by Dan Fagin
Practically every long-term employee knew someone who had died of cancer. “It would just be people you knew from around the plant. There were a lot of them, and not all of them were listed as dying from cancer,” Talty explained. Everyone had his or her own theory about where the clusters were: George Woolley was convinced that there were an unusual number of cancer cases in Building 108, where epichlorohydrin and another carcinogen, ethylene oxide, were used. Talty worried about North Dyes, where benzidine derivatives were used to make azo dyes, which were now the most important products made in Toms River. And everyone had heard about young Randy Lynnworth, the teenager who lived just outside the factory fence on Cardinal Drive and was still struggling with brain cancer in 1985. Company officials continued to deny that chemical exposures at the plant were causing cancer, but relatives of several dead workers had won large workers’ compensation awards on the grounds that the cancers were work-related.1
The factory was a maelstrom of conflicting anxieties, and as the head of the union safety committee, George Woolley was caught in the middle. Many Ciba-Geigy workers were very worried that they were risking their health yet were terrified that the negative publicity over the company’s pollution problems could cost them their jobs by forcing the closure of the waste pipeline and the factory. “Everyone was under so much stress because of everything that was going on,” Woolley recalled. “We were being put through the wringer, and it was a terrible, terrible experience. We were doing everything we could to fight to keep the plant open despite all of the bad press, but we also knew there were too many cancers at the plant and that no one had studied that.” Now the union had to choose. Should it push the company to conduct a cancer study, even at the risk of further spooking the workforce and providing more grist for damaging news stories? Or should it downplay the health risks and focus on trying to keep the plant open? For self-taught environmental health enthusiast George Woolley, a hometown guy who loved his job but did not fully trust his employer, it was a difficult choice.
Indecision was not one of Wilhelm Hueper’s problems. His 1937 dismissal from the DuPont Corporation—the second time in five years that DuPont had fired him for insubordination—might have been cause for introspection. Perhaps the world of industrial health research, increasingly dominated as it was by scientists in the pay of manufacturers, was not a natural fit for someone so bullheaded. But Hueper was not one for self-analysis. He had been trained in a very different tradition, one epitomized by legendarily cantankerous Teutonic physicians such as Rudolf Virchow and even the ancient Paracelsus. These very confident men were clinicians first: Their emphatically expressed conclusions about the causes of illness were based on the firm bedrock of their own hands-on examinations of sick patients. In the parlance of epidemiology, they were “case series” investigators. Hueper’s experimental triumph in inducing bladder tumors in BNA-exposed dogs merely confirmed what he already believed from examining workers, touring factories, and reading old case reports from factory physicians in Europe. Hueper had already been sure that dye chemicals caused bladder cancer; now he had proof.
But science was changing, and Hueper’s forceful views about what constituted proof were becoming increasingly unfashionable among cancer researchers.2 With the coming of World War II, manufacturers like DuPont were seen as crucial national security assets. Inevitably, health concerns took a backseat in the drive to ramp up wartime production of plastics, steel, and insecticides. There were scientific reasons, too, why Hueper’s ideas were increasingly out of the mainstream. The “numerical medicine” pioneered by Pierre Louis and Siméon Poisson a century earlier had come into full flower with the development of biostatistics as a legitimate academic discipline. The new biostatisticians were not only interested in tracking infectious disease, they also took the first steps to measure the extent of chronic diseases—especially various forms of cancer—across broad populations. What they learned was that cancer was increasing and seemed to be everywhere, including in many people who had never set foot in a factory or a mine. The official statistics for England and Wales showed a quadrupling of the cancer rate among men over age forty-five between 1860 and 1939 and a near doubling among women.3
Especially disturbing was the huge increase in lung cancer. Predictably, it was noticed first by the Germans, with their long history of effective public health surveillance. In the late 1930s, research at the University of Jena implicated tobacco use as the overwhelming cause of lung tumors. The strongest evidence came via one of the first true case-control studies, in which a German researcher named Franz Müller compared the smoking habits of lung cancer victims to those of healthy people or those with other kinds of cancer.4 It sounds bizarre in retrospect, in light of the participation of many German physicians in Nazi atrocities during the war, but their counterparts in Britain and the United States made pilgrimages to Jena and other German cities in the years before World War II to learn about the Third Reich’s vigorous efforts to curb smoking and promote public health among ethnic Germans—campaigns that had no analogue in the tobacco-loving democracies.5
One of those visitors from abroad was a young English medical student who would go on to have a towering influence on scientific attitudes toward pollution and cancer in Toms River and throughout the world. Richard Doll ended his week’s stay in Frankfurt in 1936 impressed with the quality of German science but disturbed by the anti-Semitism he encountered in professors and students alike.6 Doll had a good head for numbers; he was in medical school only because he had drunk three pints of ale on the night before an entrance exam and had thus failed to qualify for a scholarship to study mathematics at Cambridge. Despite his fascination with statistics, Doll wanted to be a brain surgeon, though his plans changed with the outbreak of World War II. He spent most of the war working in army hospitals and aboard ships. By the time the fighting ended, Doll had no interest in going back to school for seven years to become a surgeon.
