EDITORIAL

These are tough questions. The answers would come more easily if we could do simple univariate experiments on hapless little mice in laboratories. Nevertheless, we must go on striving to evaluate the effectiveness of public health interventions; we must seek to know, not merely to believe. Good science will facilitate effective policy. If we are to screen younger women for breast cancer, it must be because we know it will save lives, not just face. We will find it easier to answer challenging interdisciplinary research ques- tions in public health if the various disciplines collab- orate. Yet, there are some recent unwelcome signs of professional tribalism within our midst: health promoters, structural reformers, epidemiologists and public health medicine.

We also need to widen our field of vision. Profiles of health and disease have always moved in great cycles across time and between societies. So, in public health, we perennially find ourselves dealing with moving targets. In the 1970s, we had not heard of HIV, passive smoking or domestic radon exposure; today we have the rise of drug-resistant tuberculosis (and other infections caused by genetically fleet- footed microbes), of increased suicide rates in young unemployed men and of urban gun-toting violence. Beyond those ever-changing ripples on society’s sur- face are bigger, deeper changes within our over- loaded biosphere. These emergent unprecedented global disruptions have great potential impact upon the sustainability of population health. Accordingly, international agencies (including WHO), the influen- tial Intergovernmental Panel on Climate Change, and various national governments, are starting to pay attention to the potential health impact of global environmental changes.

We have spent the last ten years reshaping public health in Australia. These gains must now be consum- mated within the governmental agencies of data col- lection, advice and review. The NHMRC is at an important crossroads, and hopefully will now con- solidate its commitment to a better balance between public health science and white-coated science. The Australian Institute of Health and Welfare, its recently broadened charter allowing an inter- mingling of the social and health streams, can pro- vide researchers and policy makers with better and more systematic information. Through these agencies, environmental health monitoring-still in a rudimentary state in Australia-should also be nur- tured. However, the realisation of these potentials will require improved infrastructure; in particular it will require secure funding and professionally com- petent technical support.

In late 1993, we await the decision of the Keating Goverment about the future, continued funding of public health tertiary-level training and research pro- grams. In the meantime, as ever, there are great social tasks out there to be tackled-locally, nationally and globally.

Tony McMichael Department of Community Medicine, University ofAa!elaide [Tony McMichael leaves the University of Adelaide in January 1994 to take up the prestigious Chair of Epidemiology at the Lon- don School o f Hygiene and Tropical Medicine. He has been an inspirational force ih Australian public health and the PHA. His work o n environmental health is internationally renowned. We wish him every success in his new position. Ed.]

Lead and pollution-an overview

In this issue, ‘Living near a lead smelter’ by Galvin et al. (373) shows that deposition of lead from industrial activity results in heavily contaminated soils and dusts in the surrounding area. Only 13 per cent of soil samples in the study area fell below 150 parts per mil- lion (ppm), the background level accepted by the National Health and Medical Research Council (NHMRC) for human health (and were within range of the ‘geogenic’ level). Most soil samples exceeded 300 ppm of lead, the threshold investigation level,’ and a significant proportion exceeded 1000 ppm. Lead levels in soil were mapped as lead isolines, show- ing that the lead smelter acted as the point source from which lead was blown to the southern side and deposited onto the soil. Residential land, rec- reational land and households were heavily contami- nated, exposing people directly to lead intoxication; 84 per cent of young children tested had blood levels greater than or equal to 10 pg/dl, the level adopted by the NHMRC (June 1993) as the level for com- munity concern.

To the people in the area, this study has contrib- uted the definitive link between the contaminated soil, the point source, and the high lead-in-blood levels, a link which has been doubted and down- played in this ‘special community’. In these towns, the lead smelter was the primary economic basis of settlement, and remains central to the local economy and people’s livelihood. Although the study by the Hunter Area Health Service was precipitated by pub- lic concerns and requests from the local members of parliament, the findings were not altogether welcome.

