " That after a month in Canada I learned that capitalism is bad for workers'health? " At the time of Mario's first visit, Nicaragua was taxed by two pressing problems, a severe flood had destroyed most of the banana plantations in the North, and the Somocista counterrevolution had just begun in earnest. When I met him again last May the first problem had been wholly eclipsed by the severity of the second. This time, at an in- ternational conference on occupational health and safety, he was in the company of Oscar Berrios Guttierez, a young industrial engineer and the new director of health and safety programs in Nicaragua. " We wanted to come here to talk about what we are try- ing to do to protect the health of workers in Nicaragua, " Mario told me, " but we cannot talk about that without first telling everyone of the invasion of our country. Because if we cannot stop that invasion, everything else is.. " He shrugged. Michael Fairfax is a Canadian freelance journalist specializing in occupational safety and health. He gratefully acknowledges the translation assistance of Margaret Hilson for this interview. In one sense, it seems, the greatest threat to the health and safety of Nicaraguan and American workers is the same, Ronald Reagan and the U.S. military industrial / state. Oscar Berrios is an intent, animated man. Although I did not put specific questions to him and we did engage in some dialogue, I was struck with a sense that he was trying to tell me a story. It was not a lecture, but had the quality of a nar- rative rather than a simple answer. " When we took office in July 1979, there was a complete lack of data on occupational injuries, " he began, " We didn't, and couldn't, know what the problems were. During the time of Somoza you could say there weren't any occupa- tional health problems, because Somoza didn't pay any at- tention to that sector at all. It was accepted that you could get killed at work, you could get hurt at work and nobody did anything about it. So it was never seen as a problem or if it was, it was considered an individual problem. We have been trying since to create an understanding among our peo- ple in Nicaragua that occupational health diseases and ac- cidents are a social problem, not necessarily the worker's fault. " Nicaragua's economic base is primarily agricultural. There is some mining, though the gold, silver, and copper have been largely exhausted in centuries of exploitation. There is also a very small manufacturing sector. Health and safety problems are thus principally rural and agrarian. This is reflected in the Sandinista government's occupational health priorities: health risks of farm workers, toxic pesticides, lung diseases of miners, benzene derivative illness, and lead poisoning. " Because the major difficulties we faced were lack of in- formation and a lack of human resources, " Oscar continued, " Where would we begin? We thought that,'Well, what we'll try to do is at least deal with the worst conditions, to make them more tolerable. We formed a cadre of workers who had the skills to diagnose the situation, to identify the worst problems. In fact, we started with only four inspectors in 1979. We were up to 62 in 1982, with 15 more coming in the first six months of 1983, all of whom have had almost four years of training in occupational health and safety. Health / PAC Bulletin 19 " In the beginning, when we went out to do our first diagnosis of the work places, we found that there was such a high degree of ignorance about health problems that education had to be our starting point. We found that workers had always known that there were risks, but they had developed a belief that these were an inherent part of the job, that there was nothing you could do about them, that if you wanted a job you just had to accept them as part of the package. " Our big step after training the cadres was therefore to systematize what workers already knew about the work- place, to build on their own awareness, while giving them some new skills for dealing with problems. What we're try- ing to do is put the scientific and technological knowledge at their service. " This goal was intertwined with the broad Sandinista social policy. The government officially declared occupa- tional safety and health (which in its view is complemen- tary to, rather than in conflict with, increased productivity) as one of its three major priorities, the other two being education and public health. Although the absence of pre revolutionary - statistics makes it difficult to gauge their success in preventing oc- cupational accidents and illness, the advances in education. and general health have been impressive and well docu- mented. The two year Literacy Campaign reduced the il- literacy rate from over 50 percent to under 12 percent. This has certainly boosted workers'ability to understand the hazards they confront. Consumption of basic foodstuffs (corn, beans, rice) has increased 35 percent on average, creating a stronger, healthier workforce. The incidence of malaria, a disease which afflicted 25,000 Nicaraguans (one percent of the population) in 1976, was cut in half, decreas- ing the overall mortality rate considerably. The anti malaria - campaign did not rely on chemicals - the Third World stock - in - trade, DDT, was rejected from the start- but in- stead over 75 percent of the population was mobilized for a three - day blitz of anti malarial - therapeutics. New cases were reduced 98 percent. " In the course of classes that we held for workers, " Oscar told me, " we tried to get at the root cause of why they thought the way they did about work, illnesses and ac- cidents. We would try to look at an accident and analyze it to decide what caused it, what were all of the elements involved. " For example, of the 7,500 accidents that were reported last year for the whole country, 1,500 happened in one privately - owned sugar mill. We analyzed the accidents in this particular factory and we found that almost 50 percent of them were caused by machete wounds to the left leg. We then reviewed every single accident that had happened in that industry. After that we went over all of this with the workers and the union and they set up a training program. This was the first place where we introduced protective equipment for the workers. It started off with a model of what a baseball catcher would wear on his leg, and we kept adapting it and trying it out on the workers until we found the material that was most comfortable to wear and that would still give them protection, a sort of metal cage with cloth over it. That reduced the machete accidents over 60 percent in the one factory. " It was a very similar situation in the mining sector. When the Americans ran the mines they did very well, and the accident rates went up and up and up. Now the mines are Yiout'r'e sex agogenraltiyng eaxa ggerating exaggerating; mild pesticide! 