Baseball Caps and Sunscreen: McCain's Melanoma Cover-Up

Personal Health
Editor's note: On Monday, July 28th John McCain said a blemish was removed from his face during a physical examination The mole-like spot was discovered during the Arizona senator's routine three-month examination, which he undergoes because he has a history of skin cancer. This article offers larger context on McCain's case, and the dangers of melanoma.

When John McCain rode an airboat through the sun-drenched Florida Everglades in June, he was sure to lather up with plenty of sunscreen (SPF-30 is his preference) and wear a baseball cap. For someone with his melanoma history, this was poor preventive medicine. In a UVA-saturated wetland, this outfit made him vulnerable for more melanomas on his face, neck, hands and other exposed areas.

In fact, the most effective preventive sunscreen is not found in an expensive 6-ounce bottle, which generally offers little or no melanoma protection. It is simple avoidance of the sun between 10 a.m. and 4 p.m., proper clothing and eyewear, wide-brimmed hats (4 inches or more) and shady structures.

The facts are readily before us. McCain's cherished SPF-30 rating is meaningless when it comes to melanoma. The SPF rating scale applies only to ultraviolet-B radiation (290 to 320 nanometers along the sun's spectrum), which causes red sunburn and is a major contributor to the more easily curable basal and squamous cell skin cancers. However, the consensus of biomedical research and opinion is that melanoma is strongly related to exposure to ultraviolet radiation type A (UVA), the long solar waves (320 to 400 nanometers along the sun's spectrum) that travel beneath the skin's surface to damage melanocytes, the pigment-making cells.

And McCain's baseball cap won't protect against either type. According to the National Cancer Institute, baseball caps are insufficient sun protectors because they "do not fully protect the face, neck, and ears." The NCI is actively trying to dissuade people from using them, urging instead the use of big hats or draped baseball caps.

McCain's activities may have cost him his life (as we'll discuss), and more importantly, they may contribute to the loss of thousands of lives for those who emulate his behavior. As the most well-known melanoma victim of our times, McCain's decision to shun the best sun-smart policies, noted below, sets a very bad example.

But McCain apparently doesn't know, doesn't care, or just doesn't want to draw attention to his disease by donning a showy 4-inch wide-brimmed hat for his ongoing public appearances. One can speculate on reasons why. Fashion is a form of communication, and politicians want to communicate that they are fit and healthy. They do not want to communicate that they are a cancer victim or a worrywart.

A wide-brimmed hat, unlike the hip-hop baseball cap, may not be perceived as being "cool." The broad hat breaks a cultural denial mechanism. It's apparently far too risky, from a public relations standpoint, to send a non-macho "I fear the sun" message. For McCain, apparently, image politics trumps public health.

What's Covered Up

Melanoma is one of the fastest-growing cancers of our time. If not caught early, there's a good chance that it will metastasize and kill you. So far it might have been caught early enough for Troy Aikman, Sam Donaldson and McCain (but we cannot know for sure). But sadly it was not for Maureen Reagan, Bob Marley or rising folk musician Eva Cassidy, gone at 33. The problem with melanoma is that it is a very tricky and unpredictable cancer that can silently metastasize to the lungs and brain (common targets) years, even decades, after the original tumor was excised from the skin. The absolute key is prevention.

In 1930 melanoma was rare, with a lifetime risk of just one in 1,500 people. Since then, it has grown exponentially, with a lifetime risk in the United States of 1 in 250 in 1980, 1 in 120 in 1987, 1 in 75 by 2000 and 1 in 32 in 2007. Worldwide, it annually strikes an estimated 132,000 people with an estimated 48,000 deaths.

McCain's silence about several raging sunscreen controversies is disturbing. In June the Environmental Working Group reported on its study that tested 952 sunscreen products. It concluded that 809 should be either treated with caution or avoided altogether. The group said it acted because the federal government had refused to do so.

Earlier, in 2006, the nation's most successful class-action law firm, Lerach Coughlin Stoia Geller Rudman & Robbins LLP, filed a class-action lawsuit against leading sunscreen producers (including Schering-Plough, makers of Coppertone; Sun Pharmaceuticals, producers of Banana Boat; Tanning Research Laboratories, makers of Hawaiian Tropic; Neutrogena Corp. and Johnson & Johnson, makers of Neutrogena; and Chattem Inc., which makes Bullfrog). Samuel Rudman, a partner, claimed, "Sunscreen is the snake oil of the 21st century, and these companies that market it are Fortune 500 snake oil salesmen. False claims such as 'sunblock,' 'waterproof' and 'all-day protection' should be removed from these products immediately."

