[This take was duplicated from a 3/4 inch U-Matic original by Colorlab for the National Library of Medicine, March 2005, NLM call number HF 5029]

[HMD Black History Month Lecture, LHC Auditorium, February 23, 2005]

Opening Speaker: -- and welcome to today's program, as we pause to celebrate African-American history, a time when we pause to celebrate the contributions that African-Americans have made to our society, and the ongoing effort in which African-Americans work to create a diversity within this country.

One of the things that we love is that we pause to celebrate all of the groups of the country, and thus, today is the day that we do pause to for that. I will now bring forth Dr. Elizabeth Fee, who will introduce our speaker.

Dr. Fee: I'm happy to have the honor to introduce Dr. Keith Wailoo, and he is Professor of the Department of History at Rutgers University, New Brunswick. He is also Professor at the Institute for Health, Health Care Policy, and Aging Research.

He has a B.A., interestingly, in Chemical Engineering. His M.A. and Ph.D. are in the History and Sociology of Science from the University of Pennsylvania.

Keith Wailoo is very well known to everybody who is interested in the history of medicine.

He has several books, his first book was called "Drawing Blood: Technology and Disease Identity in 20th Century America." This won the 1996 Arthur Viseltear award from the American Public Health Association.ar award from the American Public Health Association.

His next book was "Dying in the City of the Blues: Sickle Cell Anemia and the Politics of Race and Health."

And that book garnered many awards, from the Lillian Smith Book Award, Susan Glascoff Humanities Book Prize, American Political Science Association Book Award, and Honor Book from the New Jersey Council for the Humanities.

Keith is now working on two more books.

One of them is tentatively called, "The Troubled Dream of Genetic Medicine: Breakthrough Medicine, Symbolic Ethnicity and the Changing Fortunes of Tay Sachs, Cystic Fibrosis, and Sickle Cell Disease," under contract with Johns Hopkins University Press.ohns Hopkins University Press.

And the other one, more related to our talk today, "How Cancer Crossed the Color Line: The Strange Career of Race and Disease in Modern America."

How Cancer Crossed the Color Line: Race and Disease in 20th Century America.

It is a great pleasure and a privilege to have a chance to hear Keith Wailoo talk to us in honor of African-American History Month.

[Applause]

Dr. Wailoo: Well thank you, Dr. Fee, for the introduction, thanks to the History of Medicine Division and the National Library of Medicine for the invitation, and thank you all for coming out.

I hear snow is on its way, and that often means, in D.C., that you have to get home early, so I appreciate the fact that you're here.

As Dr. Fee said, this is a talk that anticipates a forthcoming book, and what I would like to do is just to spend some time talking about the themes of the book. I'll try to be fairly quick so that we can get to your comments, your criticisms, your questions, and hopefully some answers from me.

Now, a lot of what we know about race and cancer comes from reports like these in the newspapers. This is an article from the New York Times in late 2002.

And articles like these are one among many that turned our public attention to the apparently new problem, in 2002, of prostate cancer and race.

Now, in earlier eras, speaking as a historian now, there was not a great deal of attention paid to prostate cancer or men's cancers, let alone this intersection between prostate cancer and race, or African-American men.

So the findings in articles like this highlight something that's really regarded as new and quite striking, points to strikingly high mortality among middle-aged black men, more so than their white counterparts for several diseases, not just cancer, but also diabetes and heart disease.

The image suggests that black men lead dangerous lives into their middle years. We're told that the high prevalence of prostate cancer in African-American men, apparently, is linked to high levels, perhaps, of prostate-specific antigen, known as PSA, in the blood, a newly discovered antigen, which was discovered in the 1990s, and linked to prostate disease and prostate cancer.

And along with this, there's a great deal of speculation, and sometimes what I find interesting about the newspaper stories and the scientific literature is there's often wild speculation about why this might be the case.

Is this a new phenomenon? Is this an old phenomenon that we're just recently discovering?

What is it and what accounts for these particular tragic trends in our society? To explain these high mortality figures, these kinds of articles often turn not only to PSA or the biological differences, purportedly, between blacks and whites, but to questions of things like trust and distrust.

So, for instance, some of the quotes that are buried in this article from 2002 point to this question, suggesting that, "distrust in the system and difficulties in communication are pervasive."

One of the experts quoted in the article, Ellis Cose, a Newsweek columnist notes, "Men, overall, have a particular set of pressures to show strength and not reveal weakness, and this feeling is intensified," he asserts, "in black men."

A lot of the discussion, therefore, to account for these differences, often focuses on these questions of gender and also these questions of culture.

What is it, this article seemed to suggest, about black men that provoke them or don't provoke them to go to doctors when they experience some internal trauma, when they're worried about their ill health, and could this explain the higher mortality rate in black men as opposed to white men?

This is sort of one of the subthemes of this article, in fact, one of the other experts quoted in the article notes, "There is an ethic of toughness among black men," said the president of the National Black Men's Health Network, and he called this trait  "pathological stoicism."e called this trait  "pathological stoicism."

So this is just an example of how a lot of the discussion surrounding or trying to explain these disparities in health experience often point to culture, our cultural difference as an impediment to seeking medical attention early and resolving health crises early, and somehow are seen to explain these disparities in health.

Now, of course, this is part of a larger set of discussions, prostate cancer is only one example of the ways in which ethnicity is linked to cancer.

The same article goes on to point out that men at high risk are those who have family histories of prostate cancer, and it also points out that it's precisely these men who are distrustful who are also the ones at highest risk of anyone in the world for prostate cancer.

It goes on to point out that, "men of European descent have intermediate risk and men of Asian descent have very low risk."

And, as I said, there's a lot of speculation out there as to why this link exists between a particular ethnic group and a particular form of cancer.

And if you scan the literature, not just the popular literature, but also the scientific literature, there's a wide range of speculation.

Is it genetics? Is it differences in behavior, perhaps? In diet? Perhaps in sexual activity?

Perhaps in environmental exposure to carcinogens? For instance, in 1988, one author suggests that, "the occurrence of prostate cancer in blacks may be related to heightened sexual activity or to venereal disease."

So what I want to suggest is that there's a wide range of speculation. Now, my goal today is not to talk specifically about prostate-specific antigen, or even prostate cancer, or to talk about machismo or fatalism or the biology of prostate disease, but to sort of put these discussions into some historical perspective.

One might suppose that, starting this from here, you might go back and say, "Well, let me write the history of distrust and fatalism among African-Americans or other groups, towards the health-care system."

But really, what I decided to do in this book is to write it a little differently, and to think about the study of race and cancer as really part of the study of the history of trust.