63 Don't spray with workers in the fields even if the pesticide is considered " mild. " 20 Health / PAC Bulletin run by friends of Nicaragua who have come from other countries, and there was a great decrease in the number of mining accidents - an amazing drop, in fact; every single month they decreased more and more. There's a mine where a great deal of our activity was carried out which has both increased production and decreased the accident rate. On the second anniversary of the Revolution, the workers at this mine celebrated with a display of the health and safety program at the mine; they were that proud of it. The peo- ple in the region came to analyze the situation, and everyone said, " Yes, conditions are better, but we can do even bet- ter. " A lot of people helped work on that analysis workers -- workers, people from the area, people from the ministries of Labour, Health, and Social Security. " So now every time there's an accident in the mine every single miner hears about it, and they look at it as if something terrible has gone wrong. They have a very clear analysis of some of the causes. They might say,'You know Pedro was in that accident; the scaffolding wasn't secure. Or, Juan had an accident because he didn't watch what he was doing, and Guiseppe had an accident because the con- ditions weren't good. The worker analysis also includes what the roles of the various ministries should be. " In general, we've used statistics to give us an idea of where the greatest problems seem to lie. We then visit those workplaces and together with the workers develop a plan. This has been partly responsible for the decrease in ac- cidents between 1980 and 1982. " But right now we don't know very much about the magnitude of occupational disease. You know, we're con- fronted with a situation where the accidents face us every day and we have to respond to that situation. We have much more information available to us about accidents. We're cer- tainly worried about the incidence of disease, but really don't know enough about it to be able to comment on how serious a problem it creates. AAG! FZZZZ " At the same time, though, we've made a few advances in various economic sectors. For instance, we feel that in order to make a correct diagnosis of occupational disease we need to have at least three very important facts, the oc- cupational history, an evaluation of the workplace, and a very good medical examination and history of the worker. I would say that we've made large strides on the first two; certainly we can do an occupational history and we now have most of the technical capacity to do an evaluation of the workplace and the environment. What we're still lack- ing is the medical sector capable of performing occupa- tional medicine. " There have been painful tradeoffs which have held back progress. These are often most glaring in the eyes of North Americans, though it should be noted that the Sandinistas have been remarkably candid in acknowledging their prob- lems. Margaret Hilson, who recently returned from a study tour of Nicaragua, recounted two examples of working con- ditions so bad that if they existed in North American ac- tivists would raise a clamor to have the operations shut down. " I saw x ray - workers who had no lead aprons, " she said, " They knew the risks they faced, and they chose to face them because they also knew that the patients needed the x rays -, and that Nicaragua lacked the foreign exchange to buy the lead aprons. " In 1982 over 50 cents of every Nicaraguan ex- port dollar went for interest and repayment of the $ 1.6 billion foreign debt, just one of Somoza's many disastrous fiscal legacies. At a textile mill she visited, " The noise levels were so high that workers knew they would eventually suffer hearing loss as a result, " she related, " but they were proud of the fac- tory. It had been bombed by Somoza, and they had rebuilt it by cannibalizing parts, eventually getting a third of the machines running. The factory is vital because it's the only one in Nicaragua capable of producing cotton material. This and the illustration on page 20 are from one of several booklets used to convey technical information and health and safety issues. Most such booklets rely on this simple but graphic " cartoon " style. Don't eat, don't smoke while the fields are being sprayed or have recently been sprayed. Health / PAC Bulletin 21 HEALTH: A QUICK COMPARISON Infant mortality / 1,000 Canada _ United States (1978) (1977) 12 14 Nicaragua (1970-1978 averages) 121 300 in rural areas Child mortality / 1,000 (2 years) 1 Life expectancy 74 Hospital beds (persons / bed) 143 Population / doctor 580 Population / nurse 130 1 73 na 560 (1975 data) 234 (1975 data) 149 above 70 (rich) 40-50 (poor) 410 2065 760 NICARAGUA: 1977-1982 1977 1978 Infant mortality / 1,000 121 121 Health budget, cordobas (000,000) 113 373 1980 102 1981 94 1231 1982 75 Sources: WHO, World Bank, Statistics Canada, DHEW, World View 1982 Yearbook, Instituto Historico Centroamericano Otherwise the country would have to import textiles even though it grows cotton. " The workers look on their hearing loss as another form of war wound, another sacrifice that must be made for the Revolution. They are not masochistic, but they take pride in having to make such a sacrifice. " " The biggest budget item in Nicaragua is health, " Oscar commented, " and we don't want it that way, so our goal is prevention, including occupational health and safety. " In ef- fect, however, the badly needed capital to finance public health programs such as providing potable water, shelter, protection against infectious diseases and so forth what - Oscar Berrios calls The first priority - can only be obtained through individual sacrifices of the second priority, a safe workplace. " With respect to agriculture, " he told me, " there has been a law on insecticides since about 1950, but it has