The Federal Trade Commission and the Food and Drug Administration addressed the overreaching claims of the sunscreen industry in the late 1990s. In 1997 the FTC reached an agreement with Schering-Plough, which is Coppertone's manufacturer and the corporation with the industry's largest market share, to cease its deceptions about the efficacy of its products, but Schering-Plough never complied with the agreement. The FDA has yet to require sunscreen makers to tell the truth.

Where is McCain on these issues? Why doesn't the media confront him?

False Security in the Sun Equals More Melanoma

The essential truth about sunscreen was first brought to light by epidemiologists Frank and Cedric Garland in 1990 after their soon-to-be-published work was profiled in a New York Times article. The two brothers investigated the use of sunscreen on military populations and concluded that "sunscreens give you a false sense of security" because they do not sufficiently block out UVA rays.

In other words, when a mom lathers her son up with a generic SPF-30 sunscreen for a midday soccer game, she might feel comforted that he can stay out on the sun-drenched field longer because of his protection. While he is receiving some protection from UVB radiation, more than likely he's receiving a massive dose of UVA radiation with virtually no protection. Further, the lack of a sunburn from the sunscreen will reinforce this illusion of safety, resulting in longer exposure times.

It turns out that U.S. sun-care manufacturers -- who had $1.9 billion in sales in 2005 -- do not tell people the full truth about their sunscreen products in their advertising, labeling, Web sites or commercials. Sunscreen makers willfully take advantage of the ambiguity of the term skin cancer in their marketing, avoiding any open reference to the term melanoma while strongly appealing to melanoma fears, since about 80 percent of all skin cancer deaths are due to melanoma. Over the past half century, as the frequency of melanoma has exploded, so has sunscreen production, with apparently little or no preventive effect. It is a powerful correlation that alarms epidemiologists and other researchers, suggesting causal linkages, but to many doctors it's just an irony.

In 1990, the Garlands' research conclusions were considered subversive. The American Academy of Dermatologists quickly denounced the Garlands' research, arguing that it would inhibit sunscreen use and result in more cancers. Alarmed at the attacks and afraid it would affect future research funding, the Garlands decided to avoid journalists and keep out of the public eye. Thus, the biomedical establishment successfully ostracized them, and their conclusions were mostly forgotten for three years.

Today a rising chorus of scientists, environmentalists and governments is making the same arguments that the Garland brothers made. And yet, officially speaking, in the United States this knowledge is invisible.

Drug company propaganda filters throughout the culture, creating a context where McCain can get away with avoiding the topic. Schools, sports teams, supermarkets and the media vigorously promote the idea -- through their actions, emphases and omissions -- that sunscreen is the first and most important choice in fighting skin cancer and melanoma. Incredibly, pediatricians rarely counsel sun protection in office visits, even though they provide health care to a population, children, that receives up to 80 percent of its total sun exposure before the age of 18. According to one study, doctors broach the issue in only 1 percent of clinical visits -- and when they do, sunscreen is the most recommended cancer precaution.

McCain has had little or nothing publicly to say about these issues. Instead, as the nation's virtual teacher on sun-smart behavior, he undermines the best practices through his actions.

Melanoma Prevention Down Under

Australia and New Zealand have the highest melanoma rates on the planet (one in 25 will get melanoma in Aussieland) and as a result have taken dramatic public health measures to fight the disease. They have a "No Hat, No Play" rule. Every child must wear a hat to play outside. Recess times are often scheduled outside the 11 a.m. to 3 p.m. time frame. Soccer games, played without hats under the high sun in the United States, are delayed till a safer time Down Under. Children have begun wearing neck-to-knee swimsuits on beaches and at pools. Lifeguards are directed to set an example by wearing sunglasses, wide-brimmed hats, long-sleeved shirts, zinc oxide and sunscreen, and to sit in the shade. Many pools and playgrounds are now covered by expansive tents or newly planted trees.

The government also recruits popular athletes as fashion models for sun-smart behavior. In one campaign, Olympic swimming gold medalist Dawn Fraser illustrates the above lifeguard fashions. These campaigns are associated with an increase in the use of protective clothing and shade in adults and children.

Of these necessary public health interventions, McCain has said little or nothing. Few in the United States are even aware of these important public health precautions.

Cultural Ignorance Is Rampant

Many citizens have no knowledge of melanoma. In a 1996 random-digit-dialed survey of 1,001 persons, reported by the Centers for Disease Control and Prevention, 42 percent of respondents had no knowledge about melanoma. Only 16 percent of those ages 18 to 24 were aware that melanoma is a type of skin cancer. They probably conclude that the distinction between the three types of skin cancer is not that important since sunscreen companies do not make such a distinction in their marketing -- and the government does not require them to do so. The idea that skin cancer is easily curable reinforces this false conclusion.