The RMIT Study commissioned by the NHMRC differentiates between strategies for reducing lead exposure in such ‘special communities’ and in the general community.2 Within a national strategy, this report also recognises that ‘carefully co-ordinated programs specifically designed for the varying cir- cumstances of each community are essenti al...’ Nonetheless, Galvin et al. express their concern that the issue of lead in petrol has stolen the policy debate. ‘Special communities’, with past and continuing lead pollution from industrial facilities, may be over- looked in the national scheme.

Leaded petrol, however, is the single major, con- tinuing source of lead contaminating the environ- ment. Australian cities and towns still suffer heavy lead dust falls from the leaded emissions of motor vehicles. In 1988, more than 1000 tonnes of lead were emitted from motor vehicles in Sydney, expos- ing the population and ecosystems to the effects of lead contamination.Y The recent ‘urban lead studies’ consistently found high levels of lead-in-blood of children who live in places with high levels of lead in house dust and backyard The blood in half the children studied exceeded 10 pg/dl.

Prevalence surveys have had two effects: prompting people to form local lead groups, such as the Lead Education and Abatement Design Group (LEAD Group), and helping to ensure that lead exposure is recognised as a significant and prevent- able public health issue by government and the media.

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EDITORIAL

The Public Health Association adopted a policy on childhood lead exposure in 1992. In June this year, the NHMRC declared a reduction in the level of con- cern for lead in blood, supported by the RMIT study of options and impacts, from 25 pg/dl to 10 pg/dl.‘ The Council stated unequivocally that Australia lags badly in reducing lead in petrol, a point given much attention during the first Round Table on lead, con- vened by the Federal Minister for the Environment, Mrs Kelly. At the Round Table Conference, the pro- posal to introduce a levy on leaded petrol to encour- age consumers to switch away from using leaded petrol wherever possible seemed to have wide sup- port. However, the inclusion of a levy on leaded pet- rol in the Government’s budget proposal was opposed on ‘equity’ grounds and the olpposition seemed to overwhelm and obscure the fact that the great majority of pre-1986 vehicles can take either unleaded or at least mostly unleaded petrol.

Policy and regulations on lead in petrol by state governments have still not yet changed. The reduction of lead in petrol must remain the central priority of public health: the entire population is affected, the removal of this source of lead is rela- tively easy, and many people support the removal of lead in petrol.

Lead in petrol and lead from the renovation of older houses with lead-based paints are universal sources of lead exposure. These sources will eventu- ally be eliminated. But point-source communities and people working with lead are expected to continue to ‘live with lead’. As the RMIT Study illustrat(es, with a case study of the Boolaroo community living near a lead smelter, the strategies to reduce lead exposure need to address the local site conditions and local issues of financial relief for degraded property.

What do Galvin et al. propose to reduce the risk at this locality and what are the implications of their proposals for public health practice? The locality has a high lead burden from historical industrial pro- cesses, continuing industrial pollution of lead and other emissions, and the prospect of further indus- trial development adding to the pollution. Under these circumstances, the authors propose a ‘planned program of decontamination to lower existing environmental exposure levels’, better pollution con- trols, and a more stringent process for assessing and controlling further industrial development of the lead smelter. In other places and at Boolaroo, where site remediation has been piecemeal and not planned, there has been recontamination.

It is difficult to achieve a carefully coordinated program of decontamination in the face of many unresolved issues (addressed in a recent ANZECC discussion paper) including financial liability for con- taminated land and the uncertain responsibilities of different spheres of g~vernment.~

In responding to continuing pollution and the pro- posed expanded development of the smelter, the study provokes questions about the adequacy of the existing instruments-environmental impact assess- ment and conditions on the pollution licences. Were human health a mandatory Consideration in the environmental impact assessment process, would the decision to approve development be affected?‘j Would the restrictions on the amount and manner in which industrial operators pollute be different if the

process of setting licence conditions were more open and the conditions were related to the receiving ecosystem?’