Who the cancer message has been sold to over the course of the last twenty years, what are the cultural messages associated with cancer awareness over the course of the twentieth century, and how have changing ideas about cancer intersected with ideas about group vulnerability across the century?

So the goal of the book is to view these recent developments as part of a long history of medicine, science, and technology, but also as a part of history of ideologies about race, ethnicity, gender: men are tough and don't like to express their weaknesses or their concerns about their health; women do.

Where do these ideas come from and how are they part of this history of cancer? It's also an attempt to put cancer into a broader context by understanding the implicit role that race has played in people's thinking about cancer throughout the twentieth century.

And so this book takes me into discussions about the meaning of black vulnerability, the meaning of white vulnerability, and what race is all about, what are you trying to communicate through these racial ideologies.

So against this recent backdrop of looking at newspaper articles and seeing a widespread discussion about African-American men and prostate cancer, it might seem strange, indeed, to us, that in the early 20th century, indeed for much of the first half of the century and into the 1960s, cancer was regarded as a white disease.

A disease in quote, civilized, unquote, rather than in primitive, quote-unquote, societies, habits. and cultures. And only recently, in the 1970s, did Americans begin to speak of discovering, quote, an alarming increase in cancer in black Americans.

And then, in the 1970s, you had experts like LaSalle Leffall, Howard University surgeon, and other epidemiologists or physicians looking back at the 1950s and marking the fifties as a time when cancer, without anybody really noticing it, crossed the color line, that is, a time period in which mortality rates for African-Americans began to surpass mortality rates for whites, or so the argument ran, in the 1970s.

And only later, really, did the rise of prostate cancer command any new attention, so such that by the end of the 20th century, Harold Freeman, another surgeon at Harlem Hospital, in the New England Journal of Medicine, could write, "Black Americans have a higher overall incidence of cancer and a higher rate of death from cancer than any other racial or ethnic group."

Now, this history that I'm trying to write poses some questions. Did the burden of cancer really shift dramatically over the course of the century, crossing the color line, and, if so, how, and when, and why?

And insofar as people commented on this kind of movement of a disease over the course of the 20th century, whether they were physicians, or journalists, or scientists, epidemiologists or patients, or even popular authors, what did they think was happening?

What did they imagine to be going on in society that was provoking this transformation? That's what my book ends up being about, is, as people witnessed and observed this so-called transformation, what did they think was happening?

How did they explain it?

Did prostate cancer, for example, suddenly rise in the 1970s? Was it a byproduct of, let's say, the aging of the post-World War II American male population, prostate cancer being more common in elderly men, for example?

Or was this transformation also connected with heightened social, cultural, and political awareness of prostate cancer, for instance, men's diseases as opposed to women's diseases.

It's not a coincidence, for instance, that the national prostate cancer awareness group is called Us Too, because it follows on the creation and the widespread awareness of breast cancer, as a popularly important cancer of women.

So is this what explains the increasing attention to prostate cancer in the post-1970s period? In other words, to study cancer, you can begin to see it as a microcosm of changing ideas, changing cultural values, and changing politics.

And what role did things like medical science, like diagnostic innovations, whether it's the Pap smear in the 1950s and earlier decades or the PSA tests in the 1990s, what role do new diagnostic tests play in making diseases more visible than they had been previously?

And therefore shaping these kinds of debates.

Now it's clear today, as it was 100 years ago, that cancer's transformation was a problem that was intimately linked to problems in American culture and society and that's really what I'm trying to look at, in this book.

One final introductory comment, this history gives us insight into a variety of other issues like changing ideas about group identity and vulnerability.

Now, to kind of go back to the beginning of my story, if you look at a mortality chart from the early 1930s which attempts to explain who has cancer and who's dying from cancer in America, this is the kind of chart that you would find. And, if you just look at it, by the numbers alone, in the 1920s, it's clear that cancer was much more of a problem per capita for whites than for coloreds.

Now the terminology is very important in studying this as a historical evidence, but the numbers speak in some ways for themselves. It was, as Frederick Hoffman said, who was an insurance statistician at Prudential Life...I always get him and Dublin mixed up, Dublin's at Metlife, he's at Prudential--

"Without exception, the general cancer mortality is higher for the white population than the Negro," he said, and this is sort of a truism for the first half of the 20th century.

Before we read this table as irrefutable evidence, it's important to note several things about it. First, the data in this case was drawn from what are called the registration states, that is, a handful of states where cancer and mortality data was collected.

Not all of the U.S. states, just a few of them. None of these -- well it changes from time to time, but over the course of the twenties, more and more southern states started being represented as registration states, but early in the twenties, very few.

So really what you have is different data samples, which are not necessarily comparable to one another, over the course of the 1920s. And, of course, most African-Americans, 80 percent of the African-American population were still southern residents and still largely rural.

So, to the extent that the registration states were more northern and western than southern, which they certainly were in the 1920s, the data would really not represent an African-American cancer experience.

Secondly, the gathering of cancer mortality data was complicated by the reluctance of physicians to diagnose cancer as a cause of death, for fear of offending the families of the deceased.

It's an extraordinary taint, a powerful sense of disgust and revulsion surrounding the cancer diagnosis, which more or less amounted to a death sentence.  And that's partly because cancer was diagnosed at its much more advanced stages, so what you're dealing with is sort of an awful and a horrible experience both for the sufferer of the disease and for the family.

Third, as I said, the cancer at issue, therefore, in this table, is very, very different from the thing we call cancer today.

Cancer was visualized, as I said, at the very late stages, and therefore, when death was near, because the diagnostic tools, even when they existed, like biopsy, analysis of large tissue specimens, even when they were available, they were not able to distinguish a wide range of internal cancers.

So the kinds of cancers that are represented here are the cancers that are externally visible that lead to death. There's a wide range of internal cancers, whether they're stomach cancers, or colo-rectal cancers, which may never, ever be diagnosed, even after the patient has long died.

Internal complaints of pain followed by hemorrhage just end up being diagnosed as some other internal disease, rather than cancer. Now, one of the factors, this is a very important observation, because this had the effect of making, people would point out subsequently, women's cancers more visible than men's cancers.

That is, cancers of the breast and the uterus, where you have external lesions that manifest themselves outwardly, or bleeding from the uterus, manifesting itself outwardly became much more easy to diagnose and visualize, even in its early stages, than a lot of cancers that killed men.

So, when you read these numbers, you have to read them with this historical view in mind. That, what you're talking about in the 1920s is quite strikingly different from what we talk about today.

There's one other thing to note, and it's kind of obvious for most of you, which is the categories are also different: whites and colored. Now, they meant something like what we mean today, but not necessarily. For instance, white did not often include a variety of darker-skinned, recent immigrant groups:  Jews, Italians, and so on, groups that would unquestionably be classified as white today.

