Brush with Death: A Social history of lead poisoning. (Reviews).

Brush with Death: A Social History of Lead Poisoning. By Christian Warren (Baltimore and London: Johns Hopkins University Press, 2000. xiv plus 362pp. $45.00).

Warren's study of lead poisoning serves as a window through which a major cultural shift in attitudes toward health, safety and risk can be viewed and analyzed. This shift "transformed medicine and health care and gave purpose and power to modern environmentalism, ... altered jurisprudence" and profoundly affected social behavior. (p.2) Throughout the book, Warren places the various conflicts and debates in a social and political context, which serves well to highlight prevailing ideology and changing cultural values. More than a social history and cultural analysis, which almost get lost in the book, however, Brush with Death serves as an excellent historical policy analysis that could serve to inform current policy makers dealing with environmental threats to health. Warren uses a plethora of varied primary and secondary sources in this well researched study. In order to establish his analytical framework, Warren utilizes three major modes of exposure: occupational, pediatric and environmental. Limited to t he twentieth century and a focus on lead-based paints and tetraethyl lead in gasoline, the study is divided into three parts. Part one (chapters 1-3) provides a general history of mankind's use of lead and its production process worldwide as well as the symptomatology, pathophysiology, long term effects and treatment of lead poisoning while also tracing the role of environmental activists and changing interests of the American medical profession. Occupational exposure is the subject of the second (chapters 4-7) while the third section is devoted to pediatric and environmental lead poisoning.

One of the major themes, implicit in the second section, is the issue of industrial control over occupational health and its clear attempts to thwart government intervention. Warren identifies the cultural factors at the turn of the century that "pushed aside long-standing traditions about accepting risks and side-stepping responsibility" (p.66), forcing industry to address the problem. Those cultural values were manifested in the demands of social scientists, muckrakers and labor organizations that pressured for legislative action and greater industrial responsibility for occupational health. The result was the development of workmen's compensation laws, ultimately placing the control of the industry in the hands of the insurance companies, thus avoiding government control. Although changing cultural values drove individuals demanding occupational health standards, it was industry's concern for economic solvency that led to self-imposed regulations. Many of the improvements in occupational safety and health were due to the growing numbers of industrial physicians. Research conducted by industrial medicine professionals, funded by the lead paint industry, provided the scientific basis for industry's claims that it could protect its own. Occupational health improved in the lead paint and leaded gas industries, but largely due to industry's controls, not external mandates.

In the last and longest section, Warren discusses pediatric and environmental lead poisoning. By the 1930s lead poisoning had become associated with poverty, but after World War II, when people began to realize that what is unseen can kill, public health professionals and community activists had become increasingly concerned about lead poisoning. By the mid-1960s lead-using industries could no longer direct research and publicity as they had in the 1930s since industry outsiders provided additional scientific studies, bringing industries' research into question. As a result, legislation passed in the 1970s that restricted lead based paint and leaded gasoline usage.

The study of lead poisoning illustrates an epidemiologic transition that shaped public health in America. In the early twentieth century emphasis was on acute and epidemic diseases with singular causes, based on the germ theory. That, as well as attitudes toward children in general, indicate that a changing paradigm of disease was crucial before environmental toxins would be recognized as a causal factor in children's illnesses. Gradually those attitudes gave way to a focus on chronic endemic health problems that are multi-causal and associated with lifestyle diseases. Indeed, a new disease paradigm did draw attention to plumbism.

The strength of this book is the historical policy analysis and the impact this could have on current policy debate over environmental pollution. Warren notes at the end of the introduction that his "study will argue that for most of the century lead poisoning, in all its guises, was silenced by design--and that since it was silenced once, it may be silenced once again." (p.12) One of the key issues in many health policy debates is the balance that must be struck between the rights of an individual or company and the benefit to the public. As the concern over lead poisoning moved from the factory to the slums to the general environment, the balance in favor of the leaded gas and lead paint manufacturing companies diminished and more attention was paid to the general population, all considered at risk. Warren argues that during the debates throughout the century, the definition of acceptable risk had to be negotiated and this negotiation was often controlled by industry, which funded the scientific research on which acceptable blood lead levels were determined. For this reason, the problem of lead poisoning could be silenced, sequestered away from public view. Early in the century occupational medicine and private workmen's compensation ensured that the problem would remain in the work place. By the 1930s, lead poisoning was seen as a problem of poverty and race and therefore vanished from public concern. By the 1960s, however, industry lost its ability to silence the epidemic resulting in greater government control to protect the public good. Interestingly, Warren concludes by noting that cooperation with industry is imperative in order to achieve desired results in protecting the public. Implicit in this study is the notion that there is clearly a balance to be struck between control and cooperation.

Warren's analysis illustrates the factors that affect the development of new policy initiatives, which include changes in cultural ideology, impact of community or political interests, and the recognition of a crisis. Clearly as more community groups took an interest in environmental lead poisoning and as it became increasingly apparent that large segments of the population were at risk, government policy regarding lead poisoning began to change. Warren places a great deal of emphasis on the impact of changing cultural ideology as American society developed more of an aversion to risk, resulting in increased government mandates to protect the population as well as changes in social behavior, the practice of medicine and law. Clearly, the impact of that changing ideology is crucial.