Week 6: E-response to Masco and Jain

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Have you ever wondered why the phrase “You’re the bomb” offers a slangy compliment, whereas “You are the gas chamber” would not go over well in a romantic situation? (Clearly, I have.) This translation of nuclear imagery into benign, even sexy, language is not uncommon. When the word bikini crops up, most Americans think of the swimsuit rather than radiation sickness. Though perhaps not the intent in naming the bathing suit, it would be diffi cult to think of a better way to dimin- ish the signifi cance of the Bikini Atoll’s annihilation by the twenty-three nuclear tests carried out on the South Pacifi c island by the American military between 1946 and 1958, collectively seven thousand times more powerful than the atomic device dropped on Hiroshima. In the very defi nition of obliteration, a single bomb vaporized three of the islands and sprinkled them, in the form of radioactive dust from 100,000 feet in the air, onto inhabitants of islands farther north, forcing them to evacuate. Almost seventy years on, the islanders have not been able to return to this lethal paradise.

The name Bikini Bottom for the home of the popular children’s car- toon character SpongeBob SquarePants may seal the insult. If not, the fact that UNESCO recently declared the Bikini Atoll a World Heritage Site surely does. Of the fi ve sites that were exposed to one megaton of open-air tests prior to 1963, including Nevada and two in the former Soviet Union, the atoll was selected as representative of the role that atomic bomb testing “played in shaping global culture in the second

chapter 8

Fallout Minuets in the Key of Fear

Jain, S. Lochlann. Malignant : How Cancer Becomes Us, University of California Press, 2013. ProQuest Ebook Central, http://ebookcentral.proquest.com/lib/washington/detail.action?docID=1323166. Created from washington on 2018-09-19 18:03:25.

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half of the 20th Century.”1 Over fi ve hundred atmospheric nuclear weapons tests were conducted at various sites around the world between 1945 and 1980, but UNESCO claims Bikini Atoll as “an outstanding example of a nuclear test site,” stating that the “authenticity of the material elements constituting the property is unquestionable.” Why? Because “human presence there has remained very limited because of the radionuclides produced by the explosions.” In the event that the area ever becomes inhabitable again, conservation must “include the protection of the land-based military remains.”

Specifi c state programs assisted in the U.S. domestication of terror about nuclear war. The post-WWII images of bomb tests that saturated American media, for example, choreographed a sterile, fungal sublime that many still associate with the bomb. American researchers scrupu- lously documented the effects of radiation on the Japanese, but these images were not released in the United States.2 Americans of a certain age can still hum “Duck and Cover,” the song that instructed people to hide under desks or in doorways to save themselves from evaporation. The innocuous ditty perfectly connotes the Cold War promised differ- ence of zero when it came to the balance of terror, with the American nuclear stockpile as the minuend and the Soviet arsenal as the subtra- hend. It’s natural to forget that real terror was at stake, as easy as it is to miss the fact that “premium-plus” soda crackers really are top-notch. Rote phrases have a way of desensitizing one to their meanings.

Polished images of bomb blasts, combined with spectacles such as mass evacuations, placed the potential for nuclear disaster in the realm of the everyday, posing the idea that nuclear war, similar to other kinds of disasters, was just another facet of quotidian life while at the same time eliciting support for national defense spending. The government harnessed the same rhetorical methods, if on a rather grander scale than it had used to transform traffi c fatalities into “accidents,” in its efforts to conceal and refashion the new forms of illness and death purveyed by a nuclear culture, such as radiation poisoning and cancer.

Anthropologist Joseph Masco traces the enormous effort undergone by government to convince the public that a nuclear crisis could be “incorporated into everyday life with minor changes in household tech- nique and a ‘can do’ American spirit.”3 This occurred, for example, when the government converted nuclear terror, a paralyzing emotion, into nuclear fear, which Masco describes as an affective state that would still allow citizens to remain calmish and able to act during a catastrophe. This emotional management required a two-pronged approach. First,

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government advertisements asked citizens to “take responsibility for their own survival” by knowing what to do in the case of a nuclear attack. Second, campaigns directed people to fear widespread panic, rather than nuclear war itself, thereby defusing the bomb as the main threat. Even with the release of radiation with atmospheric bomb testing, the discov- ery of high levels of radioactive strontium in American bones and teeth, and the corresponding increase in cancer rates along fallout routes and among nuclear workers, the government created an image of the nuclear threat as coming from the outside, never as the predictable and calculated consequence of American programs. News media and government spokespeople often described antinuclear activists as communists, lesbi- ans, or hippies—not fully American.