Now, it's clear that these groups didn't evolve biologically into becoming white over the course of the 20th century, what changed is the conventions by which we categorize people so that the numbers for whites represent a particular subclass,

a particular class of what were called whites in the 1920s, and similarly, the term "colored," which we no longer use, you might say overlapped more neatly with the idea of African-American or black that we use today, but not necessarily, and this is also something that I'm struggling with as I try to understand what this data actually tells us.

So these are rather significant caveats, you can't really read this and say, "Oh, whites were really dying from cancer and black people were dying from less cancer."

This table is not the end of the story, in fact, it's the beginning of the story. And what's more, there's a kind of incommensurability between the kind of evidence that's described here and the sort of observations, the way we gather evidence today.

To most observers in the 1920s, however, you look at these numbers and these numbers speak the truth.

And what do they say?

The numbers, for most people looking at them in the twenties said that unquestionably, cancer was a white disease, and rising, as well. You can just look at the rates going up;

86 per 100,000 in 1920 to 105 per 100,000.

They're going up, as well, for coloreds. In fact, a few observers, even in the 1920s here and there, might point out that these numbers can tell a lot of different stories. For instance, that colored people, they might say, "Well, African-Americans, or 'colored people,' have higher mortality rates in this time period from infectious diseases like TB, higher child-mortality rates."

Simply put, some argued that well, blacks were not living long enough to reach the cancer age, si the numbers really aren't telling you...and age adjustment wasn't really a common practice in this time period, in fact, it's not a practice at all.

So a few observers would also point out something else, if you're a quick study of numbers, that the rates were actually rising faster for the colored population than they were for the white population, even over the course of the 1920s.

So what I want to suggest is that these numbers tell a number of different and fascinating stories, but the truism of the time is at the bottom of the slide, cancer is a disease for the white population to be anxious about.

And this is captured, also, in newspaper stories from the time period, some of them quite humorous, like, "Tallest Humans are Cancer's Victims:  A Swiss Specialist Tells British Conference That the Nordic Race Leads Disease Sufferers."

Articles like this are widespread, both from the New York Times.

In novels, this is sort of a truism that's widely, widely generated.

And a few quotations from the literature of the time gives us a much more intimate feel for how experts thought about cancer in relationship  to ethnic and gender identity.

I read novels, and these studies, and medical writings and popular writings, and cancer awareness posters and messages, and I think one of the observations that I come away with is this portrait of cancer as a cruel paradox of Anglo-American modernity, that is, to become a modern Anglo-American is to confront cancer for the first time, or at least that's the portrait that you get from these quotations.

For instance, Alita Evans, in a book called "The Psychological Study of Cancer," in 1926, writes, "Cancer is a symbol, as most illness is, of something going wrong in the patient's life, a warning to him to take another road...

In women it is most frequently the maternal organs, as though there had been in the patient an unsatisfied maternity."

Another author, in a popular medical journal, writes, "Childbearing... entails a tremendous strain on organs and tissues...these organs should be guarded as much as possible from injury... a woman owes it to herself and to her family."

Another author in the thirties writes, "There is something about the nonfunctioning of the mammary glands which predisposes them to becoming cancerous."

And then Evans again, in 1926, "In the lives of primitives," by contrast, she argues,"there is no symbolism."

One of Evans's arguments was that there's a kind of internal repressed modern woman who was really not in touch with her feeling, and part of being civilized was eating differently, eating more refined diets, having fewer children, and it was this modernity, this idea of women who were not breastfeeding as much as people do in primitive societies, this is what was bringing cancer on, this was very much the ideology of the time.

So, she writes, "In primitive culture, there is no symbolism... but we, born in the collective unconscious as we all are, they never leave it, while we are supposed to educate ourselves out of it."

So her idea was women needed to understand what their modern condition was, because this modern condition was in part bringing cancer into existence, into a larger part in their lives.

So you also see that one of the motifs of this time is "underutilized mammary glands," underutilized organs, maternity unsatisfied, these are the things that explain where cancer emerges. To fight cancer, our author suggested, the importance was placed on education, self-education, self-control, and self-surveillance.

Now, by contrast, just a kind of striking contrast, is the writing of a cancer surgeon, Willy Meyer, a New York cancer surgeon, in his book, "Cancer: Its Origins, Its Development, and Its Self-Perpetuation."

And here he's trying to explain why so-called primitive people don't have high rates of cancer. Now, in retrospect, as I said, we might argue that people in underdeveloped nations of the early 20th century, the higher mortality rate in infectious disease and the lower life expectancy would naturally mean that there were lower rates of cancer, but Willy Meyer saw things differently.

He argued that, "Primitive people... in the familiar character of their restful unchanging surroundings, would almost seem to be on a par with the fish of the ocean, the life of which is spent in placid indifference in the never-changing salt solution and its always equal temperature.

Prolonged worry is almost unknown among them... [they are absent] of nervous and psychic strain... which is the bane of modern civilized man."

And this is a cancer expert speaking, in a cancer book. This, for them, explains this difference.

Here was the countervailing image of people without inhibitions, without worries, without ethics and repression, and therefore without cancer.

And it's these observations that suggested, metaphorically at least, why, in the South, for instance, stereotyped for its languid pace of life, its slow, unsophisticated rural cultures, people in the south were seemingly protected from cancer.

Fewer worries, less cancer.

Little wonder, then, that it's these images of upper-class women that dominated cancer awareness campaigns. It was th0ese women who had the capacity to educate themselves. Educating educated women was the sort of central theme of cancer awareness, about the particular risks, this is what provided a primary focus for the media messages, from movies, et cetera.

Now I found very few references in any literature of this time period, whether it's cancer awareness literature or popular literature, to black men or black women and cancer. There is an anxiety about cervical cancer rates among African-American women, but I found a few novels that try, at least, to humanize African-Americans by portraying cases of cancer victims, and one of them is really unusual, it stands out.

It's a North Carolina novelist named Paul Green, who writes a series of vignettes about a small town, but one of the chapters is about Ollie, a tenant farmer, who experiences, not unlike women who experience breast cancer, a series of personal losses, psychological trauma that brings on his cancer and ultimately leads to his demise.

Or a William Saroyan play from 1949, which is set in a San Francisco cancer hospital for dying men, cancer is never mentioned, by the way, in this, but the main character is an angry, tormented black man, and all of these characters do portray the patient as a stoic patient.

Somebody who is either unaware of the tragedy that will ultimately befall them, or who hemselves, tend to put it in the background because there are larger things that they want to accomplish in their lives before they die.

But these are not the images that really are part of the broad public presentation of cancer, these are really rare gems in a literature you have to go looking for, you have to really try to find these.