never been observed. We had a situation where workers didn't have any kind of protective equipment; where they knew absolutely nothing about the chemicals they were dealing with; and we found quite a large number of cases of massive chemical intoxication. One cause of ignorance was the absence of unionization in the agricultural sector; one of the first things we did after 1979 was unionize farm workers. " The contamination from the use of insecticides wasn't just limited to the factory or to the fields where they were used. The whole environment was being contaminated. The poisons were being dumped in lakes and rivers. They were getting into the food chain, the fish; we found them in mothers'milk. A university study discovered that DDT con- tamination of mothers'milk was ten times what is allowed under international standards. " Many Nicarguan women, in fact, were found to have breast milk containing 500 times the quantity of DDT deemed safe by the World Health Organization. " We saw this as a complex problem caused by the depen- dent socioeconomic conditions in which we live. " Oscar ex- plained, " The fruit exporting and so on. Because it's not easy to resolve we've formed a special commission to in- vestigate the use of all insecticides, which recently. presented its proposals for changes in legislation and regula- tion to the government. " The special commission is part of 22 Health / PAC Bulletin the National Commission on Integral Worker Health, which has representatives from the ministries of Labor, Health, and Industry; the National Institute of Agrarian Reform; the Association of Farmworkers; the Sandinista Workers ' Confederation (the trade union organization); and the grass- roots community groups. This National Commission has also recommended safety levels for physical agents such as heat, vibration, and noise, and chemical agents such as mer- cury and lead. In effect, it sets policy on occupational health and safety issues and ensures that workers are instrumen- tal in shaping that policy. " As you can imagine, " said Oscar, " the pest problem in the hot tropical climate is a serious one. We've set up an experimental station to try and figure out what kind of biological controls can be used and what kind of pesticide alternatives are available. " The Ministry of Health, for its part, has been training workers in the health centers close to areas where pesticides are used so that they will be familiar with signs of pesticide illnesses and their treatment. They are also going to institute a large program of cholinesterase screening to see how much people are being exposed to. " Cholinesterase is an en- zyme essential to central nervous system functioning. Its level is depressed, often seriously, by organophosphate compounds, such as parathion, malathion, diazinon, and other commonly used pesticides. " The Ministry of Natural Resources is engaged in studies with the University to determine the exact extent of en- vironmental contamination, " Oscar said, " All of this has come out of work of the Commission. We think the new law will be enacted by next year. Meanwhile, on a day to day basis, we're continuing the education program so the workers will know what they're working with, and we make sure all the materials are being properly labelled, the equip- ment is properly designed, that sort of thing. " The ideal would be to devote all our energy to health and safety, but we obviously cannot do that. There are intimate ties between occupational health and the political process. Health and safety started with the Revolution, and so to ad- vance and consolidate the Revolution is to advance health and safety in Nicaragua, and vice versa. But the most im- portant thing is to advance the Revolution, specifically to eliminate the revolution counter -. " To many North American ears this might sound like a rhetorical " commercial, " but Oscar said it with quiet conviction, as a statement of self- evident fact. " Still, " he concluded with obvious pride, all " our annual goals in health and safety have been met, and will continue to be met. One compaero who came to Nicaragua told me, ' You are doing more for health and safety in your country in a time of war than almost all countries do in a time of peace. " o Blanco Jorge Health / PAC Bulletin 23 Third Annual ~ Once In a Lifetime holiday Offer Buy One, Get One Free Thanks to the generosity of a donor who wishes to remain anonymous, Health / PAC is able to make this extraordinary offer to our subscribers: Buy a gift subscription to the Bulletin for a friend, relative, or colleague and you can have another one FREE. Our donor will match your $ 17.50, so Health / PAC will receive the full price for two subscriptions. You can even buy several subs and get an equivalent number free. Enhance this holiday season. Do well by doing good. Act now. Letters containing this coupon must be postmarked immediately for prompt service. Yes, I want to get two gift subscriptions for the price of one. Y' Payment enclosed Y' Charge my: Y' Mastercard Y' Visa credit card acct. # exp. date cardholder's signature Y' I would like to be a Health / PAC Sustainer at $ 10 a month. Send these gift subscriptions to: name address city state zip name address city state zip Y' additional names are enclosed on a separate sheet. Mail to: Health / PAC Bulletin, 17 Murray St., New York, NY 10007 24 Health / PAC Bulletin Bulletin Board Board Bio Feedback If you were impressed by the cover story in this issue, | you may want to hear about the Committee for Respons- ible Genetics. At the September 29 press conference announcing its formation, Barry Commoner warned, " We are allowing a technology that was created by public investment to be distorted with respect to what it pro- duces. Other members of the Board of Directors include Jonathan Beckwith, Eula Bingham, Ruth Hubbard, Tony Mazzochi, and Victor Sidel. The Executive Director is Terri Goldberg. The Committee's goals include increasing public awareness of the use of genetic engineering to modify gene pools, the role of gene splicing in weapons develop- ment, and the neglected potential of biotechnology to im- prove the human condition. For more information write P.O. Box 759, Cambridge, MA 02238. Engaging Aging The National Institute on Aging, a section of the Na- tional Institutes of Health, is offering a series of its pamphlets free of charge. Titles include Medicine