Only recently have governmental agencies emerged with more infor- mation, now warning people who were children, drank milk, and lived along fallout routes before 1963 to be aware of their heightened risks of thyroid cancer and leukemia as a result of their exposures.4 Current recommendations by the Environmental Protection Agency (EPA) and Food and Drug Administration (FDA) would have seen the removal of milk from U.S. supermarket shelves throughout the 1950s and early ’60s for months at a time.5 Millions of gallons of milk would not have been sold, and millions of children would not have drunk it. Despite the refusal to study the health effects on Americans of nuclear fallout at the time (American studies were ongoing in Japan), the Atomic Energy Commission (AEC) acknowledged the physical effects of radiation by agreeing to alert Eastman Kodak in advance of nuclear tests: radiation caused unexposed fi lm to fog.6

Cancers caused by military activities aside, the disease and the mili- tary served as perfect foils for one another. As a disease horrifi c enough to warrant virtually any treatment in the search for a cure, from pluto- nium injections to massive doses of radiation and chemotherapy, cancer enabled the government to demonstrate the humanitarian potential of nuclear technology. Amid much controversy in medical spheres, the military funded experimentation with large-scale, brutal, promising “weapons” against cancer, while the disease was so feared that doctors more often than not did not disclose the diagnosis to their patients.7

That cognitive dissonance between the horror of the thing and its transformation into a banal everyday occurrence reverberates in con- temporary cancer culture as well. Bad enough to warrant atomic-level treatment; how can the social narrative of cancer possibly be reduced to pink bracelets, pamphlets, and BMW test drives? A New York Times

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article suggests that people returning to work after treatment will fi nd that wearing “a wig or hat and makeup that conceals a pale complexion will put colleagues at ease and make you feel better about yourself.” Or “Try a little humor, such as asking whether people like your wig, and maintain a positive attitude.”8 Many of the ways we are asked to think about cancer fi t all too well with Masco’s observations about govern- ment strategies during the Cold War, which transformed “an unthink- able apocalypse into an opportunity for psychological self-management, civic responsibility, and ultimately, governance.”9

Just as fear incontrovertibly shapes our understanding of the bomb, so it is a central, understudied aspect of cancer. Fear of cancer starts early. If you are educated and middle class, you likely eat organic food, wear your sunscreen, and get your colonoscopy. If you take an active part in the medicalized and marketized socialization around cancer, you probably feel at least vaguely self-congratulatory as you do your bit to avoid it. Witness the shock so many people experience upon diagnosis (“but . . . but I did everything right!”).

Cancer stands in ill repute, and its bad rap precedes it. Thus, little- understood assumptions about fear (and fear of fear) pervade the interac- tions around both early-stage and terminal cancer. For instance, the Amer- ican Cancer Society’s deputy chief medical offi cer Len Lichtenfeld discusses the valid problem of how (and if) doctors should manage fear in the diag- nostic procedure, where the very word cancer may prevent a patient from absorbing important information about monitoring symptoms.10 Screen- ing debates acknowledge that diagnostic procedures carry the “risk of negative emotional consequences” and that this emotional fallout should be considered when attempting to make a cancer diagnosis.11

Even early-stage cancers that require relatively simple surgeries to remove and have virtually 100 percent survival chances can carry huge emotional burdens. Science historian Steven Shapin writes of two women, one of whom has cancer and goes through treatment and the other of whom has been tested and is negative. He notes that “their experiences eerily resemble each other.”12 This description of a similar- ity between a fear and a treatment could only be accurate in a world that takes fear of cancer as defi nitive of the experience of it (and even then it requires a rather signifi cant disavowal of the intensity of cancer treatment).13 Yet the publishability of this idea—that being-tested-for-a- disease-you-don’t-end-up-having resembles cancer treatment—shows the extent to which fear has become a powerful, and problematic, cur- rent in the very defi nition of cancer.

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From another angle, who can blame a doctor for being disinclined to give someone what is basically a death sentence, or for worrying that a patient will break down in her offi ce? One nurse told me about a patient who was removed from a doctor’s offi ce in a straitjacket after being diagnosed with metastatic disease. Little literature addresses, head on, the question of precisely how fear should be considered in the mix that we call cancer, from screening policy to physician training, from sup- porting caretakers to pamphlet design, from the period of survivorship to replacing a plastic bottle.

No matter how innocently, the attempt to assuage the fear can trig- ger misinformation. Cancer patient literature, with its ubiquitous pho- tos of smiling patients and competent, relaxed caretakers, offers another example of a place where fear might benefi t from acknowledgment and more careful analysis. In a memoir about his mother Susan Sontag’s death from chemotherapy-induced leukemia, David Rieff writes about the infantilizing language of an informational pamphlet: “The gap here between language and reality is simply too great [to convey useful infor- mation about cancer], and is actually a disservice to most patients and their loved ones, and, I suspect, even for physicians and nurses as well. . . . It may be appropriate to ‘redirect’ a small child who is upset about something. It is not appropriate to ‘redirect’ an adult cancer patient.”14 These insulting misdirections have become an inside joke in survivor cultures, as I continually witnessed in retreat discussions. Miriam Engelberg, a cartoonist whose book ends abruptly after she has been rediagnosed with metastatic disease, captures this misdirection perfectly in her book Cancer Made Me a Shallower Person (fi g. 21). Reading this laugh-out-loud book on cancer ephemera tickles that now- familiar comfort-terror-solidarity spot of chemofl age.15

When I spoke to a former nurse about the sanitized patient informa- tion, she said that if brochures and doctors adequately described the procedures—if, for example, people really understood what a bone marrow transplant entailed—they might well opt out of the treatment. In this light, the fear management approach makes sense at one level, but it comes with costs: being treated like a child or an idiot has its own psychological ramifi cations. As much as the grief of losing his mother constituted Rieff’s experience of cancer, so did his fury at the way the process of cancer was misrepresented.