These are really the dominant images of cancer that one finds in the early 20th century, and the themes that dominate are themes that I've mentioned: women protecting the uterus and the breast, which are seen as the prime targets of this new menace, women of the middle class and upper middle class women being more in danger, more vulerable, and learning to face their fears, trusting doctors,

so that's when I say that, in a lot of ways, to understand the history of mistrust in cancer, you have to understand the history of trust and how trust in the medical establishment was cultivated over the course of the first half of the 20th century by sending the message to very particular audiences.

I should say one other thing about this, which is that there is a change over time in these images. When I talk about this with my students, I try to get them to do an analysis of these changing portraits of women, so here's, in the very first slide, 1926, a woman going to the doctor with her husband alongside.

By the 1942 image, you have that partition, the woman leaning forward, talking to the doctor by herself, or talking amongst, with her friends. There is another reason for this perception of cancer as an Anglo-American disease.

Much of the evidence for cancer risk was drawn not from the cancer registration states alone, but also from the leading authorities in the life insurance industries, as I mentioned, Louis Dublin at MetLife, Frederick Hoffman at Prudential Life.

Life insurance was a relatively new product, appealing to a growing middle-class clientele, precisely those interested in taming chance, in setting aside money today, to potentially take care of their families, should illness or death befall them.

And companies who sold these policies gathered and analyzed a vast amount, a huge amount of mortality data for their consumers and for their policyholders, and they singled out high-risk versus low-risk markets.

You don't want to sell an insurance policy to somebody who's at high risk for death, relatively soon.

And they would study the demographics of disease and death, and they were really the authorities on disease mortality in general, and cancer mortality in particular.

Now, by and large, these companies shunned most black Americans, particularly black southerners, or southerners in general, as well as the poor, as too risky to hold life insurance policies because of the higher likelihood of death from infectious diseases, unpredictable life course, et cetera.

It's no secret that insurers sought out middle class, mostly white, urban populations for their business, and it was the kind of data that was generated mostly around the policy-holding population that generated ideas about who had cancer.

So it was sort of a vicious circle here, of you gather information on a small group of people, and then you use that to generalize on where the cancer problem exists.

In fact, Louis Dublin more or less acknowledged this in 1928 in a short treatise he wrote on the health of the Negro, in which he says that, "My reliance will be on materials collected for many years by the Metropolitan Life Insurance Company... which now insures," he says, "close to 2.5 million Negroes."

"If there is a serious limitation," it is this, he knows: "...the business is conducted, very largely, in the urban areas. The conditions which prevail in the rural south, where a large proportion of Negroes still live, are therefore not closely reflected by the insurance experience."

Now, a big part of the story of race and cancer would be how African-Americans go from being on the margins of the insurance experience, being on the margins of having information about their health being collected, to migrating, literally,

as in the Great Migration from the rural south into the urban south, into the urban north, migrating into areas where their health data will be collected and finally, the public can see and acknowledge the nature of the health experience in black America.

So it's social changes like the migration, et cetera, that becomes a key part of my story about how cancer crosses the color line and changes perceptions of disease.

Experts in this time also tended to believe, as did Frederick Hoffman, that rates actually were changing, and you could even see this at work, that northern Negroes seemed to have higher cancer mortality rates than southern Negroes, wherever that data could be collected.

But they tended to, once again, put it into the framework of civilization versus primitivism. So, for instance, writing in 1937, Hoffman would write, "When uncivilized peoples (Arabs, Negroes) become civilized, the death rate from cancer reaches the average for civilized people."

And then he says, so it's kind of an interesting and perverse comment he makes as a result of this, he says, well, maybe what we should do is study the southern diet because a careful study of diets in areas where there are low cancer rates might be of value to us. This is kind of ironic, if you know about the public health discussion today about the southern black diet as being unhealthy.

In 1937, Frederick Hoffman is saying we should study this because this may be what is protecting people from cancer. Let me just say one last thing, before I go on, which is, a large part of the subsequent story, then, of how cancer crosses the color line would be the ways in which various social developments, like urban migration, demographic shifts in the age of the population,

declining infectious disease mortality, or even political developments surrounding the Civil Rights Movement or the passage of Medicare, would bring black Americans and others into the insurance experience, and into, therefore, this modern world where their health was being surveilled...overseen, their health experiences chronicled, and the data actually collected and analyzed.

It was already apparent, in the 1930s, that there were untold stories buried in the numbers.  Insurance statistics revealed that cancer risk was more than just an Anglo-American female concern, right, because when you separated sex from race,

and even if all of the cancers were still combined, and people talked about cancer as one unified disease in the early 20th century, it was also clear that both Anglo-American and so-called colored females had high mortality rates from cancers.

By a wide consensus, cancer was much more of a disease of women. White males were far less vulnerable, and you see down here, colored men, if not invulnerable, and immune, then certainly far less likely to die from cancer. Such numbers always stirred debate, and their meaning about what it says about society was always up for grabs, it was always a constant source of debate.

Writing in 1935, for instance, Holmes noted, "Cancer appears to be less prevalent in the colored population,” and he suggested that one reason might be that, ". . . undoubtedly differences in diagnostic practice have some effect upon our statistics on cancer death rates."

That is, the uneven distribution of diagnostic practices, like if you don’t have tools to diagnose in a rural hospital, you’re not gonna know whether somebody has cancer or not, and it's this unevenness that explains why we believe that cancer rates are higher in white females than in black males; that's what his argument was.

And this also parallels discussions about the distribution of the PSA test today. There is a lot of discussion about the fact that you have a new technology like PSA, it rapidly diffuses, and, as Patosky wrote in 1995, the rapid diffusion of screening interventions that have the ability to detect latent, asymptomatic disease,

also along with geographical variability in the adoption of PSA testing, underscores the uncertainty and disagreement about its value. So these issues that Holmes is writing about in 1935 are still really with us today in the story of PSA.

Now, several developments at mid-century. . . it's a really fascinating period of tremendous social and cultural change, would force experts and the public alike to revise their associations between cancer and civilization. I just want to point out a few quickly, because I don't want to take too much time in the presentation part.

The late 1930s and 1940s, you have a heightened sensitivity of cancer which emerges against the backdrop of a changing face of disease in America. Americans become aware that death rates from tuberculosis, once the leading cause of death, is now the seventh-leading cause of death.

And cancer and heart disease, which were once number four and number eight as the causes of death in 1900, suddenly are there, quite strikingly, as the leading causes of death in 1935-1940.

In post-World War II America, there is a fascination with technology. Technologies like the Pap smear for detecting cervical cancer, and the possibility of radiation and chemotherapy.