and Aging, Senility Reconsidered: Treatment Possiblities for Mental Impairment in the Elderly, and To Understand the Aging Process: The Baltimore Longitudinal Study of Aging. For copies of these pamphlets or a complete publica- tions list, write Information Office, Box OP, National Institute on Aging, Building 31, Room 5C35, Bethesda, MD 20205. Uncle Sam's Bookstore The Federal government has produced an enormous number of books, tapes, pamphlets, and other materials on health matters designed for health professionals. Now you can get an easy to use listing free. Staying Healthy: A Bibliography of Health Promotion Materials, is available from the National Health Information Clear- inghouse to those who write and enclose a self addressed - mailing label. The Clearinghouse has also prepared a series of free resource guides called Healthfinders, which have up to date information on specific topics such as herpes in- formation resources and toll - free numbers numbers for health information. All of these materials can be obtained by writing Department AVM, National Health Information Clear- inghouse, PO. Box 1133, Washington, DC 20013-1133. NHELP is on the Way The National Health Law Program has just published Birth Rights: An Advocate's Guide to Ending Ending Infant Mor- tality, by Francie Hornstein and Judith G. Waxman. The guide was written primarily for legal services workers who wish to assist their clients in obtaining quality maternity care services, but NHELP wishes to make it available to health professionals, women's health ac- tivists, and others " who can play a part in reducing the shamefully high infant death rates in this nation. " Contents include infant mortality statistics, major funding sources for public entitlement programs, poten- tial of alternative providers of maternity care, and case sitnufdainets moofr tsaulcicteys srfautle sc oammmounngi ttyh eb apsoeodr eafnfdo rmtisn otroi tlioewse.r Copies are $ 8 to cover printing and mailing. Write to National Health Law Program, 2639 S. La Cienaga Boulevard, Los Angeles, CA 90034. Toxic Shock Troops ; " Taking Back 1 Our Health: An Institute on Surviving the Toxics Threat to Minority Communities Communities, " is a con- ference sponsored by the Urban Environment Confer- ence in New Orleans November 18-20. The purpose of the conference is to " disseminate and trade skills, resources, and information; and plan strategies for protection. " The advance registration fee is $ 60, which pays for meals as well. For further information, call (202) 797-0446 797-0446 or write Urban Environment Conference, 1314 14th Street, N.W., 3rd floor, Washington, DC 20005. The Public Be Damned Readers of William Shonick's article on private management of county hospitals in California in the Health / PAC Bulletin 25 - Bulletin Board > m Bulletin last year can get the full report now. UC Berkeley's Institute of Governmental Studies has just published Public Hospitals Under Private Management: the California Experience, by William Shonick and Ruth Roemer. Copies are 7.75 $ including postage. Checks inghouse at the CUNY Graduate Center, hopes to facil- itate formation of and communication among local groups, establish a library of resource materials, and en- courage communication between parents and perinatal professionals. should be made payable to the Regents of the Univer- sity of California. -. For further background, readers will want to purchase Public Medicine in Crisis: Public Hospitals in Califor- nia, by E. Richard Brown (4.25 $). Both studies are available from IGS, 119 Moses Hall, Annual individual membership is $ 15, which also brings a subscription to the group's quarterly. Support Lines. Checks should be made out to PPHRI and mailed to Maureen Lynch, Executive Director, Parents of Pre- mature and High Risk Infants International, 33 West - 42nd St., New York, NY 10036. University of California, Berkeley, CA 94720. Warm Fn eelings Shedding Light Parents of Premature and High Risk Infants Interna- tional, Inc. is a new non - profit organization established to encourage support among parents of the nearly 300,000 infants annually who require intensive care. PPHRII, affiliated affiliated with the National Self - Help Clear- Closets are Health Hazards, a slide presentation about gay and lesbian health care workers, is available from the American Medical Student Association, LGPIM Staff Liaison, 1910 Association Drive, , VA 22091. The price is negotiable. Reston CENTRAL AMERICA ARTISTS in Solidarity with the People of | 1984 Poster Calendar The calendar that features 13 original works of art- winners of a national competition for posters in solidarity with the people of Central America. * Unique combination of politics and art * 13 Stirring images 1983-4 * Full color reproduction * 8% S 18% calendar size. Order one for yourself... and several more for your Only $ 6.95 plus handling. friends. Just send in the coupon below. (40% off on orders of 10 or more) (calendars $ 6.95 cover price plus $ 1 - = 1-9, $ 7.95 each postage and handling). Enclosed is $. for 1984 " Artists s in Solidarity with the People of Central America " Save 40% on 10 or more, calendars postpaid. $ 4.50 (4.20 $ each plus $.30 postage per calendar.) Name Send your order to: Artists Solidarity Calendar 19 West 21st Street, 2nd Floor New York, N.Y. 10010 Address City City State_ Zip_ 265 Health / PAC Bulletin Media Scan W.G. Carson, The Other Price of Britain's Oil (New Brunswick: Rutgers University Press, 1982). Carl Gersuny, Work Hazards and Industrial Conflict (Hanover: Univer- sity Press of New England, 1981). David P. McCaffrey, OSHA and the Politics of Health Regulation (New York: Plenum Press, 1982). Vicente Navarro and Daniel M. Ber- man eds., Health and Work Under Capitalism: An International Per- spective (Farmingdale: Baywood, 1983). Charles E. Reasons, Lois L. Ross, and Craig Paterson, Assault on the Worker: Occupational Health & Safe- ty in Canada (Toronto: Butterworths. 