I noted in the introduction that the twentieth- and twenty-fi rst- century defi nition and management of what we call cancer tracks with the institutions that have come to defi ne America—the military, postwar

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big medicine, technology, advertising (imagine the swelling orchestra in a Made in America commercial). But one of cancer’s biologically defi n- ing features—the lag between exposure and symptom—enables us to clearly (and misleadingly) separate it from these industries. As I mention throughout this book, it is virtually impossible to prove that a particular exposure has led to a specifi c injury by cancer. This latency partly accounts for cancer’s everywhere- and nowhereness. If cause can’t be shown, how can cancer be located? Is it in the body or in the culture around it? Does it arise through practices such as smoking, or through screening that potentially detects too much of it? Everyone knows some-

figure 21. Miriam Engelberg, in her book Cancer Made Me a Shallower Person, comments on the patient who is always smiling in cancer pamphlets.

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one who has or had it, but where is the thing we can point to, the evi- dence that Something Is Being Done? American laws and regulations for the most part are built around immediate and provable causation, not a death fi fty years later, and thus the debates about how many cancers are environmentally caused are likely to continue for many more decades.

On the one hand, many Americans realize that carcinogens buttress the American economy. On the other hand, we rarely consider the actual people living with and dying from cancer as being a sacrifi ce to, and a structural result of, our use of these toxins. Some of this disjunc- ture results from campaigns (think pink) that divert attention away

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from the links between chemical exposures and the disease. Framing survivorship as a personal accomplishment further separates cancer causation from its manifestations. Cancer becomes a passively occur- ring hurdle to be surmounted by resolve rather than the direct effect of a violent environment, as incongruous a substitution as a lisp versus a gunshot wound.

Even if we did consciously decide (rather than simply fail to collect the data) that the injuries resulting from the daily use of proven car- cinogens are a worthy trade-off for a certain standard of living—one that includes chewy toys, spray cleaners, and cheap cherries—the injuries would neither go away, nor would they be evenly distributed among those who made the decision. Unlike lead exposure through gas and paint or mercury exposure through dental amalgams and tuna fi sh, which can subtly decrease coordination and intelligence in whole swaths of a population without attracting notice, cancer signi- fi es a specifi c, diagnosable, singularly borne disease. Cancer may be widespread, but it strikes clearly individuated victims. Environmen- talist advocates suggest that we could get rid of cancer if only we could get rid of the carcinogens. Whether that’s true or not we may never know. In the meantime, the languages that justify cancer at the individual and social levels reveal valuable information on who we are.

A minuet is a social dance. Partners mutually agree on the cadence of the steps. The rest of this chapter examines the underpinning cho- reography of some of cancer’s dissonances and the languages that squash these dissonances into a strict cadence. In searching fi rst for the everywhere- and nowhereness of environmental exposures, I’m not particularly arguing that the environment should be cleaned up (although I think it should) or that such a cleansing would eliminate cancer (maybe it would, maybe it wouldn’t). Rather, I want to exam- ine the broader costs of accepting the general lack of proof, despite serious suspicion, about cancer’s causes. This sets the stage for the second act of this chapter, where I analyze the virtual eradication of cancer and carcinogenic exposures as legally compensable injuries through “fear of cancer” lawsuits. The government’s attempt to use graphic warnings on cigarette packaging serves as the chapter’s denouement. Somewhere in each of these episodes, we’ve been inter- polated as partners, asked to accept a logic of cancer that both piques and diminishes the fear.

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exposure

In 1971, Congress charged the newly constituted President’s Cancer Panel with monitoring the multibillion-dollar National Cancer Program. Each year, this panel of two to three experts writes a report to the U.S. president on cancer-related topics. Reports generally cover noncontrover- sial aspects of cancer, such as diet, survivorship, racial disparities, insur- ance, and drug development. However, the 2008–2009 report, written by two members appointed by George W. Bush, examines the use of indus- trial, military, and agricultural carcinogens. Making the case that cancer programs have grossly underestimated the real costs of environmental pollutants, it details the true burden of environmentally caused cancers. The report notes, for example, that of the eighty thousand chemicals in daily use in the United States, only a few hundred have been studied for carcinogenicity. Ultimately, the report “most strongly” urges the presi- dent “to use the power of your offi ce to remove the carcinogens and other toxins from our food, water, and air that needlessly increase health care costs, cripple our Nation’s productivity, and devastate American lives.”16