What interested Doll instead was the growing movement, spurred in England by the creation of the National Health Service, to take chronic-disease epidemiology out of the factories and mines—Wilhelm Hueper’s domains—and apply it to the whole of society. In Britain, the first target of this new effort was the mysterious leap in lung cancer cases. In 1947, the country’s leading statistical epidemiologist, Austin Bradford Hill, was asked by a government committee to devise an epidemiological study on an unprecedented scale, involving many hundreds of hospital patients. Hill chose Richard Doll as his collaborator. Doll knew of the work Müller had done in Nazi Germany before the war identifying smoking as the key cause of lung cancer but thought that the studies were too small to be convincing. He hoped to reach a much more definitive conclusion.
The series of studies that Doll and Hill undertook would become the most celebrated pieces of research in the history of epidemiology, rivaled only by John Snow’s work on cholera almost a century earlier. They would also marginalize the workplace-centered research of rivals like Hueper and cast serious doubt on the usefulness of investigating cancer clusters like the one in Toms River. Doll’s studies, first with Hill and later with Richard Peto, not only established that smoking and other “lifestyle” habits were major risks for lung cancer and heart disease, they also enshrined two relatively new forms of research—the case-control study and the prospective cohort—as the new gold standard for epidemiology. Everything else, including the “case series” studies and animal tests that had been important for so long, were now seen as suspect.
By virtue of their design, the smoking studies could withstand skeptical analysis in ways that Hueper’s case-by-case reports on his examinations of DuPont dye workers, as well as his experiments on dogs, could not. Doll and Hill’s first major lung cancer study, published in 1950, adopted the case-control format that had been employed only sparingly in the past, and never on such a large scale. Seven hundred and nine confirmed lung cancer patients from twenty London hospitals were included, and their habits were compared to a
n equal number of patients hospitalized for other reasons. The non-cancer control group was selected to match the cases in age, wealth, male-to-female ratio, and area of residence. Most of the participants smoked, but Doll and Hill discovered that those with lung cancer were twice as likely to smoke more than twenty-five cigarettes a day. The cancer/smoking connection was especially strong among men: Just two of the 647 male lung cancer patients did not smoke, compared to twenty-seven of an equal number of cancer-free men.7
It was a convincing result, bolstered by a similar study published four months earlier in America.8 (Doll was chagrined—he wanted to be first.) But the research was not entirely bulletproof because it depended on the patients’ uncertain recollections of their smoking history. Moreover, there was a possibility that Doll and Hill had overlooked some other possible cause. So they planned a second study, a prospective cohort, in which they would follow a very large population over many years, periodically quizzing them about their habits and waiting to see how many got lung cancer. Because they wanted to find a group they could count on to stick with such a long-running study, Doll and Hill chose physicians—forty thousand of them. Doll would ultimately follow the group for decades, obtaining results that were similar to the earlier case-control study but less vulnerable to challenge by the tobacco industry. Unlike the case-control study, the cohort results did not depend on participants remembering their past smoking habits, and with such a large group it was easier to be confident that smoking really was the most important factor determining a person’s lifetime risk of developing lung cancer.
Wilhelm Hueper watched with alarm as Doll’s “risk factor” studies soaked up acclaim that his own work had never received. In 1942, soon after his second firing from DuPont, he had committed his vast knowledge to paper, producing a massive tome—its 896 pages included citations to almost four thousand studies. Called Occupational Tumors and Allied Diseases, it is still considered a classic in the field. The book was so highly regarded that in 1948 the National Cancer Institute hired Hueper as the director of its new environmental cancer section. Even from this exalted perch, however, he had little influence, especially after the worldwide sensation of Doll’s smoking studies. Hueper was an outspoken skeptic of what he dismissively called “the cigarette theory,” questioning how an “ill-documented, simple, unitarian theory” could be a major cause of conditions as pervasive and diverse as lung cancer and heart disease.9 His objections ran much deeper than a mere scientific dispute over the strength of the evidence. Ever since Rudolf Virchow had manned the Berlin barricades in the failed revolution of 1848, German public health investigators had identified strongly with the laboring classes. They saw themselves as fighting for safer conditions and fair recompense for the human casualties of industrial production. Many of those workers smoked, drank, and ate poorly, so the new emphasis on “lifestyle factors” as causes of chronic disease would not only draw scarce research dollars away from workplace studies, it would also, Hueper feared, allow companies to avoid taking responsibility for conditions in their factories by shifting blame to the bad habits of their employees.
Hueper was completely wrong to minimize tobacco’s importance as a health risk. Cigarettes turned out to be at least as damaging as Doll and Hill had asserted in the early 1950s. Their work helped save millions of lives, including many of Hueper’s beloved blue-collar laborers who gave up the destructive habit of smoking. Doll eventually became so convinced of the importance of cigarettes as carcinogens that he would argue that smoking caused 30 percent of all cancer deaths. Workplace chemical exposures, he boldly asserted, were responsible for only 4 percent and pollution just 2 percent.10 Doll’s critics attacked this claim, questioning his data and his motives: In the years just before his 2005 death, Doll, a former socialist, served as a paid consultant and expert witness for manufacturers of pesticides, industrial chemicals, and asbestos.
