The Politics of Cancer

Cancer is the plague of the 20th century: More than half a million Americans die every year of the disease.

If present trends continue, it will become the First World's leading cause of death sometime in the 21st century. The tragedy is magnified by the fact that the causes of the disease are largely known. Cancer is caused by chemicals in the air we breathe, the water we drink, and the food we eat. Cancer is caused by bad habits, bad working conditions, bad government, and bad luck, the latter including things like the luck of your genetic draw and the culture into which you're born.

Such knowledge as we have of causes, however, has done little to aid us in our search for solutions. Notwithstanding repeated and glowing pronouncements from the American Cancer Society, treatment has made little progress since Richard Nixon declared war on the disease in 1971. Five-year survival rates for lung, colon, breast, and stomach cancers remain essentially what they were 20 years ago—despite more than $22 billion spent on research by the National Cancer Institute. It is hard to deny that the war against cancer is being lost, not won.

What is going on here? How can the largest medical effort in history, with some of the world's brightest brains behind it, have proved so futile?

Part of the problem is that the question of what causes cancer is the object of a great deal of controversy. Environmentalists argue that industrial pollutants constitute a major cause of the disease; industry trade groups defend the innocence of specific substances with concepts like "acceptable risk" and "genetic susceptibility." There is controversy over the relative significance of lifestyle and occupation and over the roles of stress, personality factors, and "natural carcinogens" in things like beer, barbecue, and bruised broccoli.

Competing interest groups jostle one another to exculpate or blame a particular chemical, dietary, or lifestyle carcinogen. Tempers run high, because much is at stake. Environmental groups depend to a certain extent on public fears to solicit funds; manufacturers stand much to gain or lose from whether and to what extent dioxin, vinyl chloride, or pesticide residues are judged public health hazards. Even "industry interests," though, are not what they used to be. Billion-dollar industries have sprung up to "abate" or "remediate" environmental hazards such as asbestos, radon, or lead. The net result is that experts commonly disagree about what is a hazard and what is a risk. Even when experts do agree, opinions often differ about what is to be done, when and where, by and for whom, to what end, and at what cost.

Tracing the origins and outcomes of these controversies is a major goal of my current research, but I also want to say something about the nature of modern science—about what I call the "political philosophy of science."

Why, for example, do we know what we know, and why don't we know what we don't know? Historians and philosophers of science have tended to treat ignorance as an ever-expanding vacuum into which knowledge is sucked. Ignorance, though, is more complex than this. The persistence of controversy is often not a natural consequence of imperfect knowledge, but one of the political consequences of conflicting interests. Controversy can be engineered; ignorance can be manufactured, maintained and disseminated.

Scientists often speak royally about how "we" know this or that—but who is that we and why does it know what it knows? Trade associations, I have found, often make it their business to exploit, disseminate, and, if need be, produce uncertainty about environmental carcinogens. (As one tobacco company put it: "Doubt is our product.") But support even of good science may assist an industry in deflecting attention from the hazards of its product—as when the Tobacco Institute promotes genetic research. (I call this the "smokescreen effect"—the effort to jam the scientific airwaves with true but trivial work.)

This production and management of uncertainty has important consequences for public perceptions of science. It has facilitated what might be called the "McNeil-Lehrerization of science": the media display of equal and opposing views on apparently settled questions, generating the sense that endlessly "more research" is needed to resolve guilt or innocence in questions of carcinogenesis. Philosophers of science have not yet paid sufficient attention to this use of science as an instrument of public relations. Science has a face, a house, and a price: It is important to ask who is doing science, in what institutional context, and at what cost. Understanding such things can give us insight into why scientific tools are sharp for certain kinds of problems and dull for others.

It might also help us see why the war against cancer is going so badly. Ignorance is surely one of the most prominent features of our knowledge about cancer. This ignorance is not just a natural consequence of the ever-shifting boundary between the known and the unknown, but a political consequence of decisions concerning how to approach or neglect what could or should be done to eliminate the disease. This ignorance is socially constructed by failures to fund, by the presence or absence of interested parties, by outright censorship, and by efforts to jam the scientific airwaves. Science, public policy, and public opinion are all affected.

Robert N. Proctor, Ph.D., is associate professor of history in the College of the Liberal Arts, 1012 Oswald Tower, University Park, PA 16802; 814-863-7303. This essay was condensed from a seminar presented at the Davis Center, Princeton University, January 8, 1993, while Proctor was a Davis Fellow; it derives from his forthcoming book on the politics of cancer. Proctor's work is funded by the National Institutes of Health's National Center for Human Genome Research.

Last Updated June 01, 1993