The report offers a succinct and straight-talking overview of can- cer causation in the United States, pointing out that U.S. rates of cancer remain higher than those of other industrialized nations. It also lists the primary challenges faced by Americans, as follows: lim- ited, underfunded, and scattered research on the environmental causes of cancer; reliance on animal studies (whose subjects can be bred to have higher tolerances for chemicals); a lack of data on low- dose exposures and combinations of exposures; ineffective regula- tions; medical radiation exposures that are often underestimated by physicians; and hazardous, unmeasured, and concealed exposures by the military (in weapons testing and development, for example).17 The report further notes that the medical community has not taken seriously clear correlations between environmental exposures and cancer. Although less than 5 percent of cancer diagnoses can be linked directly to inherited genetic traits, the primary focus of medical can- cer research has consistently honed in on the genetic causes of can- cer.18 Physicians rarely ask about exposures to carcinogens in patient interviews, even though rates for certain types of cancer can be clearly correlated to occupational exposures.19

Using well-known examples such as lead, asbestos, plastics, and other common household and medical materials, numerous authors have

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detailed the political barriers to regulating dangerous chemicals and products.20 Unlike European regulations that tend to rely on a precau- tionary approach, in the United States “a hazard must be incontrovertibly demonstrated before action to ameliorate it is initiated.”21 In other words, while European governments regulate chemicals based on initial evidence of toxicity, the U.S. government allows even chemicals ranked as “likely,” “potential,” and “actual” carcinogens to be produced and used for many years until adequate proof of danger has been gathered (the passive voice is appropriate here, since it isn’t clear, often, who would collect the data). Industries maintain unique access to political power through well-funded lobbyists who work to keep ingredient lists off product packaging and ensure that manufacturers need not disclose the carcinogens in proprie- tary ingredients.22 Commonly used known carcinogenic chemicals such as cadmium, phthalates, asbestos, chromium, diesel fuel, mercury, and formaldehyde require no federal labeling or warnings.23

The report identifi es numerous hazardous materials in our everyday lives. For example, agricultural industries pour eighty million pounds of the herbicide atrazine, an endocrine disruptor and possible carcinogen, onto U.S. soil each year, though the chemical was banned in Europe in 2004 because of its toxicity (despite its being manufactured by a Euro- pean company, Syngenta).24 Often these chemicals linger in the environ- ment. The pesticide dichloro-diphenyl-trichloroethane (DDT; see fi g. 22), banned in 1973 thanks in large part to the work of Rachel Carson, remains ubiquitous in American bodies, foods, and environments forty years later.25 A recent study of randomly sampled foods found DDT metabolites in 60 percent of heavy cream samples and 28 percent of car- rots,26 while another study found a fi ve-fold increase in the risk of breast cancer among young women who as girls had been exposed to DDT.27 Similarly, polychlorinated biphenyls (PCBs), slowly degrading carcino- gens banned in the late 1970s, are still found in human fl esh, soil, water sources, and the walls of buildings.28 The EPA classifi es approximately forty registered chemicals used in pesticides as known, probable, or pos- sible human carcinogens.29 Over 75 percent of food in American grocery stores has residues of one or more pesticide chemicals.30

Bisphenol A (BPA), used in the manufacture of plastics, is found at biologically active levels in 93 percent of Americans, and 130 studies have linked BPA to breast cancer, heart disease, and liver abnormali- ties.31 Despite much recent attention in the media, BPA is still legal and commonly used in food packaging; it requires no labeling or warning. It has only recently been banned in children’s chewable toys

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and bottles—just because the popular Nalgene water bottles are now BPA-free doesn’t imply an industry-wide level of regulation. Even when a particular carcinogen has garnered press, most Americans remain ignorant of most known carcinogens, and low-income people are more likely to suffer exposures due to working conditions and geographical stratifi cation.32

The Cancer Panel Report, at nearly 150 pages, details the hazards of living and dying in America and the ways and reasons that these risks continue to be underestimated, unknown, and covered up. From this exhaustive document, two critical points emerge for thinking about

figure 22. Photographs and fi lms in the 1940s and 1950s often featured children playing in DDT or being sprayed with the chemical while eating lunch. None of these children were followed to gain a long-term understanding of the effects of DDT. (Photo by George Silk, 1948; reproduced by permission of Getty Images)

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toxic exposure. First, we simply do not understand toxic body burdens. Studies have shown that virtually all Americans are now born with body burdens of known toxic chemicals.33 However, well over a decade after the EPA was mandated with identifying human exposures to endo- crine disruptors, it has yet to develop screening tests.34 Not only do we have no frameworks to understand exposures, but the “pure” body that underlies so many ideas of cause simply does not exist. When it comes to toxic exposure and humans, there is no such thing as a blank slate.

A second problem arises from the fact that U.S. regulatory agencies tacitly permit the use of toxic chemicals if their benefi ts outweigh the risks they pose. The EPA allows chemicals that do not pose an “unreasonable risk to man or the environment, taking into account the economic, social, and environmental costs and benefi ts of the use of any pesticide.”35 (Atra- zine, for example, increases agricultural productivity by an estimated 3–6 percent.) Obvious contaminants pollute this logic. For one thing, citizens unequally absorb the risks, costs, and benefi ts depending on factors such as their occupation, gender, race, age, and geographic location, such that the categories used by the EPA—“man,” “environment,” “costs,” “benefi ts”—bear no necessary overlap to enable comparison.

