Balkinization  

Wednesday, October 25, 2006

Bush Administration Authorizes Separate but Equal Schools

JB

Yes, you heard that right. No, the Administration is not asking to overrule Brown v. Board of Education and bring back the days of Plessy v. Ferguson. Instead, it's issued new regulations that will allow local school districts to have separate classes for boys and girls, and even separate schools.
Two years in the making, the new rules, announced Tuesday by the Education Department, will allow districts to create single-sex schools and classes as long as enrollment is voluntary. School districts that go that route must also make coeducational schools and classes of "substantially equal" quality available for members of the excluded sex.

The federal action is likely to accelerate efforts by public school systems to experiment with single-sex education, particularly among charter schools. Across the nation, the number of public schools exclusively for boys or girls has risen from 3 in 1995 to 241 today, said Leonard Sax, executive director of the National Association for Single Sex Public Education. That is a tiny fraction of the approximately 93,000 public schools across the country.

"You're going to see a proliferation of these," said Paul Vallas, chief of schools in Philadelphia, where there are four single-sex schools and plans to open two more. "There's a lot of support for this type of school model in Philadelphia."


It's worth noting that Philadelphia has a long history on this particular issue. In Vorcheimer v. School District of Philadelphia, 532 F. 2d 880 (3d Cir. 1975), aff'd 430 U.S. 703 (1977), the Supreme Court upheld, by an equally divided vote, a decision rejecting a girl's application to attend Philadelphia's all-male academic high school, Central High School. Because the Justices split 4-4, there was no opinion and the affirmance is not a precedent. In 1983, in Newberg v. Board of Public Education, 26 Pa. D.& C. 3rd 682 (1983), a state court ordered integration of Philadelphia's all-male high school on the grounds that the all-female high school and the all-male high school were "materially unequal" in facilities and education opportunities. In essence, the court found that the promise of separate but equal facilities for girls and boys was not genuine.

Since the 1970's there have been two major arguments for separate but equal schools dividing the sexes. The first wave of arguments was that single sex education actually benefited girls; the argument was that what benefits women at elite single sex private colleges like Wellesley or Smith also could benefit girls at public elementary and secondary schools. The second wave of arguments was that single sex education benefited boys, who were often emotionally behind girls of the same age and increasingly in need of educational discipline. That argument hasn't flown as well, in part because it requires that girls' educational interests be sacrificed to boys' interests, which, of course, reminds people of pretty standard forms of sex inequality practiced over the centuries. (One federal district court held a plan for single sex education for African-American boys in Detroit unconstitutional on this ground.). Hence the current argument made by advocates of single-sex education is that it benefits both girls and boys. (One also assumes the argument is that it benefits them equally.)

It's important to note that if these arguments were made for the constitutionality of educating whites and blacks separately, they would almost certainly fail. It's also important to note that the issue presented here is different from affirmative action programs, which courts have sometimes upheld under a strict scrutiny analysis. Affirmative action does not separate the races, it integrates them by including more minorities in majority white schools; the constitutional problem with affirmative action is that it employs overtly racial criteria to achieve this goal. Sometimes courts hold that this is constitutional, other times they hold that it is not. A school policy that required blacks and whites to attend separate schools, even based on purported educational benefits, would bear a very heavy burden of proof, and if there were any way to improve test scores without employing separate but equal, the program would fail.

Under current law, sex discriminations must be based on an exceedingly persuasive justification to survive a constitutional challenge. Assuming that improving test scores is a sufficiently important interest, state run or supported schools must show that they could not achieve these benefits without the separation.

Back in 2002 I wrote an short essay on an earlier version of these regulations for the Journal of Blacks in Higher Education. They wanted to know about the consequences of such a policy for African-American children, and whether single sex education might lead to single-race education. The essay is shaped with those concerns in mind. But I hope that it also gives you some insight into what the constitutional issues are and why Americans have viewed separating the sexes differently from separating the races. The focus of the essay is also important because many of the arguments for single-sex education are now being made not for the benefit of suburban schools but for charter schools in inner city areas, so questions of sex, race, and class are inevitably combined.

The key issue, as I explain below, is whether single-sex education revives old stereotypes about women's roles, whether single sex education sacrifices girls' interests to benefit boys, and finally, whether single-sex education is a cheap fix that does little to solve longer term issues of quality education in inner-city schools. These are key questions to consider in assessing whether the new Bush Administration regulations are constitutional.

* * * * * * * * *

Balkin, Jack M. "Is There a Slippery Slope From Single-Sex Education to Single-Race Education?" The Journal of Blacks in Higher Education (August 2002).