Despite his errors about tobacco, Hueper was right about the chilling effect that “lifestyle factor” research would have on the identification and mitigation of chemical hazards in the workplace and in neighborhoods like Toms River as well. Beginning in the mid-1950s, medical journals began publishing fewer case reports and more case-control studies. Instead of physicians reporting on their examinations of a few dozen patients and describing perceived patterns of illness, the authors of these new studies were often biostatisticians who had never actually examined a patient but instead relied on paper records from thousands of cases.11 Hands-on physicians, who had dominated the search for cancer’s causes since the days of Paracelsus and Bernardino Ramazzini, were rapidly losing influence. Young doctors increasingly looked to large epidemiological studies for information about what was making their patients sick, instead of emulating Ramazzini and drawing their own conclusions based on what they saw and heard from patients.
In Toms River, this attitudinal shift ensured that people like George Woolley and Linda Gillick would be met with skepticism, and even condescension, when they started asking questions about all of the cancer cases they noticed. Richard Doll’s smoking studies were more reliable than the old case series studies because their use of matched control groups made it easier to exclude alternative potential causes. But there was an important caveat: To reduce the confounding role of chance, the study populations needed to be large—much larger than a single factory or town, ideally. That was especially true if the disease being studied was rare. Otherwise, no one could be sure whether a detected association between a risk factor and a disease was real or merely coincidental.
Researchers responded predictably to Doll’s triumphs. They gravitated toward very large studies involving thousands of people and relatively common diseases. That was very bad news indeed for proponents of factory-based health studies. Even at a huge plant such as DuPont’s Chambers Works, only a few hundred workers were likely to be directly exposed to a particular suspect chemical, and that chemical might be used in only a few other places anywhere in the world. With such a small population to study, a difference of just one or two cases of a rare disease could drastically alter the results—and could easily be dismissed as nothing more than luck. For industrial workers, who had long benefited from case series reports, the rise of the new epidemiology was unwelcome in two ways: Those old case reports were now dismissed as unsubstantiated, and the new, more credible case-control and cohort studies were rarely attempted in factories—or in small residential communities like Toms River.
Wilhelm Hueper recognized the trend and railed against it, but as the years passed, fewer people listened. It was at least partly his own fault. He was as combative as ever at the National Cancer Institute—his boss once said Hueper was “usually right about what he said and what he did, but the way he was right was wrong. He had an uncanny facility for abrasiveness.”12 His past clashes with DuPont continued to plague him; he would later assert that DuPont officials had accused him, at various times, of being a secret Nazi and of having “communistic tendencies”—an interesting juxtaposition of ideological extremes.13 Hueper eventually made so many enemies that his supervisors at the cancer institute told him that he could no longer do factory studies. He responded by speaking out more than ever. At the request of Rachel Carson, Hueper vetted portions of Silent Spring before her profoundly influential book was published in 1962; Carson cited his research approvingly in the text. He retired five years later and died in 1979, at age eighty-five, after venting his spleen in an intricately detailed autobiography few people have ever read. He called it Adventures of a Physician in Occupational Cancer: A Medical Cassandra’s Tale. It was never published, and it exists in manuscript form only at the National Library of Medicine in Bethesda, Maryland, not far from the cancer institute.
Like Cassandra, the mythological prophetess who foretold the fall of Troy but was ignored by her father the king, Wilhelm Hueper lived to see his own unhappy prophecies fulfilled, including his prediction that research into cancer’s causes would come to be dominated by studies of li
festyle choices like smoking and nutrition, with relatively little attention paid to involuntary chemical exposures like the ones in Toms River. Just like dismal Cassandra, Hueper was powerless to stop it.
Case series reports were already falling out of fashion when a forty-five-year-old man walked into Dr. Arthur Wendel’s Cincinnati office in January of 1958 complaining of blood in his urine. The man worked on the factory floor of the Swiss-owned Cincinnati Chemical Works, and no one—doctor, patient, or employer—was surprised that he had ended up in the care of one of the city’s busiest urologists. The men who worked at the Cincinnati Chemical Works often complained of trouble urinating, and if their symptoms persisted the company sent them to Wendel for a more thorough examination.14
Wendel met his new patient and took his history, learning that the man had worked at the factory for eight years and that one of his principal jobs was shoveling benzidine into kettles. Wendel then did what he always did in such cases: He performed a cystoscopy, an uncomfortable procedure in which a thin tube equipped with lenses is inserted into the urethra. Looking through the lens, Wendel discovered a cancerous tumor in the man’s bladder. It was the fourth case of bladder cancer Wendel had diagnosed in a Cincinnati Chemical Works employee over the previous twelve months, and he was sure it was not a coincidence. “He was seeing a disproportionate number of patients from the chemical industry, and he picked up on that,” recalled his son Richard, who was also a urologist and later joined his father’s medical practice. The four affected workers not only worked for the same company, they also worked in the same building and performed similar jobs, handling benzidine.15