Thankfully this instrument is no longer in use, but it shows you the grand hopes associated with targeting radiation, electrons, cobalt bombs, the products of the age of radiation targeted at disease, and the possibility that targeting disease precisely will lead to its eradication, so it's a period of high technological enthusiasm.

And in that era, you also see the idea about cancer actually changing, and, in a lot of ways, cancer becomes a new kind of phenomenon in the mid-part of the century. What do I mean by this? Well, it's captured really nicely in this Ladies Home Journal article from 1955.

The author notes that, "Improvements in the technique, " she's referring, here, to the Pap smear, for the early detection of cervical cancer, ". . . now make it possible to detect not only cervical cancer in the early stages, but conditions which, it is believed, may be precursors to cancers. This makes it possible to deal with a cancer before it is a cancer!”

The very nature of cancer is changing because of the possibilities of early detection. And so the focus of a lot of the cancer discussion shifts from these diseases that were about to kill you, death, cancer mortality, to things like cancer "incidence," or the ability to visualize these internally invisible signs, suddenly changes peoples’ ideas about how you find cancer and who has it.

The Pap smear is arguably a key moment in the modern-day process by which innovative tools, like the BRCA1 test, like the PSA test, are created to detect cancer before they are cancers.

The difference being, today, the level of analysis has moved from the cell to the gene, so you have things like, "We can find the breast cancer gene in an infant or in a young adult long before breast cancer will ever materialize." The problem here is that, the earlier one finds cancer, of course, the more one enters the realm of probability, statistical likelihoods, and internalized senses of risk.

So what you're trying to do is to sell awareness not based on a certain vision of cancer, but on a new vision of cancer, which is rooted in the idea that you have to believe that this phenomenon will grow inside of you at some point, maybe years from now. That's what you have to act on if you’re diagnosed with having a BRCA1 gene. So the cancer awareness really changes because ideas about cancer change.

I just want to briefly point out that, even though these ideas are changing, if you look at the American Cancer Society’s annual reports, you'll see who the audiences are in these portraits. They're still the same audiences that are seen as most vulnerable: white women being educated by a cancer expert.

It's not surprising, therefore, that when the first breast cancer self-examination film comes out in the 1950s, these are the audiences, once again, because these are the groups who are seen as the most vulnerable historically, and still into the 1950s.

I'm going to skip past this part really quickly to try to get at another thing that’s going on in the 1950s, which is the sudden realization that we really shouldn’t talk about cancer like it's one disease. We really should talk about each cancer separately, and this also leads to changes in public awareness and how you talk about cancer. So not only is society moving from focusing on cancer mortality to cancer incidence

because of these new diagnostic tools, they're realizing that each cancer tells its own story about race, ethnicity, and risk. So this is, for instance, a congressional report from 1950 which highlights that breast cancer is, and skin cancer is, more of a white disease, in terms of cancer incidence.

But here you see cervical cancer, stomach cancer, and prostate cancer finally making its appearance, as not more of a black disease, but as a non-white disease. Now this is an important new development in the way people are categorized in the cancer literature.

No longer categorized as colored. This is an attempt to take into account diversity and immigration and a more diverse population, and to sort of chronicle the relationship between white cancer experience and the non-white cancer experience.

Subsequently, critics of this policy would say all this does is it lumps everybody who is not black into one category, and it compares all of those people to whites, who are also kind of an amalgam of all different kinds of groups, and then it tries to account for those differences.

One argument was that this makes it very difficult to actually understand the specific experience of Asian-Americans, of African-Americans, of Mexican-Americans, and Latino-Americans. So the 1950s is kind of this bewildering time period of, you know, certainly civilization and primitivism is no longer the framework that people are using.

They're using frameworks like white and non-white, and each cancer is telling a story about many different kinds of divides. For instance, on the story of cervical cancer, it turns out that there are a whole set of theories relating to sex and sexuality.

The theories of the day suggest that, for instance, captured here by Lewis, that “the higher rate [of cervical cancer] found in women who first have coitus at an early age, who marry early and remarry frequently, and whose men are uncircumcised."

There are all of these theories about circumcision and cervical cancer, and there's fascination, also, with the fact that Jewish women have such low rates of cervical cancer, the argument being that perhaps circumcision of Jewish men, perhaps religious proscriptions against sex during menstruation, perhaps the way in which religion relates to sexuality explains this low rate.

On the other hand, and turning to lung cancer, and you have lung cancer experts like Rosenblatt and Lisa, who argue that, "Tuberculosis and other infectious diseases are still responsible for higher death rates among Negroes and prevent them from reaching the cancer age."

So here you see how every cancer can have its own story, its own built-in moral about how people are living and dying in the United States, at the middle part of the century. Unquestionably, one of the things that are changing peoples' ideas about cancer is, as I said, urban migration: during World War I, the inter-war years, and during World War II.

And you see, in the 1950s, a whole set of new studies emerging around race and cancer which use very different data than the insurance company data. They use hospital data, autopsy data, like this one from the Los Angeles County Hospital.

Paul Steiner writes a book in 1954 called “Cancer: Race and Geography, " and he points out that, "African-Americans who migrated to this area. . .  [had once] formed a small proportion of the [autopsy] population in the early years of the study, but it increased after World War II because of the heavy migration into this area."

You see many of these studies in city after city which suggests that whatever we used to believe about race and cancer, it doesn't really match what we're finding in our hospital study. We can't talk about this right now. Now let me just fast forward a bi, then, because, in a lot of ways, this time period is a confusing time period, the mid-century, because the cancers are changing, people are generalizing based on very different cancers.

Let me turn to the early 1970s, because it’s this time period, particularly in 1972, Americans would awaken to something new, an alarming increase in cancer in America’s black population.  As one Newsweek article pointed out, ". . .  rising steadily since the beginning of the century, due in part to the control of such major killers as tuberculosis and pneumonia, yet the sudden rise of cancer deaths among Negroes was a new feature that can't easily be explained."

Now, it's very much of a post-civil rights era story, where society intensely debating the reach and limitations of African-American equality.  In this context, the same kind of data which seemed to tell one story in the1920s could be looked at in a very different way.

In fact, where in the 1920s, for example, this chart would have focused the reader’s attention on the gross differences between white and colored cancer experiences, in the seventies, very similar data would focus readers on the pattern of change over time. In other words, why is it that colored cancer rates were rising faster than white cancer rates, even in the 1920s?

The work of Howard University surgeon, LaSalle Leffall, focused attention on seemingly dramatic changes over time in the black and white cancer experience. Leffall, using particular data, argued that, "from 1950 to 1967, the U. S.  cancer mortality rate per 100, 000. . .  rose for blacks rose from 147 to 177, an increase of 20 percent, while it remained unchanged for whites at 150."