The Bush Administration has recently issued regulations permitting school districts to experiment with same-sex classes for elementary and secondary schools, arguing that in some cases separation of the sexes might help the educational process. The announcement of this experimental program has been greeted with only mild controversy in the daily papers. This in itself says a great deal about how the law of equality has developed in the United States in the past half century. The Bush Administration did not dare suggest the possibility that students might benefit from single-race schools, or from schools solely for Latino youth. After all, the canonical event in American civil rights law is the decision in Brown v. Board of Education, which held that schoolchildren could not be deliberately separated on the basis of their race. Yet single-sex education continues to exist in this country; and the U.S. Supreme Court has never squarely held that single-sex education in elementary and secondary schools is forbidden.

The Bush Administration's recent proposal suggests two related questions: First, why isn't single-sex education as troublesome as single-race education? Second, if single sex-classes could have genuine educational benefits, why wouldn't single-race classes for African-American children?

To answer these questions, we need to understand how race discrimination differs from sex discrimination. But more importantly, we must understand how these two forms of inequality have interacted with each other and with inequalities of class--in American history. That is because one cannot evaluate calls for single-sex education or single-race education for that matter-- without paying attention to the economic inequalities they tend to obscure.

The primary methods of unjust subordination of blacks in American history have been degradation and separation; for women they have been paternalism and role differentiation, emphasizing women's special responsibilities as caretakers. So whites-only policies always meant something different from men-only policies. Separation of blacks signaled their social inferiority and their enforced separation from white society. By contrast, separation of women actually reinforced their connection to men and their roles as men's wives, mothers, and daughters. While gender discrimination presumed that women would play a subordinate role within families headed by men, race discrimination was premised on keeping black and white families separate, so that they would not be social equals.

For these reasons single-sex education has never carried the same social meanings as single-race education. Moreover, as University of Chicago legal historian Jill Hasday has pointed out, single-sex education has always possessed a more benign connotation precisely because of the ways that it intersected with and reinforced class and race discrimination.

When we think of single-race schools, we think of dilapidated schoolhouses for blacks in the Jim Crow era; when we think of single-sex schools, we think of Wellesley. This is no accident. Single-sex education for women was an instrument of class inequality: it was originally reserved for elites, particularly in the East, in order to prepare women for life in society, and this led to its contemporary image as being largely innocuous, genteel, and even beneficial for women. Single-sex education for women, particularly at the university level, was a sign of class position, given that lower class women often received little education at all. This contrasts markedly with racially segregated education: Rich and poor whites alike were segregated from blacks because racial segregation confirmed and established white superiority and white solidarity, which was particularly important for lower class whites.

In fact, sex segregation in public schooling was connected in important ways to race segregation; especially after the decision in Brown v. Board of Education. Separating the sexes prevented mixing white women with black men. In the Jim Crow era, schools for blacks were usually not segregated by sex, because legislatures did not care much about the possible corruption of black women.

A recurring theme in calls for sex-segregated education has been the need to keep boys from being distracted by girls. Put another way, women were often seen as a cause of men's lack of success, so that it was necessary to separate them in order to ensure that men thrived. In the case of private religious schooling-- to which some poor and middle class parents might aspire-- single-sex education was a symbol of moral rectitude, suggesting the ability of school officials to instill proper ( i.e. traditional) values in their charges. Only much later did the notion gain credence that sex segregation allowed women to develop self-esteem so that they could effectively compete with men.

These historical facts tend to suggest why single-sex education carries very different freight than single-race education. Single-sex education, especially in private schools, was a symbol of economic status for women, not a symbol of material deprivation. That made it easier to for it to survive the second wave of American feminism in the 1960's and 1970's. Its elitist origins allowed it to be reinterpreted as an educational device that helped women become leaders and that even poor and middle class girls could aspire to and benefit from. Conversely, coeducation often did not guarantee an end to gender steering in programs and instruction, an end to separate facilities and programs for men and women, or equal opportunities for women, as one can witness from the continuing struggles over Title IX and women's athletics.