Whole libraries of books have been published detailing all the ways that American industry and the military have produced deaths, fear, and uncertainty. We don’t need more proof of that. Rather, I’m struck by the seeming inability to bring this production of cancer (with the notable exception of cigarettes) to the fore of cancer research, law, and history. There is a pervasive social taboo—an uncoolness, so to speak—around recognizing cancer production, opposing that produc- tion, or expressing genuine fear about living in this chemical cesspool. This cultivated inhibition plays a key role in the making of cancer.

The most powerful culture-makers—industry, government, medicine— have been slow to recognize, let alone advocate for research into, the con- nections between environmental toxins and the disease. If fear results in part from the unknown, then keeping things unknowable contributes to the circulation of an unattributable anxiety. Ask anyone whose heart has pounded when a kindly doctor responded to her questions with a shrug and a sad look in his eye.

faustian bargain

As we saw in chapter 4, tort law offers an awkward and expensive cost- sharing ideal. Theoretically, the law protects citizens from the dangers

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of products or actions.36 A plaintiff must prove, in launching such a suit, that, fi rst, he has an injury, and second, the injury has been directly (“proximately”) caused by the product or action of the defendant. His- torically, tort law ensures that all costs of production—including the costs of injury—remain visible and taken into account. However, in the case of exposure to a carcinogen, such proof is virtually impossible to provide. Thus, exposing people to carcinogens carries virtually no risk of lawsuits from injured parties.

The delay in the onset of some kinds of injury—such as cancer—has led courts to accept a claim for “toxic tort,” which enables someone to bring a suit long after the statutes of limitations would normally have run out. Some cases have successfully been brought because a cancer was rare enough to be directly related to an exposure (asbestos and mesothelioma, hairspray and angiosarcoma of the liver, cigarettes and lung cancer), even past the usual one- or two-year statutes of limita- tions. But most generic, common cancers have no demonstrable cause. Perhaps they resulted from multiple exposures, or perhaps only one. Perhaps none. Who knows?

People who have been exposed to carcinogens have two practical legal choices, each of which differently juggles the problem of proving an injury and proving its proximate cause.37 In the fi rst scenario, a potential plaintiff can wait to see if she develops cancer and then attempt to prove proximate cause in a toxic tort. The necessary delay in bringing this kind of complaint will run several risks: the company may no longer exist when the suit is brought; the cancer may not be linkable to the exposure; the patient will have to front the costs of the cancer screenings and treatments.

Alternatively, a plaintiff can open a case immediately after exposure under standard tort rules. Since the plaintiff will not yet have devel- oped cancer, she must claim that the injury is emotional rather than physical. In “fear of cancer” cases, injury refers not to cancer itself, but to the plaintiffs’ fear that they may, in the future, develop cancer as a result of their exposures.38 These suits have proven practically impos- sible to win. Consequently, the tort system has failed to render cancer into a legible injury.

One such “fear of cancer” suit that set the standard in California and most of the United States came before the state Supreme Court in 1993. In Potter v. Firestone Tire and Rubber, the court acknowledged the legitimate nature of fear-of-cancer claims; nevertheless, for reasons dis- cussed below, it reversed a lower court’s award of punitive and general

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damages and remanded the case for retrial.39 The court acknowledged the legitimacy of the plaintiff’s fear-of-cancer claim; yet it found for the corporate defendant. In its decision, the California Supreme Court set an extremely high bar for the plaintiffs to meet in order to recover dam- ages under a negligence theory. One could reasonably argue that the intent of the Potter decision was specifi cally to prevent further fear- of-cancer lawsuits.

The facts and allegations presented in the case were as follows: Between 1967 and 1980, Firestone disposed of toxic chemicals and known human carcinogens at the Crazy Horse dump in Salinas, California, despite hav- ing been required to abide by environmental standards for disposing of hazardous waste because of the dump’s proximity to local residents’ drinking-water sources. In 1984, benzene, toluene, chloroform, and vinyl chloride were found in local wells, in a chemical fi ngerprint later found to be identical to that of the chemicals dumped by Firestone. About 6,200 people within three miles of the site had consumed contaminated drink- ing water, and in 1987 the City of Salinas bought the houses in the affected area and bulldozed them.40 Two families sued Firestone.