For the novice, there are three simple levels to understanding the disease. The first is scanning the body to identify a possible tumor. Often it's a dark mole with irregular borders and about the size of a pencil eraser. The second level is surgically excising a thick section of flesh around the skin tumor to capture any errant melanoma cells that may have traveled a few inches from the mole. Often lymph nodes are removed as well. The third level is the waiting, year after year, to see whether any melanoma cells have silently escaped from the original lesion and gathered in the internal organs (often the brain or lungs), where they will then likely kill you. There is about a 50 percent mortality rate during the first year after such an event has been discovered.

Will the Sunscreen Kill Him?

A dermatologist checks for new independent tumors on the skin that usually have nothing to do with a possible metastasis from another tumor. McCain has had at least four independent lesions over the past 15 years. In 1993 a small, relatively thin melanoma was removed from his left shoulder. This event was enough to provoke McCain to realize that he had to be very cautious in the sun. After the 1993 scare, McCain developed a routine, he says, in which he lathered up his body with SPF-30 sunscreen each morning and began wearing a baseball cap when out in the sun (though McCain is often photographed without one). This meant that he ignored medical advice that he should wear a wide-brimmed hat (4 inches or more) whenever he was in the midday sun.

However, seven years later, in 2000, right after he dropped out of the presidential race, McCain had a much more dangerous tumor removed from his left temple (or cheek). This is a very common area for melanoma and one that a baseball cap does not sufficiently protect from the harsh UVA rays. It was 2 centimeters wide and as deep as the depth of a nickel (0.22 cm.). Doctors called it a Stage 2a melanoma, which has about a 35 percent mortality rate over 10 years. We are now eight years into that decade-long wait, and it is likely that McCain has beaten it. According to his physician, the chance of metastasis is now under 10 percent .

But there are no guarantees. People with this sort of melanoma have been known to die 15 years after the original tumor was discovered.

And then, amazingly, in 2002 it happened again. McCain was diagnosed with a fourth melanoma, this time on his nose, the left nasal sidewall. What makes this all the more remarkable is that, even after a near-mortal blow to his face, McCain persisted with the same strategy of sunscreen and a baseball cap.

So, did McCain's use of sunscreen contribute to his possible death? The uncomfortable facts are these. If McCain had relied on a wide-brimmed hat (or a baseball cap with a drape over the cheeks and neck) and avoided the midday sun between 1993 (when he was originally diagnosed with his first melanoma) and 2000 (when he got his second melanoma on his face), his chances of escaping a serious blow from melanoma would likely have been improved. Moreover, if McCain had been better educated on the pitfalls of sunscreen, he might have sought other solutions. Also, if McCain had used a sunscreen product with a higher UVA protection ingredient (for example, zinc oxide, or avobenzone and mexoryl, which though imperfect and lacking in long-term photostability, do offer slightly more protection than the majority of sunscreens on the market), he may have been better protected. After searching widely, I was not able to discern the specific sunscreen product or products McCain used between 1993 and 2002. It is difficult to determine the type of sunscreen McCain uses today, in 2008.

Interestingly, McCain's presidential Web site lists a variety of $15.95 McCain hats ... all of them baseball caps. Imagine if McCain did the right thing and sold sun-protective hats? He would have a powerful influence on the culture.

There is a twist to this. McCain is watched like a hawk, receiving full body scans by his physicians as well as his wife, Cindy, who has been trained to know what to look for. Supposedly, the thinking within the McCain camp is that it is all right for McCain to risk another paper-thin melanoma lesion since his image of a strong man must be protected. It is probably thought that he can afford to go on without a wide-brimmed hat because any suspicious lesion will be rapidly excised. But one must remember that this strategy did not work for the period 1993 to 2000, when the invasive (35 percent mortality rate) tumor was discovered.

From a public health standpoint, this strategy is harmful to millions of people who are influenced by McCain's melanoma practices.

Also, while McCain might be able to afford the best in medical care, with immediate dermatological care, for tens of millions of Americans, this is not available. To make matters worse, dermatological ignorance is rampant. According to a 2006 study in the Archives of Dermatology, 43.4 percent of 934 students graduating from seven U.S. medical schools had never examined a patient for skin cancer. Only 28.2 percent rated themselves as somewhat or very skilled in skin cancer examination, a rate that dropped to 19.7 percent among 553 students who had not completed a dermatology elective. Segments of the public health community have reinforced this practice. In 2003 the U.S. Preventive Services Task Force updated its research and reached the disappointing conclusion that the evidence is insufficient to recommend for or against routine counseling by primary care clinicians to prevent skin cancer.