Uncertainty or data limitations, the RMIT Study cautions, should not provide an excuse for delay on action to reduce lead in the environment. Importing lead into a region for industrial use poses a threat of lead contamination and serious or irreversible environmental damage. Evoking the precautionary principle here helps to shift the burden of proof to the potential polluter and to make us look to the future.

In the broader context of ecologically sustainable development,8 we can find a framework for risk reduction of lead and other toxic substances. In 199 1, the OECD prepared the way for globally coop- erative activity on risk reduction from lead (poten- tially as a forerunner to reduction of other chemical risk^).^ In such a framework, we can appreciate the OECD’s suggestion of sunset conditions on certain uses of lead (such as the phasing out of lead in paint) and restrictions on any new uses of lead.

Therefore, Australiais not alone in embarking on a national and comprehensive strategy to address all sources of lead in a bid to control and reduce lead exposure-a significant step for a large producer and processor of lead. A strategy on reducing lead exposure intersects with other strategies such as air quality and stands to reduce ecological disruption and effects on health. These relationships and the desire for greater integration of the economy, the environment and health poses further challenges to the structure of decision-making processes and how practitioners in the public interest may use these avenues for more healthy public policy.

ChloE Mason SYdW

References 1 .

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8.

ANZECC. Guidelines fin the assessment and management of con- taminated sites. 1992. Available from Commonwealth Environmental Protection Agency, Canberra. Berry M, Canard J, Greene D. Redun’ng lead exposure in Aus- tralia. Risk assessment and analysis of economic, social and environmental impacts. Final report. Known as the RMIT Study, funded by the NHMRC, Commonwealth Environ- ment Protection Agency, and Department o f Health, Hous- ing, Local Government, and Community Services, July. 1993. Castles I. Australia’s environment. Issues and f&. Cat. no. 4140.0. Canberra: Australian Bureau of Statistics, 1992. Fett MJ, Mira M, Smith JB, Brokenshire T, Alperstein G. Community prevalence survey of children’s blood lead levels and environmental contaminants in inner Sydney. MedJ Auct 1992; 157: 441-5. ANZECC. Financial liability for contaminated site remediation. A discussion paper. Canberra: Commonwealth Environment Protection Agency, 1993. Whitehouse JF. Will the pecautionaty principle affect environ- mental decision making and impact assessment? Paper presented at the Precautionary Principle Conference, Institute o f Environmental Studies, University of NSW, Sydney, 20-21 September, 1993. Farrier D, Fisher L. Reconstituting decision making pocess and structures in light of thepecautionatyprincipfe. Paper presented at the Precautionary Principle Conference, Institute of Environmental Studies, University o f NSW, Sydney, 20-21 September, 1993. McMichael AJ. Ecological disruption and human health: the next great challenge to public health [editorial]. AuctJPublic Health 16; 1 : 3-5.

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EDITORIAL

9. The development of a ‘thought starter’ for the development of an OECD Council Act on lead risk reduction is the start of such cooperative activities to reduce risk. See also OECD Cooperation on existinK chemicals: risk reduction. Lead cuuntm rep& on lead. Paper presented at 16th Joint Meeting, 28-36 May, 1991.

Is there life after Foucault? Poststructuralism and the health social sciences

The pages of the Australian’s weekly Higher Edu- cation Supplement were recently enlivened by a debate concerning the usefulness of poststructuralist theory applied to the humanities and social sciences. While the relevance of these arguments to social sci- ence health research was not made explicit, such debates have been current for the past decade in the British a m of the sociology of health and illness. In Australia, the social constructionist perspective, which emerges from a poststructuralist stance, has made slow inroads into research and teaching in the sociology and anthropology of health and illness and the history of medicine. However, in this country there has not been a vigorous evaluation of the com- peting theoretical perspectives applicable to the health social sciences.