Why had this not been detected earlier? Leffall argued that institutions like the National Cancer Institute had developed a piecemeal understanding of ethnicity, they had used this "non-white" category to such an extent that it had lumped all different non-white ethnic groups' cancer experience together. Because of this practice of lumping non-whites into one category, they were unable to see specific groups' experiences closely.

He, in doing this study, used the census data and arrived at other conclusions. His observations were a crucial part of the realization that the categories we use for classifying are themselves, help to constitute the reality that we see. And other scholars argued, like for instance, Burbank and Fraumeni that “non-white predominance [in cancer mortality] began in 1950 for females and in 1956 for males."

Now, I'm not sure, given what I've said about how difficult it is to read data and make generalizations from it, I don't how they actually came up with this rather precise sense that this is when cancer crossed the color line. But you see what's going on in the 1970s is, researchers looking back and saying, "This is a phenomenon that has been going on for 20 years and we’re only just seeing it."

Why do we see this rise in black cancer mortality?

As a historian, you can speculate about a number of different factors bringing cancer across the color line, and I want to just speculate about few of them, since I'm still in the midst of writing this book, and maybe I can beg your help in helping me think through how this could happen. I think one factor that needs to be looked at closely is, you have to sort of look at what is bringing African-Americans and their experiences into the awareness of these major institutions.

And, unquestionably, one of them is our political changes like the passage of Medicare and Medicaid in 1965. Insurance, expanding coverage and also alongside the urban migration phenomenon, making disease experiences more visible. The government is now keeping tabs on how their money's being spent on what diseases in whatever population.

Insurance is a way of both expanding access to health care, but also expanding the data that's collected on a wider range of the population. Another argument to speculate about is the decline of tuberculosis and the infectious diseases, which disproportionately killed African-Americans and poor people at earlier and earlier ages.

Once those are no longer leading killers, to what extent do African-Americans enter the cancer age at a more rapid rate in the post-World War II era, a transition that white Americans had been going through rather gradually over the course of the 20th century.

Others speculate that, well, perhaps what explains this transformation are changes in diet and behavior, which I think is less firm ground to stand on, but even LaSalle Leffall, in trying to explain this rise over the course of the fifties and sixties resorted to the argument that maybe it is that as blacks adopt the quote, so-called, white diet,

this could explain the rise in cancer rates.  Once agai, wide speculation abounds around this. Others have sort of pointed to environmental exposures, or exposures to carcinogens.

I think the weakest argument to make, historically, anyway, is that anything has changed biologically. That, somehow, fundamental biological changes in blacks or in whites over the course of a mere hundred years, explain this. So this is one of those examples where, to explain the change over time, you have to look at society, culture, politics, and the changing awareness of these disorders.

I had intended to talk a little bit more about prostate cancer, but let me just skip to my summary, because I'm running overtime here. So, in doing this book, "How Cancer Crossed the Color Line, " I'm really trying to tackle three different sets of issues, or speak to three different sets of concerns.

One is, I hope to have left you with just a very basic understanding of how a disease can change over the course of a hundred years and how the story of how cancer crossed the color line is really intertwined with the question about the history of urban migration, the rise of political movements and legislation like Medicare, which allow African-Americans to come into the insurance experience,

or the changing demography of aging, the impact of aging on disease in America. But to tell the history, I also have to tell the history of the health industry and consumerism itself. In a lot of ways, the story that I'm telling is also a story about the sociology of disease detection.

Who counts and who gets counted?

And how is that story a political story and a social story?

So it takes you from the era in which insurance --life insurance, health insurance -- was the main way of chronicling cancer mortality, into the era of what I call cytopathology, where you have the Pap smear being used by pathologists in hospitals to come up with their own ideas about race and cancer, to the rise of what's going on today,

which is the emergence of commercial risk detection, like the PSA test, theBRCA1 test, which are testing very different kinds of things than were tested back in the 1920s and '30s.

The second thing I hope to provide you with is an understanding of, you might say, the story of trust, that -- well, let me go back to the very beginning -- that, to me, the history of cancer, therefore, and race, is not so much a history of distrust, fatalism, machismo, pathological stoicism, or cultural "obstacles" to cancer awareness, but we need to understand, we need to study distrust in relationship the cultivation of notions of risk in relationship to group identity.

We need to study it in relationship to the history of trust. And I think the reason that I say this, in the public health community, anyway, there's a lot of anxiety about why do certain groups, black men, men in general, Hispanics, people from different cultures and ethnicities, why don't they buy the cancer awareness message the way others do?

And part of what I want to suggest is that well, the cancer awareness method has been tailored, very precisely, to a very specific constituency, for much of the 20th century, to middle-class, upper-class, white, Anglo-American women and their internalized ideas about their own vulnerability, of their sexual organs, reproduction, et cetera.

It's not a kind of message that you can just pick up and translate very neatly into another group and say, "Well, why don’t you go in for early testing? It worked for women, why doesn't it work for you?”

So I think we need to sort of think more critically about how to talk about cancer in different groups, and how the success of cancer awareness in one group doesn’t necessarily mean it will be successful elsewhere, because cancer awareness really is tapping into these very profound ideas and anxieties around group identity.

And that takes me to the last stage, which is that, implicit in this history is the history of cancer detection and medicine, which is a very difficult history to find, given what I've just described. Unquestionably, black men have been dying from prostate cancer since the early 20th century and before, but it’s very difficult to chronicle their experiences.

What I have so far are a few indications, people like Ollie, the tenant farmer in the Paul Green story from 1927, or Greedy Reed in the cancer hospital in the William Saroyan play, or, a really important development, the character of Max Reddick in a novel by John Williams in 1969 called "The Man Who Cried 'I Am.'"

And in this, prostate cancer plays a very central role in the whole narrative, but, in a way, it gives you some insight into, well, maybe it's into pathological stoicism, I don't know, because throughout this novel, Max Reddick is in pain, he knows that he's about to die, but one of the things that animates this novel is his awareness that he's part of momentous changes in American society and politics of this time.

And a lot of the challenge that he faces is pushing his pain aside in order to participate in the march on Washington and the momentous political changes that are redefining American society in the 1960s.

A key quote from it, "So much had happened the day of the march in Washington. There, you could forget that the cancer tests were positive, you could forget with more than a quarter of a million people surging around you."

And I want to suggest that, in these sorts of documents, there's another story to tell about the story of race and cancer, unfortunately, it's a very difficult story to tell because the sources aren't there. And as we enter the 21st century, we might think about ways in which we could fully chronicle these sorts of experiences, so that a hundred years from now, we're not looking back and thinking, well you know, how did cancer change over the course of the 21st century?