Where was McCain? FDA Defeated in Behind-the-Scenes Corporate Battle Over "Commercial Speech"

In 1999, the FDA drafted new, more stringent language to specifically restrict the use of misleading claims of sunscreen manufacturers. The FDA was about to crack down on labels with "unsupported, absolute, and/or misleading and confusing terms such as 'sunblock,' 'waterproof,' 'all-day protection' and 'visible and/or infrared light protection'" (Brune 2005), but over the next few years there was an intensive lobbying effort by sunscreen manufactures and their trade group, the Cosmetics, Toiletries and Fragrance Association, and the FDA was persuaded not to implement the rules. Lobbyists argued that "commercial speech" protection for sunscreen manufacturers was more important than truthful consumer protection for the public.

Leading the lobbying charge was John Roberts, a White House lawyer who had convinced President Ronald Reagan in 1985 to tell the public that science had not yet proven that casual contact or simple touch was safe enough to ensure protection from AIDS, thus setting back HIV prevention and education efforts for a significant period. According to FDA records, Roberts met with FDA officials, including FDA chief counsel Daniel Troy, a strong Bush supporter, on Jan. 4, 2000, and on Oct. 29, 2001. A few months after the last meeting, the FDA suspended the stricter rules for labeling sunscreen products. Between 1998 and 2004, Schering-Plough spent $28 million in lobbying efforts. Roberts' future successes are illuminating. In September 2005 he was appointed chief justice of the U.S. Supreme Court.

McCain voted in favor of Roberts.

In a telling irony that underscores the continuing assault on First Amendment rights in the United States, on May 30, 2006, Roberts ruled with the 5-4 Supreme Court majority that approximately 20 million governmental employees no longer have full free speech rights. The implications are chilling. In effect, this ruling means that the sunscreen industry is free to continue deceiving the public under "commercial speech" protections while, at the same time, an employee within the FDA, CDC, NIH, or any other governmental agency who witnesses corruption between his superiors and corporations like Schering-Plough is not free to blow the whistle without the risk of being fired or prosecuted. Thus, "commercial speech" has made gains over "free speech" as the United States slips closer to authoritarianism. According to social theorist Henry Giroux, "within neoliberalism's market-driven discourse, corporate power marks the space of a new kind of public pedagogy, one in which the production, dissemination, and circulation of ideas emerges from the educational force of the larger culture."

It is unlikely that the FDA will reverse itself. In a Federal Register notice published on May 16, 2002, the FDA states that "recent case law has emphasized the need for not imposing unnecessary restrictions on speech." However in a surprising move, on May 29, 2007, Connecticut Attorney General Richard Blumenthal filed a formal petition with the FDA urging that it implement its 1999 rules. "The FDA is AWOL-enabling false labeling, and encouraging overexposure to the sun," Blumenthal said in a press release. "It has shelved rules that could save lives. Reliance on voluntary compliance has led to pervasive deception," he said. "The FDA's delay is unfathomable and unconscionable. Claims to block 'all harmful rays,' and 'waterproof' are mostly truth-proof. The FDA has put new sunscreen standards in bureaucratic limbo, making them dead letter, useless and unenforceable."

In May 2006 the European Union acted to do for European citizens what the FDA has not done for U.S. citizens, launching a dramatic initiative to improve its sunscreen labeling system. The EU argues that claims like "sun blockers" and "total protection" are untrue.

We Addressed Ozone; We Can Do It With Other "Sunscreens"

The ozone layer is nature's sunscreen, blocking about 94 percent of all ultraviolet radiation from the sun. A simple molecule with three atoms of oxygen, ozone inhabits the earth's stratosphere, a layer 10 to 22 miles above Earth. Worries about the ozone had been known for years. In 1974 the first clear and credible early warning came out regarding the threat to the ozone layer and increased skin cancer. The cause was a "miracle compound" of capitalist culture, chlorofluorocarbons (CFCs), first identified in 1927. One CFC, Freon, became common in household refrigerators and air conditioners. Colder air helps to separate chlorine atoms from the CFC. Each chlorine atom can destroy about 100,000 ozone molecules.

In the 13 years after 1974, a contentious battle took place over ozone depletion, led by chemical companies who fought restrictions on products like aerosol sprays. The Natural Resources Defense Council brought a lawsuit against the EPA to force tighter restrictions on CFCs. Aerosol sprays containing CFCs were banned in 1978. Then, in the mid-1980s, scientists found shocking proof of the theory, a dramatic ozone hole above the Antarctic. The result was the historically momentous Montreal Protocol of 1987. It was the first-ever global environmental agreement, signed by 57 nations. It halted the production of CFCs in industrial countries by 1996. Today more than 180 nations have signed on.