Today, when we think about proposals for single-sex schooling, we should keep in mind that both elements of race and class will inevitably be involved. One should have no illusions that simply because single-sex education seems benign in schools like Wellesley or Smith that it necessarily is so when it is transposed out of the paradigm of elite women's education and placed in the setting of inner-city schools In the urban setting, single-sex education tempts school administrators to focus on the interests of black boys to the detriment of black girls. It repeats in racialized form the familiar idea that girls are the cause of boys' lack of educational success and that boys must be kept free of distraction. Single-sex education may seem to serve the goals of class equality and upward mobility because it gives poor families something that only rich families were once able to afford, as well as offering the promise of discipline and moral rectitude. Yet it can also unwittingly become a method of preserving traditional gender roles for women. Perhaps most importantly, it can be embraced as a relatively cheap solution to educational problems in urban schools that diverts attention from severe long term problems of inequality and lack of educational opportunity in public education. Given a fixed educational budget, dollars could better be spent on improving general educational quality than on creating single-sex schools and classrooms.

As for the possibility that single-race schools might improve educational opportunity, the answer is quite simple: America already has plenty of single-race schools. They have been produced by the de facto segregation that reigns in this country fifty years after Brown v. Board of Education. A recent study by the Civil Rights Project at Harvard's John F. Kennedy School of Government estimates that more than a third of the nation's black schoolchildren currently attend schools with a minority enrollment of 90- 100%, and the percentage of black schoolchildren who attend such schools has been rising since the mid 1980's. There is no evidence that this de facto segregation has worked to the advantage of black and Latino children. If it has worked to the advantage of white children in suburban school districts, it is because those schools generally have vastly superior resources. Given these facts, it is highly unlikely that moving from de facto to de jure separation of the races will improve the lot of African-American or Latino children.

Separation of the races, like separation of the sexes, is a diversion from the real issue: educational equality in funding, resources, and attention.

Jack M. Balkin is Knight Professor of Constitutional Law and the First Amendment at Yale Law School. His latest book is "What Brown v. Board of Education Should Have Said" (N.Y.U. Press 2001).


Comments:

I confess I'm not persuaded; "states as laboratories" seems to apply here, and the invidious kind of gender discrimination that existed 100 years ago is largely past.

The devil is of course always in the details, such as funding, faculty, and programs for the schools.

I also wonder whether parents have to have the option of sending their kids to gender-integrated schools. It's not intuitively obvious that such an option would be de jure only (as opposed to the racial situation, where we could predict 90% of white parents opting against the integrated school).
 

You seem to focus on the impetus of single gender schooling being for the benefit of male students to the exclusion of female students. My education law prof told us that studies have actually shown the opposite; girls do better in all girls schools, but boys do not do better in all boy schools. Assuming this is true, does that change your opinion at all?
 

To the extent that gender roles are socially constructed, there is an argument and some evidence that these roles are reinforced in the coeducational setting and subverted in the single-sex setting. Anyway, one cannot simply deny as an article of faith that there are biological differences between boys and girls that might have some relevance to learning. I think there is a legitimate empirical question here about the value of single-sex education for children that should not be too readily foreclosed. To say that “single-sex education has always possessed a more benign connotation precisely because of the ways that it intersected with and reinforced class and race discrimination” is a pretty rhetorically loaded way to approach this question. One might say the same of education generally. Education has always been an “an instrument of class inequality.” The question is whether single-sex education for children promotes gender inequality, and, if so, which gender is disadvantaged. And, of course, there are other questions to be addressed. What about the value of socialization, for example?
 

Racial segregation makes very little sense unless you believe the melanin content of one's skin has an effect on learning.

However, the science appears to indicate that gender has a profound impact on the way a pupil learns. The claim that gender is merely a social construct has lost much of its currency over the past couple decades. This becomes even more obvious when children enter puberty and gender differences become stark.

I am not familiar with the science on how males and females interact in the classroom and how that may affect the learning of each gender. However, if the science indicates that the learning experience of a gender could be significantly improved in a particular subject or all subjects if the genders are segregated, I do not see a constitutional problem with gender segregated classes so long as participation is voluntary. It will be interesting to see if the Courts agree with my view.
 

"In the urban setting, single-sex education tempts school administrators to focus on the interests of black boys to the detriment of black girls. It repeats in racialized form the familiar idea that girls are the cause of boys' lack of educational success and that boys must be kept free of distraction."

I am not quite sure what this passage is intended to mean. You seem to be suggesting that even if single-sex education works, somehow the inner-city schools can't be trusted to get it right. I detect a whiff of paternalistic condescension here.

"Perhaps most importantly, it can be embraced as a relatively cheap solution to educational problems in urban schools that diverts attention from severe long term problems of inequality and lack of educational opportunity in public education. Given a fixed educational budget, dollars could better be spent on improving general educational quality than on creating single-sex schools and classrooms."