Because internal Firestone documents revealed that plant managers knew that the company had been illegally dumping the chemical wastes from its vulcanization processes since 1977, the plaintiffs were awarded over $1.3 million in compensatory and $2.6 million in punitive dam- ages. When Firestone appealed, the California Supreme Court reversed the decision on the grounds that the plaintiffs had failed to prove that they had a legitimate fear, which would require establishing the follow- ing: (1) that Firestone’s conduct was specifi cally directed at them and (2) that the exposures were more likely than not to result in cancer.41 The court remanded the case for retrial to allow the plaintiffs to prove that the defendants were “aware of the presence of these particular plaintiffs and their use and consumption of the water.” They chose instead to settle out of court.42

The state Supreme Court interpreted the law as requiring plaintiffs to prove that their fear of cancer stems from knowledge, corroborated by reliable medical or scientifi c opinion, that they are more likely than not to develop cancer in the future due to the toxic exposure. Plaintiffs, the court stated, could avoid this high standard of proof only if they are able to show that the defendant acted “recklessly” or “outra- geously.” In that case, they would only have to demonstrate that the “actual risk of cancer is signifi cant.” (Though just what “signifi cant” means is not clear.)

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Meeting this burden of proof would require nothing less than a ran- domized controlled trial, and one that exposed a population to a similar panel of chemicals and compared it over time to an unexposed group— both unethical and impossible given the short span of human lives and the newness of many of the chemicals. Practically speaking, the court made it impossible to bring a complaint against a person or company who knowingly exposes others to carcinogens.

The pseudoscientifi c language of a “more likely than not” threshold makes it appear sensible. Yet closer scrutiny suggests that this threshold would allow a chemical exposure that kills off 20, 30, 40, or even 49 percent of a population—as long as the company does not directly tar- get individuals. If, after an exposure, forty-nine in a class of one hun- dred sicken and die, the more-likely-than-not threshold will not have been met. Even after an actual cancer diagnosis, each individual would initially have been more likely to not have developed cancer. The levels of cancers caused would have to be stunningly high—and provable in advance—for these cases to be won.

Ironically, one of the court’s major concerns in fi nding for the plain- tiffs was the vast political and economic problem of carcinogenic expo- sures. The court stated: “All of us are potential fear of cancer plaintiffs, provided we are suffi ciently aware of and worried about the possibility of developing cancer from exposure to or ingestion of a carcinogenic substance.”43 In the early 1970s, scientists found that one such sub- stance, vinyl chloride, at low doses causes cancer in animals. Yet this ubiquitous chemical continues to appear in hairspray, saran wrap, car upholstery, shower curtains, fl oor coverings, and hundreds of other consumer products. As a chemical supervisor wrote in 1973, if lawsuits were brought over vinyl chloride, the industry would have “essentially unlimited liability to the entire U.S. population.”44 While the Califor- nia Supreme Court recognized the depth of the problem, at the same time it refused to take on the role of adjudicating the justness of such exposure.

In making its policy claims in the Firestone case, the court relied heavily on an article by Robert Willmore, an attorney who, according to his website, “supervised the defense of over $100 billion in tort claims against the federal government involving such areas as asbes- tos, Agent Orange, radiation exposure, environmental and toxic torts, and aviation disasters.”45 Willmore states that allowing fear-of-cancer claims would “make it much more likely that a person exposed to small amounts of a carcinogen will sue rather than shrug off the risk

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as one more of the numerous small cancer-causing risks to which we are all constantly exposed.”46 Willmore, in other words, asks us to wave off all exposures as equivalent, everyday occurrences. In his analysis, the Firestone exposure would be no different than using a microwave.

Rather than demonstrating that large awards may act as a deterrent to companies like Firestone, Willmore worries about plaintiffs. He claims (without grounds) that large awards are more likely to increase the number of plaintiffs who are willing to deceive. “They may feel, after all, that they are entitled to something for having been exposed in the fi rst place.” He further argues that “the understandable fear of a surge of cancerphobia liability was one of the issues that led to the ultimate defeat by fi libuster in 1988 in the Senate of a Worker High- Risk Notifi cation Bill (S. 79),” a bill that would have required employ- ers to inform workers about their exposure to carcinogens.47

Potter v. Firestone represents just one of many instances of litiga- tion in which the court has justifi ed erring in the defendant’s favor with the argument that a fi nding for the plaintiff might lead to a land- slide of claims about dangerous exposures. The Cancer Panel Report, meanwhile, indicates that fear-of-cancer claims (and the judicial fear of such claims) would in some cases have validity. Turning claims about exposures into claims about fear or a platform for potential deceit at once diminishes legitimate fears and concerns and prevents cancer injuries from gaining traction as compensable injuries. This legal logic increases the ability of some people and companies to expose populations to carcinogens without incurring any costs, while decreasing the ability of those exposed to those chemicals to chal- lenge such exposures. For anyone living with exposure, fear, cancer, or all three, such logic increases cognitive dissonance to a near-toxic level.

prodigal son

Tobacco, now the most politically acceptable object of anticancer awareness, history, and activism, offers the most visible representation of disease and death. With cigarette warnings, the government has attempted to manage behavior through a unique combination of aware- ness about the inherent dangers of tobacco products and negative provocations about the consequences of using it. Because of its extreme lobbying power, the tobacco industry has dodged regulation by the

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FDA, Occupational Safety and Health Administration (OSHA), and other federal agencies and so legally produces one of the few products that regularly and predictably injures and kills its consumers as a matter of course. We’ve now reached a stalemate: governments rely on the taxes that sales generate, and many smokers have been unable or unwill- ing to quit.