1981). by Tony Bale When the current occupational safety and health movement burst on the scene in the early 1970s, much of its energy came from a stream of books graphically exposing work- place slaughter in America. Labor activists Ray Davidson and Frank Wallick, journalists Rachel Scott and Paul Brodeur, Naderites Joseph Page and Mary - Win O'Brien, all produced vivid books that got people mad and moving. Now the movement has come of age a bit and its concerns are well known. Enter the social Tony Bale is a sociologist specializ- ing in occupational safety and health and a member of the Health / PAC Board. scientists. A new literature is emerging that's less dramatic in its presentation of the dangers faced by workers, but more probing in its analysis of issues and forces underlying occupational safety and health. This new literature com- bines radical perspectives from the social sciences, concrete historical and social analysis, and attention to developments in other parts of the world. It digs deeper into the intellec- tual ground opened up by the journal- ists and safety and health activists. Much of the early literature simply noted that the pursuit of profits and safety and health were incompatible and then provided vivid examples of employer greed. The new goes deeper, identifying links between capitalist production in specific historical configurations and work- place injuries and illness. Fine, tex- tured analysis of the role of law and the state are combined with political economy to trace how pressures on particular industries or firms lead to dangerous practices. This analysis may help the occupa- tional safety and health movement in the United States become more aware of what it's about, the forces underly- ing hazardous conditions, and possi- ble new political directions. Unfortunately, most of the best material remains deeply buried in academic journals and doctoral dis- sertations; this essay looks at five of the more notable books of the past few years. At the heart of Work Hazards and Industrial Conflict is an elegantly detailed picture of the industrial car- nage among Massachusetts textile workers around the turn of the cen- tury and the means employers and in- surers used to limit their liability. Sociologist Carl Gersuny uses sources such as local hospital records and correspondence between insurers and manufacturers to reveal as well as anyone ever has this world of frequent accidents where employers would go to outlandish lengths to concoct legal defenses alleging the employee's own negligence contributed to the accident. Textile companies commonly bought off doctors, coroners, and in- terpreters; workers had little hope of winning a lawsuit or getting a decent settlement. Gersuny dedicated the book to Bridget Linehan, a Chicopee machine operator " injured by a lever of the machine she operated when a loose nut caused the lever to slip. " In- jured through what she felt was no fault of her own, she wanted the com- pany to pay her lost wages and ex- penses. A manager of the company wrote the insurer, " I can settle with her.. by paying her time and Drs. bills... Tried to beat her down, but she said she would not take a cent less. " Anyone wanting to know what ac- cidents and compensation were like for workers before the enactment of the workers'compensation laws can find no more elegantly presented pic- ture than Gersuny's book. Following the textile material is a discussion of the subsequent legal en- vironment of workers'compensation, collective bargaining, and the Oc- cupational Safety and Health Admini- stration. The elaborate legal process involved in an OSHA investigation of the death of a New Hampshire card- ing machine operator crushed in the rollers of his machine serves as a con- trast to the earlier period. Gersuny opens up the important discussion of the sources and forms of class conflict involved in occupa- tional safety and health; unfortu- nately, he doesn't probe very deeply into it. He regards the conflict of interest between workers and employers around safety and health as endemic, but gives no sense of the potentially explosive nature of these events on workers'consciousness. In fact, fatal accidents like the ones he describes may serve as a crystallization of OE Health / PAC Bulletin 27 humane pace of work, refusals to work in hazardous situations, wildcat strikes, etc. Current movements against occupational diseases are not even mentioned. Sociologist David P..McCaffrey P..McCaffrey, a former employee of the Bureau of Labor Statistics, has written a concise book on exactly what the title sug- gests, OSHA and the Politics of Health Regulation. His explicit aim is to use OSHA's regulatory activity- activity- particularly standard setting on toxic chemicals to shed light on several theories of the state. The pluralist view of the state as a battleground of interest groups explains the most, he argues; the efforts of the state regu- latory bureaucracy to preserve its own power and routines explains much of the rest. Least appropriate to OSHA'S activity, in McCaffrey's view, is the capitalist state thesis, which asserts that the state expresses the interests of the capitalist system as a whole, even against special interest - business groups. His book provides a detailed. thoughtful analysis of OSHA's regu- latory activity through 1980. Actually, what he achieves is less illumination of theories of the state using the OSHA regulatory experience than new light on OSHA's activity as seen through the conceptual prism of con- flicting theories of the state. He does dispel two myths: the rightwing myth that OSHA has been an aggressive regulator, and the left- wing myth that OSHA totally caved in to business pressure. The book documents the give and take of various actors in the regulatory pro- cess; it shows how interest group pressures, the nature of the Occupa- tional Safety and Health Act itself, historical circumstances, and new demands placed on the agency by the courts set the irregular pace of regulation. The result is a valuable first attempt to present and analyze the sweep of OSHA regulatory activity within a framework that encompasses con- crete historical events and substantive social theories. Its depth and careful attention to facts is a distinct improve- ment on the usual two or three sentence throwaway remarks about how some activity of OSHA " proves " a particular point about the nature of the capitalist state. Assault on the Worker is the best single volume - introduction to occu- pational safety and health for nonspecialists available. It combines the talents of a sociologist, a jour- nalist, and a lawyer from Western Canada. Unlike the two books described above, it captures the con- temporary reality of efforts of in- dividuals and unions to win safety and health. Photographs and stories of in- jured