Well, again, let's assume hypothetically that single-sex education is proven to be beneficial. Because it is a "relatively cheap solution" you want to deny it to inner-city children? I would suggest that it would be a good idea to spend some of a limited budget on something that works and is relatively cheap.
 

"Separation of the races, like separation of the sexes, is a diversion from the real issue: educational equality in funding, resources, and attention."

Is it fair to say that in addressing the "real issue" the "funding, resources, and attention" can vary in bringing about "educational equality" based upon needs?

As for separation of sexes, might this unintentionally or indirectly deprive heterosexual students of equality of socialization?
 

Here's a fast observation:

There is a huge hetersexist assumption that many proponents of single-sex education make. That boys won't be sexually distracted by the girls and vice versa.

Of course, if some of the kids are gay, lesbian or bi.... Hmmmmmm.

Honestly, as a policy person, single sex schooling is an expensive perk most PUBLIC districts can ill-afford. And if history is any guide, the girls will get poorer materials, facilities, etc.
 

"unless you believe the melanin content of one's skin has an effect on learning"

In reality, this sort of thing occurs. Yes, not via "science," that is, innate abilities and such. But, socially and so forth. Such was a major factor behind arguments for segregation.

Separation by groups tend to be problematic when the state is involved because reality turns out to be messy. The split turns out to be rough, depending on the personalities involved.

This is why, e.g., we have a law to protect women sports. Previously, it was assumed women as a whole didn't really focus on sports. Or certain sports etc.

Integration is in place in public school to bring all citizens together to prepare themselves for adulthood. It is unclear to me how this development -- core to public school -- is advanced by balkanization by sex, race, gender, religion, or whatnot.

Each might have special needs; each surely do in some respect. Thus, certain religious groups have special needs, but the SC refused to allow a religious gerrymander. Some girls are better than some boys in certain subjects. etc.

Finally, one reason some (including women) argue for same sex education is that boys get special attention. This is likely true in various case, but the net result of segregation is that boys and girls are not educated together. They do not learn to live with each other.

Is this really a good thing from an educational standpoint? Social development is a key part of education. Thus, though experimentalization might have its good points, this sort of thing really rubs me the wrong way.
 

There is a paradox here which I will address in conceptual terms skipping the ultra-grammarian letter of the Department of Education's rule: namely, by the intrinsic effect of separating children, both residua, males/females, are disadvantaged.

The net effect is the absurd condition in which the sum of the parts is less than the whole.

That is, disadvantaged males without female companionship in studies; and similarly sequestered female children fail to develop social consciousness in a balanced heterosexual civilized way.

Simply put, the DoE regulation is perverse. But it will elicit lots of parsing and fretting from ostensible liberals who omit recognizing that there is nothing explicit in the Brown series of cases about ethnicity which foresaw the dualistic turn of events when the DoE would decide to separate children by gender.

Amiably viewed, however, it is in the tradition of western culture to do the most extravagant things in the name of some supernatant spirituality. To separate the boys and girls is like stripping the plants from the field and saying we will have monoculture. Children may be segregated legally, but the smart parents will keep their children from segregated schools, and both sexes in segregated schools will receive inferior education; the balanced kids, and the progeny of parents with insight and influence will attend gender balanced institutions.
 

The effect of segregation of the sexes will be to disadvantage the girls. This is because right now the boys are seen as somehow or other the victims of coeducation, incapable of performing in a so-called feminized environment. That teh environment was one created by males for males over the past centuries seems to escape male notice; the fear is that since girls are starting to equal or exceed boys performance, boys must be disadvantaged, so we must save the boys from themselves and push girls out. Since nowadays we believe that girls can do well in this anomalous and male created environment, no one will review the results for the girls, and they will expend huge amounts of money trying to detach boys' brains from the TV culture they are immersed in, while the schools for girls will gradually dissolve into "stupid" farms. And boys schools are notorious for the nastiness and bullying that occurs between boys, as well as for homosexual behaviors (girls schools have a lot of homoeroticism too) If anyone thinks this all is silly, please review the history of all boys' schools in England, and realise that "Lord of the Flies" was about English schoolboys, although granted it is a story and not to be confused with reality.
 

"And boys schools are notorious for . . . homosexual behaviors (girls schools have a lot of homoeroticism too)"

Not that there is anything wrong with that, of course.
 

Bart,

The whole nature/nurture nonesense is exactly that. We can't know how socially constructed gender is, because we can't seperate out the variables. All we can do is look at specific issues, such as which genes affect gonad-development, and how much does giving kids guns as toy influence their loves of guns. The big questions are pointless attempts to get funding.