Poststructuralism is an approach which questions claims to the existence of essential truths. It argues that all knowledges are inevitably the products of social relations and are subject to change. The approach thus calls into question claims to the auton- omy, objectivity and political neutrality of medicine and public health. It argues that changes in medical knowledge have owed as much to material, political and economic changes occurring in the wider society as to scientific ‘breakthroughs’. There has been an increasing emphasis in poststructuralist scholarship on the importance of language in constructing people’s subjectivity, or their lived experiences, self- perception and conceptions of reality. This includes the identification and examination of discourses (pat- terned systems of ideas, expressions and ways of thinking in historical and social contexts).’

The translated work of the French historian and philosopher Michel Foucault and the emergence of the second-wave feminist movement in the past two decades have been major impetuses for the growing importance of poststructuralism in the health social sciences. For Foucault and his followers, analysing the ways in which the body is viewed and constituted via medical discourses and practices, and identifying the mechanisms of power which underlie these, is central. Feminist critiques of scientific medicine and public health have attempted to highlight the pre- viously neglected dimension of gender in analysing how women are diagnosed and treated in the health care system. They argue that, commensurate with its rise to power since the eighteenth century, the institution of medicine (including its practices and discourses) has played a pivotal role in preventing women from entering the public domain.

The poststructuralist position, as applied to medi- cine, has been criticised for its extreme relativism;

that is, for its insistence that bodily experiences, dis- eases and illness symptoms do not exist as realities outside social processes. However, many contempor- ary scholars now reject that argument, instead con- tending that the ways in which such phenomena are described, experienced and treated by both medicine and the lay public are always socially mediated. For example, menopause may be viewed as a condition that has certain physical effects, such as the ceasing of menstruation, but these effects are experienced very differently by women according to historical factors, environmental or cultural background and the domi- nant discourses of menopause in the medical setting, in conversation or in mass media.

Although Foucault and his followers have been taken to task for nihilistic ‘discourse determinism’ or for reducing the agency of social actors under the power of language, most social constructionist scholars nowadays argue for the possibility of resist- ance. That is, that individuals do have the scope to step beyond the confines of dominant discourses, to oppose them actively and to construct alternative discourses.

In British sociological research in health and ill- ness, poststructuralism has been embraced with enthusiasm over the past decade, as demonstrated by the increasing proportion of articles published in Sociology of Health and Illness which have taken this approach. North American scholarship, although still dominated by positivist methods of inquiry (which rely upon experiment and observation), is becoming increasingly influenced by the inter- disciplinary approach of medical anthropologists and historians, as evidenced by such books as Biomedicine Examined‘ and recent articles in Social Science and Medicine, Social Problems, Medical Anthropology and Medical Anthropology Quarterly. By comparison, Aus- tralian scholarship in the health social sciences appears to be lagging behind these developments. However, given the long lag time common to the publication of articles in academic journals, it is inevi- table that current publications do not fully reflect the extent of progress of scholarship in a field. Recent papers from a number of conferences held in Aus- tralia attended by sociologists (for example, the Postmodern Body conference in June 1992, the Aus- tralian Sociology Association conference in Decem- ber 1992 and the Sex/Gender in Techno-Science Worlds meeting in June 1993) testify to the growing interest in applying the poststructuralist perspective to medical or public health issues.

A little over a decade ago, the Australian sociol- ogist Evan Willis published a review of research and teaching in the sociology of health and illness in Aus- tralia and New Zealand.s When Willis was writing, two major perspectives on the sociology of health and illness were taught in Australia: the functionalist per- spective, based on the work of Talcott Parsons, which focused on illness as potential deviance and the use- ful role played by the medical profession in managing such deviance; and the political economy perspec- tive, emerging from a Marxian concern with medi- cine as an institution of the capitalist state in producing and perpetuating inequalities leading to illness. In the years preceding 1982, according to Willis, most research and scholarship in the sociology

298 AUSTRALIAN JOURNAL OF PUBLIC HEALTH 1993 VOL. 17 NO. 4