workers make their problems real and haunting. They are com- plemented by concise information on hazards. labor struggles, and legislative matters. Most of the examples are from a Western Canadian context not too dif- ferent from the United States. Readers might find the Canadians have better workers'compensation systems and more active worker par- ticipation in safety and health mat- ters; on the other hand, their regulatory apparatus seems weaker and accidents more frequent. The slight unfamiliarity of the Canadian context to American readers is more than balanced by the explicit political exhibton SC /Nations United analysis and forceful presentation. Some of the best new work on oc- cupational safety and health has come from social scientists working in the area of crime and law. They are help- ing to unravel the ways in which legal practices embedded in workers'com- pensation and the regulatory process allow employers to get away with forms of murder. The title Assault on the Worker aptly describe the book's central image: workers are assaulted at the workplace; the consequences of this are smoothed over by the legal system; workers continue to struggle on an individual and collective basis to win a measure of justice. " Should the company which threatens the workers'safety and health for profit be less culpable when death occurs than the armed robber who threatens the workers'safety and health for pro- fit? We think not, " say the authors. The International Journal of Health Services has been the best single source for new critical work on occupational safety and health. Health and Work Under Capitalism collects some of these pieces from 1977-1981. It reflects the International Jour- nal's interest in the relationship be- tween work and health in the broadest sense as a producer of ill health. as well as for the narrower version of 28 Health / PAC Bulletin that relationship conventionally understood under the term " occupa- tional safety and health. " The anthology contains discussions of occupational safety and health in different countries. India, the United Kingdom, and the United States are treated historically; West Germany receives a more analytical look. The comparison most likely to raise American consciousness comes in the Assennato and Navarro discussion of how workers'control at the shop floor developed out of Italy's 1969 hot autumn; the International Journal is one of the few places where one can read about these astonishing events. when grassroots workers'committees and homogeneous groups tried to take control of the shop floor, collect and evaluate data on workplace hazards, and even create a new model of oc- cupational health science. Some of the work included in the book has become well known - in oc- cupational health circles - Dan Ber- man on the United States; Barry Castleman on asbestos proliferation: other pieces deserve to become as well known -- Barbara Ellen Smith on the social production of Black Lung: Vicente Navarro's continuing in- vestigation of the relationship of work to health, science, and the production of capitalist social relations, and the forms of struggle to transcend those relations; and Cristina Laurell's wide- ranging use of a Marxist approach to work relations to analyze the " wear- ing out " of the population in Third World countries. One regret is that the rhythms of publishing are such that by the time this valuable collection came out, a similar number of related articles of comparable quality had already ap- peared in the International Journal. W.G. Carson is a Senior Lecturer in Criminology at the University of Edinburgh who has done valuable work on both the British Factory Acts of the nineteenth century and enforce- ment of contemporary British health and safety regulations. In The Other Price of Britain's Oil Carson has com- bined his own digging and the investi- gations of several official bodies with the perspectives of several social sciences to provide a concrete, de- tailed, and convincing picture of a safety and health disaster. Accidents in North Sea oil explora- tion and development have been caused primarily by failure to observe routine, well known - safety mea- sures - not because the multinational oil companies were operating on the " frontiers of technology, " as the popular conception would have it. Carson presents the work operations involved exacting detail. He shows how particular serious accidents developed from lack of proper safety procedures, neglected in the drive for quick exploitation of Britain's oil. His narrative reveals how this " political economy of speed " evolved from links between the oil industry and the British economy, the multinationals and the regulators, and the " institu- tionalized tolerance " of mundane design faults and unsafe practices. Carson's attention to Scottish law is tough going, but it is the detailed ac- count of relations between political economy, the state, legal practices, and preventable injuries that makes this book so convincing and so much better than any other on the subject. Carson has gotten each step of the story, made it vivid, and drawn a complete causal and historical chain. The result is a book which conveys the full complexity of the causes of an occupational safety and health disaster better than any other work I know. In his words: At one level, of course, it may be that the industry's own penchant for getting on with things as quickly as possible - for its own sound economic reasons - may be a significant contributory factor in the generation of a high accident rate. More central to my thesis, however, is the argument that the commitment of - successive Governments and Departments to the policy of speedy exploration and exploitation permitted a situa- tion to arise in which operations ran on ahead without adequate legislative provision for their safety. Even when such provision was made, the focus on speed still meant that the pace of offshore developments continued to outstrip the formulation of the necessary subordinate regulations. The preoccupation with haste also permeated the practice of enforce- ment, contributed to the mainten- ance of a'privatized'relationship between controllers and control- led, and became one of the main bones of contention in the in- ternecine wrangling which came to surround the administration of off- off- shore safety in the second half of the 1970s. Not leaste, the