Well, let me end there, because I think I’ve gone on much too long, and I’d love hear your questions and your suggestions about how to make this book reach its full potential as a book, so thanks a lot for your attention.

[Applause]

Dr.  Fee: Let me mention that you have a microphone in front of you. If you press the little button, I think it says "mic," then everybody will be able to hear your question or your comment.

[Pointing] Yes?

[Male Audience Member 1]: Keith, the one factor that you didn't address, at least directly, is economics. And I know that Harold Freeman has showed data for African-Americans and that cancer rates are very highly correlated with income level.  I should say inversely.

Dr. Wailoo: Yeah, that's true. I think that. . .  how to put it. . . it's implicit in my talk. In a way, what I'm trying to do is present a story of American ideas about race and cancer, and you are absolutely right that, in America, there is a tendency to talk about race rather than economics as the key factor explaining these phenomena.

And I think it's telling that, when I go back and I look at this history, and I look at the history of epidemiological statements about why these disparities exist, economics plays a very small part in shaping the history of the explanations. Do you see what I'm saying?

So I think you're right. But my goal is not. . .  I'm really trying to tell the story about why Americans persisted thinking the way that they do about these problems, rather than prescribing an answer. But there's room for Harold Freeman’s comment, and I should pay attention to it, maybe in the conclusion of the book.

[Female Audience Member 1]: I have a couple of unrelated things. Last year I heard Otis Brawley speak--

Dr.  Wailoo: I'm sorry, who was that?

[Female Audience Member 1]: I heard Otis Brawley, from Emory University, speak. And he did a whole comparison of breast cancer in African-American women, it was real interesting to hear him talk about women who were in the army, and basically, they all had the same treatment and so the African-American women's outcome was the same as the white women's outcome.

Equal treatment, equal outcome. The one thing that stuck with me is, he was talking about obesity, and that with higher rates of obesity in the African-American community, it seemed like there was speculation that African-American women could get more virulent types of breast cancer. So there might actually be a difference in the type of breast cancer that was being diagnosed, so I thought that was interesting.

So it might not be a matter of when it’s detected or genetic differences.

Dr.  Wailoo: Right, I guess that would have a question back to you, which is that, I follow these debates and these speculations about, well, it may be biological, it may be connected with obesity, it may be early detection. I guess the question that I always have is: how will we actually answer those questions? Or are we going to resign ourselves to constantly debating those issues?

And, I guess, studying it, in other words, how do you resolve that? How do you actually definitively show that the reason we're noticing this phenomenon is because of X rather than Y?

To me, it's an ongoing theme in American, in our society, relating to cancer, this persistent speculation about whether it’s obesity, whether it's early detection, whether it's a biological difference, and partly what I'm trying to do in this book is to understand why we always have these debates. Maybe you can help me with that.

[Female Audience Member 1]: I work in the press office, I'm not a scientist, but I think that the hope is that sciences going to show us the way and we’ll actually be able to look in the microscope and see the difference. The other point, James and I both work in outreach, and the other point is about these public health messages.

And I've been at NCI for three and a half years, and I was here when there was a big brouhaha about mammography and I think that it's very difficult to have public health messages about early screening and detection that really make a lot of sense.

We know a lot, but then what’s a man or a woman supposed to do once they find out that they have a higher PSA or an abnormal mammogram. We can screen for things, but then what action are people supposed to take?

Dr.  Wailoo: Especially as the meaning of what a high PSA is, is still being debated and changed over time. So very good comment, thanks.

[Male Audience Member 2]: I was wondering if you'd looked at region, especially for the earlier period. If you took data on poor white southerners and compared it with data on poor blacks in the early part of the 20th century...similar? Different? How is it depicted in the poor white community of that region?

Because you do recognize a difference, you do say that the urban migration seems to make a difference.

Dr.  Wailoo: Well, I started this project when I was in North Carolina, on the faculty there, and spent a lot of time reading the regional southern medical journals, and, I have to say that, the one thing that is striking, which is that southern surgeons and physicians did not appear to buy this idea that cancer was an Anglo-American disease,

because the literature in the southern medical journals are filled with -- now, to be sure, these are all literatures on women with cancer, and many of the articles are on cervical cancer, but the surgeons who were writing about cancer, if you were to show them the authoritative documentation from MetLife and Prudential Life, I suspect that they would say, well, this doesn't really correlate with what we actually see in the New Orleans County Hospital.

So that's what I've actually been able to see, but the trick is that, the question is: which of these stories are part of the broader understanding of cancer? And, unquestionably, it's the information being generated out of Prudential Life and MetLife rather than the stories that are being generated in the Southern Medical Journal.

And that tells you something about American society, in terms of who is authoritative and what knowledge is authoritative in the early part of the 20th century. So that's partly how I would answer that question.

[Female Audience Member 2]: Well, I think it’s interesting how you look at data, in particular, or when you look at a group of data and you're looking at it from past to present, I think that's exceedingly important in terms of evidence and truth.

And, even now, in academia, when you see data that’s published, you question the truth about that data as well as the politics behind who gets to publish information and how important it is to the kind of truth that we're seeking. And, when you look at clinical trials, now,

and you look at how a lot of black people don’t even participate in clinical trials, and then there's that trust issue that you’re referring to, so I wonder, about the current information that you're collecting, how relevant is it to finding the truth?

Dr. Wailoo: Well, that's a very good question, and, I have to say, I wonder that myself. And the reason I say that is that the best kind of data that we have today comes out once, and it emerges in the wake of the criticism of LaSalle Leffall, when he criticizes NCI for not taking account of African-Americans or different ethnic groups, but lumping them all under "non-white."

NCI changes and creates this new program called the SEAR Program, the Surveillance, Epidemiology, and Results Program, and that produces the most authoritative cancer data and tries to be representative. Well, every three years, it changes.

The first year that they did it in the early seventies  after about three years, they decided, well, you know, we still aren't getting enough African-American representation, particularly rural representation. So they expanded their catchment area and collected more around the Atlantic area. And then for a while they collected around New Jersey to try to get other ethnic groups, and every three years it changes.

It's almost like, you're always trying to find the data sample that, once and for all, finally captures the state of your society at this time, and it always has flaws in it, especially when a new census comes along, right, because of course we never really know what our society looks like. A new census comes along and they say, "We have to be collecting data very differently now."

So, I guess what I'm interested in is how the story of data collection, as a way of chronicling the experiences of our population, is an ongoing one. And it's always going to be imperfect for precisely the reasons that I was describing, because our tools are imperfect, like the PSA test.

