Public health policies regarding hazardous waste sites and cigarette smoking: an argument by analogy.

In 1962, more than a half century after the rise in lung cancer was first detected, the United States Surgeon General convened an Advisory Committee on Smoking and Health (1). After a painstakingly critical review of the literature, the committee noted the causal relationships between smoking and several diseases such as lung cancer (in men). Also noted in the committee's report were conditions for which an association could as of then only be inferred: lung cancer in women, oral cancer, cancer of the esophagus, bladder cancer, emphysema, coronary artery disease, peptic ulcers, and low birthweight infants. A year after publication of the committee's report, Congress mandated that a health warning be placed on cigarette packages (2). Smoking rates began to fall. Over the ensuing 20 years, approximately 750,000 smoking-related deaths were avoided or postponed (3). Americans were responding to the warning. As indicated in various surveys, the American public strongly believes that toxic industrial chemicals pose a significant threat to human health (4). Communities such as Love Canal, Times Beach, and Bhopal provided well-publicized indications that past industrial practices may indeed be harmful. There may be hundreds of thousands of sites where hazardous wastes were dumped, without controls, in the past. Of concern here are the worst of these, the Superfund sites. These sites are designated by the U.S. Environmental Protection Agency (EPA) under the Superfund Act, known formally as the Comprehensive Environmental Response, Compensation, and Liability Act (CERCLA), enacted in 1980 (5). The issues Superfund and its amendments were designed to address are as follows: 1) Are there dangerous hazardous waste sites? 2) If there are dangerous hazardous waste sites, how can the risks to the surrounding communities from these sites be minimized? 3) How should the most dangerous sites be remediated (cleaned up)? 4) Who should remediate the sites? 5) Who should pay for remediation? This commentary concentrates on the first two questions. More than 30,000 hazardous waste sites have been identified under Superfund. The EPA has conducted at least preliminary assessments for most to reduce the number of sites requiring the most serious attention to slightly less than 1200. This shorter list is the National Priority List (NPL). These few sites are known to the general public as Superfund sites. In an attempt to ensure that the first question above would be addressed, Congress, in the Superfund Act, created the Agency for Toxic Substances and Disease Registry (ATSDR) within the Public Health Service. Thus the law separated the public health component concerning hazardous waste sites from the regulatory agency EPA. The 1986 Superfund Amendments and Reauthorization Act (SARA) passed in the wake of the tragedy at Bhopal, India, better defined ATSDR's role. The ATSDR must conduct public health assessments for sites on EPA's NPL, list the chemicals commonly found at sites, classify these chemicals based on hazards posed, publish summaries of the toxicological data available for each priority chemical, and investigate the effects of exposure to the toxic agents at hazardous waste sites. After 10 years of experience with Superfund, all parties involved express intense dissatisfaction. Many communities believe the cleanup process is inadequate and too slow. Industry often agrees that the process is too slow, but counters that remediation requirements and costs are excessive. Both groups argue that billions of dollars have been spent under Superfund with little effect. Independent observers agree. The U.S. Office of Technology Assessment (OTA) has noted inordinate expenditures for transaction costs involved in identifying the perpetrators at these sites (the potentially responsible parties) and negotiating with or prosecuting them to ensure that the potentially responsible parties pay. These funds otherwise could have been allocated directly to remediation (6). At this point it is worth remembering the purpose of Superfund. Do any hazardous waste sites pose a human health risk? A committee on environmental epidemiology appointed by the National Research Council (NRC) found sufficient evidence that hazardous wastes have produced serious health effects in some populations (7). More specifically, the U.S. General Accounting Office (GAO) last year evaluated ATSDR's health assessments (8). The poor quality that was found related in large part to the extreme time constraints for completion of the reports. Nevertheless, GAO noted that ATSDR had no formal plans to reevaluate past assessments and had no procedure for outside, independent review of their health assessments (8). The battle against cigarette smoking stands in stark contrast to the lack of progress in reducing the threats posed by Superfund sites. Although cigarette smoking still remains a substantial public health threat, it also can be seen as a U.S. public health success story. Today, almost half of all U.S. adults who ever smoked have quit. Because the rate of smoking has decreased, it is estimated that by the year 2000 nearly 3 million lives will have been saved (9). As obvious as the link between disease and smoking is today, additional risks associated with smoking continue to be identified. In the process of establishing the health risks of either exposure to cigarette smoke or to hazardous wastes, two primary sources of evidence are used: animal bioassays and epidemiology. Industries that benefited from uncontrolled dumping of waste insist that traditional epidemiology must be used to conclusively prove the risks of exposure before hazardous waste sites are remediated. Here we compare exposure to cigarette smoke and exposure to hazardous wastes. Through the comparison, the difficulties of obtaining such epidemiological proof in cases of exposure at Superfund sites will become more clear. For example, although the number of persons exposed involuntarily to tobacco smoke is quite large, only a few thousand persons face potential exposure at any one Superfund site. Nevertheless, the total number at possible risk from all Superfund sites exceeds 40 million (7). Difficulties of proof are compounded by the fact that exposure to either tobacco smoke or toxic waste involves exposure to complex mixtures. Considered one by one, many of the individual constituent chemicals are known to cause many adverse health effects. In addition, many of the