urgency with which the objective of getting Britain's oil ashore was pursued left a stream of legislative and organi- zation chaos in its wake and thus further hampered the establish- ment of effective controls. Carson makes a fundamental con- tribution to the study of production pressures at the industrial and shop- floor levels as fundamental deter- minants; he shows how such pressures also effect the structure and operations of the regulatory apparatus. Analogies with gung - ho industries " regulated " by captive agencies in the United States spring to mind -- most notably the nuclear power industry. Our own offshore drilling also merits scrutiny. It's turned out that the frontiers of science and technology have pro- duced less dangers to the public and workers than faulty gauges, shoddy welding, dropped wrenches, and the like. High pressure to get the nuclear plants on line lead to adopting faulty designs and, abetted by shoddy reg- ulation, has produced a potential disaster for all of us. These five books constitute some of the best new work in the field. Taken together, they show a deepening in- terest in the wide ranging - connec- tions between work and health; in exploring the forms of class struggle involved in occupational safety and health; in decoding the ideological forms embedded in legal theories and practices; in connecting analysis of safety and health with the vigorous OE Health / PAC Bulletin 29 peoples'understanding of oppressive work relations and lead to spon- taneous outrage. Similarly there is no reference in the book to the constant workplace efforts to maintain a debates on the nature of the capitalist state. The social scientists among them have gone beyond generaliza- tions about connections between oc- cupational health and safety and capitalist economic imperatives; they use historical and social analysis to specify linkages between the various elements involved. This new work provides access to European analysis more complex than American leftists are ac- customed to. It offers the American occupational health movement an op- portunity to break out of its intellec- tual and national parochialism and do what radical analysis does best: get to the heart of the matter so radical surgery becomes possible. continued from page 4 and films that show elementary medical processes, and the instructor provides commentary before and after. Our orientation is practical in both the three month training and in our weekly visits. These visits are also important to encourage the worker and to give the community the sense that we are involved so it will have more confidence in the health worker. If there is an emergency, say a case of acute appendicitis, the patient is brought to the health station, which usually is no more than about ten kilometers away. If, for example, someone has a kidney stone, the health worker will give anti- spasmodics. If that doesn't work after two or three tries, the patient will go to the health station, at which there are two people. One is the medical assistant, who takes care of security, and the other is the health assistant, who takes care of health and preven- tive medicine. The health station is responsible for five or six villages, which usually means about 20,000 people. And then there is the health center, which could be considered a very small hospital. One type is the mobile care hospital (MCH), another is the polyclinic, and the third is the mobile clinic. The MCH has between 15 and 20 people and a laboratory, and can admit between five and ten patients. It can handle diseases which aren't very severe, such as malaria, pneumonia, renal stones. Above this there are ten or twelve regional hospitals, depending on the military situation; we have one big central hospital which has a capacity of about 1200 patients. About 35 percent of the local health workers are women. We have about 100 nurses in all, of which 80 or so are women; one of our 22 doctors is a woman. Generally the health services aren't overwhelmed because of the pyra- midal structure, which sends only the serious cases outside the village - most of the problems are the standard ones: diarrhea, malaria, schisto- somiasis, stones. We do have patient lines on the local level and try to shift personnel around to meet needs. Moreover about 30 percent of the population is nomadic, so we have to provide mobile clinics for them as we do for the third of the population in militar- ily contested areas. When the health workers are brought a child whose basic problem is obviously malnutrition, it's a very painful situation. The health worker has to explain this to the parents, and of course the immediate question is " Where can we get food? " We try to give them information on which foods are most vital - generally the child needs more protein - and we give what we can through our relief organization. Children get priority in food distri- bution. We don't believe the problem of malnutrition can be solved in the clinics and hospitals. We believe it has to be attacked at its roots by the departments of Agriculture and Relief. We try to get millet from the Sudan - - it's the main source of carbo- hydrates; vegetable oil, which is the main source of fat; and sometimes butter from Europe; and we also try to distribute chickpeas and lentils for protein. This is the cheapest more or less balanced diet. Of course it's lacking in some vitamins and minerals as well as fruits, but it will enable people to survive - and to see the benefits of a balanced diet. The drugs we supply to the village health stations are mostly vitamins, antibiotics, drugs for intestinal infections, and painkillers. We've been trying to ex- plore herbal medicines, but because of the conditions we haven't gotten very far; we have done some work with skin infections. We've gotten a pill making - machine and can make them from powders we import for about a dozen of the most widely used pills. Obviously our resources are quite modest. People who would like to help can send donations to Eritrean Medical Association, P.O. Box 421, Radio City Station, New York, N.Y. 10101. Neravo Tekle Michael, M.D. Eritrean Public Health Coordinator te v continued from page 6 on the picket line, but it wasn't long enough for victory. Their efforts did win national attention, particularly among nurses and other healthcare workers and, in the words of a Cali- fornia Nurses Association