You could gather data on PSA around the country, but if you're not in agreement on what PSA tells you, or if you’re not sure that your data sample is representative of what you're trying to study. So these are questions, I mean, I'm not an epidemiologist, and I'm not a clinical researcher, and I don't really work in the realm of statistics, but I do study how people critique and think about these.

Let me say that I agree with you, and I’m not quite sure, yet, where we are today, relative to where we were a hundred years ago.  I know we're better, because more groups are part of that record-keeping, data-gathering enterprise, but I'm not sure that there’s as much critical attention paid to what is it they're actually collecting as there might be.

[Female Audience Member 2]: Well, what do you expect to gain from your findings, and based on the information you've gathered so far, do you have any kind of preliminary conclusions about the widespread of prostate cancer amongst black men?

Dr.  Wailoo: Well, what I expect to find. . . you know the NCI has this new program called Cancer in Communications, and one of the reasons I think that there's an initiative like that is there's a sense that we can know more and more and more about the science and the biology of cancer, but the real goal is communicating it to different people.

And I see this book as much more of an attempt to talk about how cancer has been communicated over the last century, as a way of understanding and maybe criticizing and thinking about how cancer is being communicated today.

So it's a fairly modest goal, it's not about cancer awareness, per se, it's not about changing health practices, it's not about finally resolving the question about whether African-Americans have higher rates of prostate cancer or why. I can't get into that because I'm not a medical researcher, I'm not a clinical scientist, I'm not an epidemiologist.

I'm a historian and I'm interested in basically communicating about how a society thinks through these issues. So. . . I'm punting on the question of what difference it will make in that realm.

[Female Audience Member 1]: Just a quick thing to add, a couple years ago, we had a big conference about whether abortion might be a risk factor in women getting breast cancer, and it was decided that it was not, but there were things that contributed to risk factors, and one of them of had to do with delayed childbirth, I think breastfeeding was a factor.

So as we learn more, we are learning that this isn't all mythology, that there is a reality to some of these lifestyle and societal changes.

Dr.  Wailoo: Yes.

Dr.  Fee: This gentleman here.

[Male Audience Member 3]: I would like to congratulate you on the work that you’ve done so far. I work for Dr.  Harold Freeman and he tends to focus on socioeconomics as one of the driving forces. That even when they control for socioeconomic status, race still persists, from what he himself has said. My comment to you as a follow-on to the one about data, and for you as a historian: please keep track that we have effort now to eliminate cancer health disparities.

And, for your volume two, even while you’re working on volume one, please try to keep track to see if cancer crosses the race line back, as we try to eliminate disparities.

Dr.  Wailoo: Well, that's a good, a nice challenge, especially for a historian, who is more comfortable reflecting on the past than thinking ahead. You know, based on the history that I’ve told, though, I have to say that one of the things that I'm quite sure will happen, if I'm around 20 years from now, I strongly suspect that, just like the categories colored and white,

and who belonged in those categories changed from the 1920s to the 1950s where "non-white" starts to appear, and now you have Latino or Hispanic, which is an amalgam of a number of different groups.

I'm fairly confident that, because this always happens in American society, that the categories themselves will, unquestionably, be different 20 years from now. And it will throw us all into a tizzy because we won't know what is it that we're comparing what to.

So I'm sure cancer is going to cross some line 20 years from now, it's not clear what line it's going to be. I'm actually going to be sort of heretical and say that one of the things that I think we need to start to do is kind of rethink this category "white." Which is. . . talk about myths.

We're talking about so many different ethnic groups that are lumped under this category, and then we compare other groups to this phantom category as a way of. . . now I think it's politically important, and I think it's socially important to continue to measure the progress made by minority groups against whites, I'm not syaing we shouldn't do that, but I’m saying that we should also be aware that that thing that we call "white" is an amalgam. It's a creation.

And we need to think about what we're trying to compare what to. I'm not sure that that's going to go anywhere, it's just sort of my pet peeve, because I find it difficult. I moved to North Carolina and I found people talking about Scots-Irish and I thought, I grew up in New York City, I'm like "What the heck is that?"

I had no idea that this was still a meaningful category of ethnic identity, two hundred years after the Mayflower, et cetera. But you move to Milwaukee, you're not going to find people talking about Scots-Irish in the same way as you're gonna find people talking about German-American heritage.

So, I think there's something to be said for rethinking this category of "white" as a way of understanding and measuring health and health disparities. And I suspect that, if those changes don’t happen, then something will come from somewhere. Because most of these things emerge because of political changes, right, so the comment for the person who mentioned about cancer and abortion. . .

I tend to study, why is it that we're even debating the issue of cancer and abortion? That’s explainable in a cultural and political context, and that's what I end up looking at closely, rather than the answer to the question.

I'm always interested in how people frame questions, and what questions they choose to ask. So that's what I would forecast for the future.

Dr.  Fee: I wanted to make just a general comment on this issue. It’s very fascinating for me when we have a mixed group of scientists and historians because the scientists usually want to know "Okay, well what's the answer?" whereas the historian wants to know "What is the question?" and "How are we thinking?" and "Are there more sensitive ways we can look at our process of thinking and process of asking questions?"

So it's always very interesting to see that both types are needed in the world. I had one question for you. I loved the emphasis you placed on the gathering of the data and the idea of the Great Migration as a migration into places where your data was liable to be gathered.

I wondered, too, though, if the Great Migration wasn’t also a migration into places where you might be exposed to more toxic chemicals, hazardous working or living conditions. . . The movement to the cities was, after all, largely a movement to industrial jobs. And wouldn't that also be a piece of the story?

Dr.  Wailoo: Once again, a good question that is hard to answer. I would say that it would depend on where you’re migrating from and where you're migrating to. One of the thigns I've been looking at, for instance, is the rise of "cancer alleys."

Cancer hot spots, and the awareness of them, and we have a bunch in New Jersey, and we have one, in particular, in New Jersey, which is always in the context of New Jersey being thought of in exactly these terms. Industry, urbanization, as well as higher rates of detection.

But, interestingly, you also have cancer alleys in places like Louisiana, where it's the rise of the petrochemical industry that is linked to environmental exposures. So I would say that the story about migration, whether it's from the rural South into the urban North, can cut a number of different ways in terms of this question about environmental exposure.

It's very difficult, and I think that's kind of a book in itself, in a way. One of the dangers of writing a book like this is that you're skimming across the surface of what are, in fact, really complicated questions in themselves. That's one of the things, you have to decide to go broad and not deep.

Dr.  Fee: Oh, I think it's admirable to take on the big questions. With that, let me ask you to join me in thanking our speaker for a wonderfully provocative lecture, and to invite those of you who still have questions or arguments to come on up to the front and continue the discussion. Thank you.

[Applause]

Dr.  Wailoo: Thank you.  Thank you all.