Public health implications of components of plastics manufacture. Regulatory aspects and research needs.

In this issue we publish two papers which focus particularly on issues relating to the provision of the Health Service in the United Kingdom. Michael Richards and colleagues address the use of resources and cost implications for the care of patients' advanced breast cancer (Richards et al., 1993). They seek to describe the costs in the UK and compare them to earlier work published in relation to advanced breast cancer in other countries (de Koning et al., 1992; Hurley et al., 1992). Their results certainly show a striking similarity to the costs described in The Netherlands by de Koning and colleagues (1992). As Richards et al. point out, all costing estimates involve making assumptions and are subject to error and often criticism. In the UK Health Service at the moment standard tariffs for use in costing studies and comparison of treatments are not available although they are being developed as part of the NHS Reform. In another paper Malcom McIllmurray and colleagues describe the development of a cancer support organisation, CancerCare, in North Lancashire and South Lakeland (Mclllmurray et al., 1993). In describing the use of relaxation therapy and high demand for it they draw attention to important issues that need to be addressed by the providers of heath care in the UK. These papers address Service issues. They reflect an increasing interest in research into the quality of health care provision and its costs. These issues have importance across the world as advocates of expensive developments in health care are confronted by economic constraints. In the United Kingdom, research into optimal provision of health care has been brought to increasing prominence by the National Health Service Research and Development initiative led by Professor Michael Peckham (1991). The evaluation of any health care intervention is a proper subject for research and is of considerable interest to the British Journal of Cancer. In our earlier articles on editorial policy (Selby, 1991; Twentyman & Selby, 1991a and b) we emphasised our commitment to the publication of high quality research into the provision of care particularly when it draws on sound methodological approaches including ran-domised prospective trials. A formal economic evaluation will include an appraisal both of inputs (costs) and the outputs in terms of patient well-being and survival. Careful measurement of survival output, remission status, toxicity and quality of life have been emphasised for many years and the current difficulties in the …


Regulatoy Aspects and Research Needs by Glenn ESchweitzer*
This conference has underscored the many gaps in our understanding of the behavior of vinyl chloride and the inadequacies of current research efforts to improve the data base which supports the regulatory decisions that must be made now. In addition to the need for much better information on the human health effects of exposures to low levels of vinyl chloride, we know relatively little about the persistence of vinyl chloride in air and water and the degradation products associated with this chemical, the ecological effects of vinyl chloride, particularly as it interacts with aquatic organisms, and the rates of migration of unreacted vinyl chloride monomer from products containing PVC during their use and disposal.
Perhaps, even more importantly the conference has highlighted what many environmentalists are calling the "tip of the iceberg"san iceberg of chemical problems that will continue to float to the surface during the decades ahead. For example, the array of hundreds of chemicals added to plastics that was shown here clearly illustrated the complexity of the task of the researcher in attempting to provide an early warning of future problems.
It certainly appears that, except for continuing concern over spills and accidents, government and industry have been rather complacent with regard to the potential environmental threat from the high volume industrial chemicals. This complacency is in large measure attributable to the relative absence of visible and uncontrolled dangers from exposure to the chemicals during their long histories. In addi-* Office of Toxic Substances, Environmental Protection Agency. Washington, D.C. 20460. tion, since many of these chemicals are manufactured by a number of companies, firms may lack incentive to invest individual company resources to clarify the safety aspects of their usage. Clearly, the experience with vinyl chloride-the twenty-second leading chemical in terms of production-underscores the problems that can result from such complacency. Despite the continuing commercial importance of these high volume chemicals, it cannot be assumed that adequate research, testing, and related safety measures will be taken by industry, and vigorous governmental leadership in this area seems essential.
The most immediate task confronting us all is how to organize the limited resources-and I refer principally to dedicated scientific talentof government and industry to sort out the areas requiring the most urgent attention. Should the Toxic Substances Control Act be enacted, the Federal Government will have a new responsibility of particular importance to the prioritization of these efforts. Hopefully, such a legislative mandate can provide the impetus for more concerted efforts toward early recognition and correction of potentially serious chemical problems.
This conference has been a useful first step toward imparting a sense of direction for addressing the many unknown aspects of the plastics industry. It certainly has helped clarify the dimensions of the problem. Clearly industry must play a key role in monitoring, testing, and, where appropriate, restraint-for in many cases only the manufacturer of the chemicals is in a position to suspect the likelihood of hidden hazards associated with his products. June 1975 225