commen- dation, " the knowledge and experi- ence gained by these nurses can be used to facilitate positive outcomes of future collective bargaining. " " Proud to Be a Staff Nurse " A powerful grassroots insurgency in Seattle, WA has culminated in a vote by 1200 registered nurses at the Group Health Cooperative to affiliate with the National Union of Hospital and Health Care Employees - District 1199. Increasingly dissatisfied with the Washington State Nurses Associa- 30 Health / PAC Bulletin tion, the RN's ~ including five WSNA officers who resigned their elected positions - formed their own unit last January. This Group Health Regi- CENTRAL AMERICA stered Nurses Union voted a few months later to decertify WSNA and affiliate with 1199. Propelled by the momentum gen- erated in this switchover, the nurses won a contract by August that secured their rights on professional issues such as continuing education and pro- tection from " floats " to unfamiliar units. The reverberations of the success- ful 1199 campaign, waged under the banner " Proud to be a staff nurse, " will be felt across the country. Rank and file participation was exception- ally high, the Group Health Cooper- ative nurses unit is quite large, the WSNA had represented the RN's there for 23 years, and Washington State is the home base of the President of the American Nurses Association. ON THE EDGE OF DISASTER A New Vietnam. President Reagan, at his July 26 news conference, said, " First of all, there is no comparison with Vietnam and there's not going to be anything of that kind in this. " Unfortunately, there already is. Like Vietnam, Central America has a long history of economic and political repression going back to colonial times. " Outside forces, " whether China or Cuba, are not the cause of the upheavals in either of these regions. Like Vietnam, unpopular regimes are backed by US money, arms, and military advisers, one of whom has already been killed in El Salvador. Now thousands of US combat the verge of another war ... and the time has come to stop it. A President Out of Control. By large majorities the American people have made it clear they do not want US military involvement in Central America. But a divided Congress has failed to stop an administration bent on the worst kind of " gunboat diplomacy. " Don't let Congress fail again. Tell your Senators and Representative they must cut off all funds for military aid, overt or covert, in the whole region. They will be home for recess this month: go see them. Tell them the administration center of citizen pressure on Congress " to change Central American policy. For five years the Coalition has coordinated virtually all constituency work on Central America and built up a network of thousands nationwide. Our fifty one - member organizations include ten Protestant denominations, five Catholic groups, three Jewish groups, the National Council of Churches, several ecumenical organizations, ADA, SANE, US Student Association, YWCA, and several other human rights and peace groups. To stop this war we need your help. Join our network and send us They'd Rather Fight and Switch soldiers are committed to maneuvers in Honduras, and a fleet of twenty must be brought under control. oe & whatever contribution you can afford. We will keep you posted about ships is stationed off both The Coalition for a all key events in Congress District 1199 won several more vic- coasts of Nicaragua. Will there be a new Tonkin New Foreign and Military Policy represents millions and Central America itself. Your dollars are tories in Michigan. After a bitter 54 day - strike against Bay Medical Center in Bay City, MI- " The J.P. Stevens of the healthcare industry, " Gulf incident, like the one that deceived Congress in 1964? Americans have memories, and they of Americans who want to reassert popular control over a reckless and inhumane foreign policy. The Congressional needed urgently at this crucial moment. COALITION For a New Foreign and Military Policy according to one nurse who works there licensed - licensed practical nurses and registered nurses wrested a decent contract from management. know a disaster when they see one. We are on Quarterly last year called the Coalition " the nerve- 120 Maryland Ave NE Washington DC 20002 Richard Healey, Director Se SS SS Sa SAD SN SE STS Sp GUE ND SOS SED GS ES ANN AE DS Lo cs co an SD SAY SENT CD GOED cu SE om OE YES! Sign me up for the Coalition's | network an d send me rI egular Actio n Alerts | on key legislation, Action Guides on the Stop the War. Send Your Message Today. The LPN's were 1199 members. I issues and resources for local organizing work. Here's my $ 20 for one year of I Dear | TMihcehi ga3n0 M0i chRigNa'n sMi cRhiNg'ans R Nh'sa Ndu rsdees cNuerrsets iNfuriseesd A sdoecicaetirotn iAsfioceiadt iotnh aend H Nurses formed their own union two years { ago, but they were so impressed impresismperde ssed by I Coalition materials. I urge you to oppose all further U.S. military aid, exercises, and covert action in Central America. I urge you to press the administration to suspend rt! Y' YES! 1 sent a message to stop intervention | current military support and actively engage in unconditional negotiations to in Central America. bring lasting peace and justice Central to Central America. We can no longer support governments at war with their people own people. Please stop this dangerous spiral of I i intervention. ment tactics that they have affiliated I Name their their success success in in coalition coalition with with the the | Address Address LPN's LPN's in the face face of of tough manage- manage- manage-! City, State, Zip I I f Your Representative Your Senator U.S. House of Representatives ! Washington, D.C. 20515 U.S. Senate Washington, D.C. 20510 I with 1199 as well Sa cae ee SS a ee a settee memes lms ene ete ey SU a SG SS SS Moving? Since the post office doesn't ordinarily forward magazines, be sure and let us know at least six weeks ahead so you will get your Bulletin. Please include your old address, with zip code. We regret that we can't replace issues not received if you haven't notified us in time. Mail any changes or corrections to Circulation Department, Change Division. Health / PAC, 17 Murray St., New York, NY 10007. Health / PAC Bulletin 31 Health Health PAC / Health Policy Advisory Center 17 Murray Street New York, New York 10007 2nd Class Postage Paid at New York, N.Y.