One reason for unanimity was almost universal recognition of the potential threat. In 1991 the EPA estimated that even if everyone phased out CFCs right on schedule, ozone loss would cause 12 million skin cancers in the United States and 200,000 deaths over the next 50 years. The EPA's worldwide estimates put skin cancer almost in league with AIDS, projecting a billion skin cancers from ozone loss, including 17 million deaths by 2031. In 2000, the Montreal Protocol's scientific assessment team stated that without the global agreement, ozone depletion would be at least 50 percent in the mid-latitudes and that as a result, ultraviolet radiation would double in the mid-latitudes in the Northern Hemisphere and quadruple in the mid-latitudes in the Southern Hemisphere.

The Montreal Protocol was one of the environmental movement's greatest achievements. A similar approach, one that follows the Precautionary Principle, is required to combat the cancer epidemic, largely a result of capitalist social relations.

Private Fashion Advances, But Not Much Else

There is an emerging market of sun-smart design clothing and furniture, e.g., long awnings and boat tops. This includes Lands End and some other popular retailers that are now promoting sun-protective clothing in their stores. The quality of the fabric is not uniformly protective from manufacturer to manufacturer; however, the cultural phenomenon of associating clothing with sunscreen is a significant improvement. This new market is not as yet a serious challenge to sun-cream dominance.

According to several studies, fluorescent light exposure remains a potential risk factor for melanoma, and "chronic exposure to indoor lighting may deliver unexpected cumulative UV exposure to the skin and eyes." This means that it would be legitimate -- even necessary -- to wear a sun hat and full-face drape inside an office setting. It also requires worker efforts to petition against the use of fluorescent lighting and find better alternatives. But what affect might that have on one's career trajectory, even if one were permitted to do so? Employers need to develop a formal sun protection program in order to promote a safe work environment. In 1992 the Occupational Safety and Health Administration (OSHA) wrote an interpretation of its Personal Protective Equipment Standards (1910.132[A]), stating that employers have a duty to protect workers who are overexposed to solar radiation on the job because this could result in serious physical harm or death. But most corporations and employers have no such policy. Unfortunately, there is only limited research in this area.

Can you imagine McCain taking a position on these issues? He most likely won't, because to confront these issues challenges the deep structure of our culture.

In the end, melanoma must also be understood as a disease that occurs within a wider holistic context. The exponential leap in melanoma incidence over the past 50 years, conjoined with the evidence herein presented, indicates that serious political, economic, environmental and cultural causes are at root. Melanoma is a byproduct of our capitalist culture, which transfers responsibility back to the individual as the state diminishes its role in areas such as health care, public education and social services. McCain is a product of this neoliberal culture and will most likely not, of course, address it.

Let's Call It "Melanoma Whitewash"

When people think of "sunscreen," few think about the ozone layer, or about skin pigmentation, clothes, shade structures over tennis courts, or hats. All are hidden "remainders" in the concept of sunscreen. Corporate culture's use of the term sunscreen actually comes to mean the very opposite of what it is usually taken to mean. That is, the white creams screen from consciousness the darker meanings -- and pigments -- associated with being in the sun. In other words, sunscreen creams, to a significant degree, literally and figuratively whitewash melanoma.

Sunscreen is a near-perfect representative of neoliberal capitalist culture. The bottle represents an apparent private solution (the bottled cream) to a public problem (sun-smart infrastructure, less toxic production practices and education). These public associations of "sunscreen" are excluded in the marketing. When we add to this equation that sunscreen, in the vast majority of cases, does not to do what it implies it might -- prevent melanoma -- the resulting sunscreen-related disease becomes an example of cultural iatrogenesis, a disease ironically caused by those who assert their healing roles, be they physicians, the pharmaceutical industry or more broadly, the culture at large.

What is required is a cultural transformation of how we think and act about "sunscreens" and the sun. As part of this undertaking, a vast educational campaign is required. I suggest that efforts be made to establish a surgeon general's warning on sunscreen bottles:
SURGEON GENERAL'S WARNING: Sunscreen does not sufficiently protect you from melanoma, the most deadly skin cancer, responsible for about 80 percent of all skin cancer deaths. Sunscreen may actually cause melanoma by giving you a false sense of security in the sun.
If elected, John McCain is not likely to appoint a surgeon general of this mindset.

If McCain cannot grapple with the causes of his own mortal wounds -- and seek to publicly confront them -- how can he be trusted to protect us?

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