The fi rst health warnings appeared on cigarette packages in 1966. They resulted from a great deal of negotiation between the Federal Trade Commission and industry, and read: “Cigarette smoking may be hazardous to your health.” The industry soon came to see this warning as positive, since it bolstered their assertion in litigation that consumers knowingly accepted the dangers when they opened a pack of cigarettes.

The peculiar legal, regulatory, and marketing history of cigarettes eventually led to the partial regulation of tobacco products through the FDA (a result of the 2009 Family Smoking Prevention and Tobacco Control Act). In an effort to undo the age-old image of smoking as a glamorous, sexy, daring, pleasurable habit, the agency chose a set of warnings for 2012 release based on their ability to stimulate strongly negative emotional responses. The proposed cigarette warnings attempt to overcome the lag between smoking and injury by illustrating the potential consequences of smoking directly on the box. These images can’t be mistaken for the Lance Face.

The FDA aimed to scare people away from smoking—in their words, to elicit “strong emotional and cognitive reactions to the graphic ciga- rette warning label,” to enhance “recall and processing of the health warning.”48 These graphic warnings would offer—as they do in Can- ada, Australia, and other countries—one of the few places in the public domain where realistic images of cancer appear: no sanitized, patroniz- ingly pretty pictures here. (Early detection ads also aim to instill a fear of cancer and of the consequences of delay, but more often they convey a stylized or sentimental notion of cancer, which is no image of cancer at all.)

In selecting a warning for the tagline “Cigarettes Cause Cancer,” the FDA studied a series of images. These included one used in Cana- dian labels, which depicts a former model who was photographed as she was dying of lung cancer (or being killed by cigarettes?). Cropped down from a larger photo that includes a nurse and hospital IV equip- ment, the image (fi g. 23) clearly portrays a young woman (young to be dying of cancer, anyway) in an angled hospital bed, her gender evident

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only from the painted fi ngernails—perhaps the fi nal gift of a friend, family member, or lover. The Canadian warning depicts consequences by naming this person and stating her age at death: “Barb Tarbox died at 42 of lung cancer caused by cigarettes.” The warning itself—“this is what dying of cancer looks like”—poses as both information and fear factor, though it could be read with a hint of sarcasm—You still want to smoke? The ad then gives encouragement (“You can quit”) and an offer (“We can help”), followed by a phone number and a website URL.

The FDA ultimately found that an image of mouth cancer (fi g. 24) better met the ability of viewers to remember and respond to it, and so chose it over the Tarbox image and several others. The studies that the FDA relied on suggest that disgust provokes more of a physiological response in individuals than does fear (though both are related and dif- fi cult to measure), accounting for the greater recall success of the mouth

figure 23. This image of the late antitobacco activist and smoker Barb Tarbox appears on Canadian cigarette boxes with the warning, “This is what dying of lung cancer looks like.” The Canadian warnings take up three-quarters of the surface of the package.

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cancer image.49 Arguably, it matters whether cancer is represented as something to be avoided because it is disgusting or because it is scary. Still, the negative affect differs from the airbrushed visual iconography of cancer hospital brochures, patient pamphlets, or pharmaceutical advertisements, which aim at encouraging affective attachment to an HMO, reducing the fear around a potential treatment, or plugging a chance of survival.

At the date of this writing, a U.S. Court of Appeals in Washington, D.C., has upheld the tobacco companies’ claim that the warnings vio- late their First Amendment right of free speech, since the warning requires them to engage in advocacy on the government’s behalf. A Cincinnati Federal Court of Appeals upheld the FDA, leading many to speculate whether the Supreme Court will hear the issue. The graphic warnings signal an ambiguity. While unwilling to take ciga- rettes off the market, even though they present many dangers and no benefi ts (the standard cost-benefi t model for other products), the gov- ernment at least aims to provoke a physiological and psychological response at the moment of purchase and consumption. The cigarette warning conveys the message, “If you smoke, a bad thing will eventu- ally happen, so choose not to buy this package.” In other words, the images imply governmental and regulatory protection against the

figure 24. In 2009, the FDA, authorized to regulate the manufacture, distribution, and marketing of tobacco products, proposed graphics intended to cover 50 percent of each cigarette package. In 2012, a Washington, D.C., federal judge and a federal appellate court both ruled that the requirement was unconstitutional, as it compelled specifi c kinds of commercial speech. In the FDA’s defense, the government claimed that the warnings offer legitimate public-health messages. At the time of writing, the Supreme Court has yet to decide whether to hear the case. (Courtesy of the FDA)

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dangers of cigarettes, even as the addictive qualities of cigarettes con- tinue to go unregulated. Something Is Being Done, the warnings seem to say. And to be sure, regulations now control such issues as where people can smoke and where and how the product can be advertised. But the physical design of the product remains in the hands of the manufacturers.50

Cigarette development, consumption, epidemiology, and litigation offer an extreme exception to environmentally caused cancers, rather than an exemplary case, despite the prominence of tobacco and ciga- rettes in many mainstream cancer histories. The product remains, now, much easier to “expose” to a mainstream audience than, say, the mili- tary or medical causes of cancer. Antitobacco advocates and govern- mental health agencies represent tobacco as the “leading cause of pre- ventable death”; however, a more accurate description would portray tobacco as the substance most easily correlated with cancer. Although the initial epidemiology making the link between smoking and lung cancer was anything but straightforward (as chapter 7 examines), the rarity of lung cancer prior to cigarettes and the solid science that has proven smoking’s addictive and carcinogenic aspects have led to an accepted causal connection. Despite the unique aspects of the smoking issue, one might well ask why the so-called leading cause of death attracts so much governmental attention (albeit an attention focused solely on product use rather than product design), while other potential causes (as outlined in the Cancer Panel Report or the chapter on IVF) attract practically none. And not only do they garner no attention, but anyone who dares consider these forms of causation risks being labeled a paranoiac. Only dorks worry about environmental toxins. After all, they’re everywhere.

In his ethnography of New Mexico, Understories, Jake Kosek cap- tures the specter of cancer as pervading the environment, hovering beyond explanations of cause. Kosek relays a conversation he had with a woman about her husband, a blue-collar worker in Los Alamos whose job required him to scrub the radiation out of worksites. After he died of cancer, she said, “He [knew] where the cancer came from—we all do—but it’s hard to admit you were wrong and it’s hard to bite the hand that has fed us for over thirty years. Besides, . . . it’s hard to know for sure.”51

Perhaps the creation of the special case, such as cigarettes, gives an impression of controllability and causality, as opposed to resigning our- selves to the fact that we all live in a general cancer universe. When

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cause seems clear, shame, fear, and the diminution of fear build a social and biological paradox of uncertainty.52

conclusion: fallout

When I see the obituary of someone who had a cancer recurrence after two decades, I panic, thinking that someone close to me will read it and, reminded of my tenuousness, not want to be my friend. I dread seeing friends and family get skinny and old-looking and bloated; I’m fright- ened of what the people who take the corpse will say as they lug it down the stairs and out the door, of what my own dead face will look like. Fear, that sticky, primal emotion, cements so many unspoken elements of the cancer conglomerate.

The advice in the New York Times article mentioned earlier in this chapter (just tell a joke and wear a wig!) turns cancer survivorship from an emotional and physical state into an ability, a private trait rather than a communal effort and responsibility. Such advice instructs the cancer survivor to position herself in a socially accept- able role as an ennobled survivor who has undergone a personal trag- edy, bravely shrugging off the failure of the state to regulate carcino- gens, to provide healthcare, to control medical costs. This self-help literature rarely addresses the material needs of survivors. Nor does it recognize a system that often ejects patients without educating them on follow-up care, the symptoms of recurrence, or even, often, the basic details and potential consequences of the treatments they have already received.53 None of the literature acknowledges another aspect of being a survivor: that feeling of sacrifi ce, of having taken the fall for all those others who now don’t have to enter life in prog- nosis. I’ve never seen a scrap of oncology literature address the “why me?” question—not the existential “why me?,” but the real, caus- ative question of why, specifi cally, me?—though most cancer patients or survivors I know speak of how excruciating it is to try and piece together an answer.

There’s nothing wrong with trying to pass, with wearing a wig so as not to be stared at. There’s nothing wrong with turning inward to one’s family in times of struggle. It’s like the bomb shelter images from the 1960s, which, as Masco describes, confer the normalcy of gender roles onto cement-walled living rooms, where mom prepares a meal while dad reads the newspaper or fi ddles with the radio, protected from the dark cloud outside (fi g. 25).54 But there may be other responses as well

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as taking comfort in the structures we know so well, especially when it isn’t clear that they serve us well.

One study found that “hospice in-patients who had witnessed the death of other hospice patients were signifi cantly less anxious and depressed than those who had not.”55 Sometimes we die in the way we

figure 25. In the popular Fallout Shelter Handbook (New York: Fawcett, 1962), Chuck West describes how to build and stock a bomb shelter. The cozy space replicates a midcentury living room, complete with an aproned housewife preparing dinner as Daddy fi nishes reading a magazine. One does not fi nd in this booklet information on the military’s role in creating cancer, even though one in ten Americans today lives near a toxic military site.

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predicted, sometimes earlier, sometimes capriciously. Dancer Isadora Duncan died when her hand-painted silk scarf tangled with the open spokes of a car in Nice. Sometimes a cancer patient dies of a stroke, and sometimes someone who would eventually have been diagnosed with cancer dies in a terrorist attack. But we will all die. And when added to all the other levels of perpetuated fear and unknowing—cultural, chem- ical, legal, emotional—denying looming death only increases the fright- ening cognitive dissonance.

As any kid on Halloween knows, even a fun wig can make things scarier.

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