However, any genetic bases for differences in gender learning argue FOR coed education, not against. For example, if females do have an average disability in learning math due to genetics/hormones, then separating the genders will inevitably lead to female mathematical geniuses having limited opportunities to train their craft; they won't have the teachers allocated to them, and they won't have peers to help them hone their skills.

As a sociological question this is just a slam dunk -- the individual variation in brain development are massively greater than inter-gender differences, without even trying to eliminate the effects of socialization. And eliminating the effect of socialization, anyhow is impossible without controlling socialization, since sociological differences in human being have to be reflected as biological differences.
 

A few points perhaps worth considering.
1. There may be a big difference between majority imposed segregation that hives off a minority, and the self-segregation of members of two groups that are basically equal in numbers and growing more equal across relevant measures of social welfare. The element of choice present here leads one to think that the decision whether to be in a divided school brings with it the logic of the market. Those who will on balance benefit from single sex education can sign on, those who would not can stay put, and the individual "consumer" is in a far better position to know the category into which she or he falls than others.
2. What is the relative weight of student performance vs. facilities in measuring whether sex segregated schools are desirable? Perhaps improved performance--which of course is an empirical matter for which there ought to be reliable studies--is more important than equality of facilities such that any deviations from equality might be thought an acceptable cost for higher achievement.
But perhaps not. Arguably unequal facilities would impact the ways in which the segregated sets of students understand and experience the educational component of their lives. And since this component looms so large in any student's life, it could also impact self-worth and the understanding of one's place in society and life prospects. What I am suggesting is that facilities, level of qualification of teachers, and the like may, at first blush, be thought mostly to have instrumental value, in which case their evaluation might best be accomplished by the ends that they are instruments for--namely student performance (academic and otherwise). On second thought, however, the inevtable attachment between students and their schools could very well mean that the material quality of schools matters in other ways that are personal and part of the store of objects which people rely on to provide meaning to their own circumstances and events.
3. What effect would segregation have on unmooring young men and women in these schools from gender stereotypes. Without first hand knowledge, it seems two very different stories are plausible. Perhaps segregation causes schools to allocate their curricular and extra-curricular resources and tune their pedagogy towards what females and males traditionally want, value, or do.
Alternaitvely, it may be the case that segregation is more liberating than confining--that it gives men and women the space and breathing room to explore without having to fight through the difficulties of the status quo of gender roles being simply assumed or imposed "from above."
4. Any thoroughgoing examination of this policy would, I thin, have to kbe concerned with what happens upon graduaton--when the segregation ends and the graduates enter the next phase. How would women and men educated in segregated instituions relate to one another when the segregation is over? Would differences emerge as a result of being isolated during important and formative years of learning and growth? If so, in what ways positive, and in what ways negative?
And, for that matter, would segregation during these formative years bleed into increased levels of the self-segregation of the sexes in adulthood?
 

There are single-sex publically funded schools in the United Kingdom. Most of them are grammar schools, implying that the fees are paid to the mortgage holder rather than to the school. It is not clear that any increase in outcome in these schools is due to sexual separation rather than selection.

However, this study indicates that girls attending single-sex comprehensives (non-posh) showed better results than those in co-ed, though for grammar school students there was no difference. The differences for boys were limited to specific areas, though there appears to be some benefit from single-sex education.

"The analysis of the impact of single-sex education on pupil performance indicated that, even after controlling for prior achievement and other background factors, girls in single-sex comprehensive schools achieved better results than their peers in mixed schools for all the outcomes measured, except the number of GCSEs taken. The measured difference was particularly striking for average GCSE science score, for which girls in single-sex schools could be expected to achieve over a third of a grade better than similar pupils in mixed schools. The analysis also suggested that single-sex schooling particularly benefited girls at the lower end of the ability range. In contrast, no performance gains were detected for girls attending single-sex grammar schools.

No overall differences were found between the performance of boys in single-sex and mixed comprehensive schools. However, more detailed investigation revealed that boys with lower prior attainment achieved better average GCSE scores in single-sex schools, while boys with higher prior attainment took slightly more science GCSEs and achieved higher total GCSE science scores in single-sex schools. It was also found that boys attending single-sex grammar schools achieved better results than those in mixed grammar schools for many of the outcomes measured."
 

mesothelioma Mesotheliomais a form of cancer that is almost always caused by exposure to Asbestos In this disease, malignant cells develop in the mesothelium, a protective lining that covers most of the body's internal organs. Its most common site is the pleura (outer lining of the lungs and internal chest wall), but it may also occur in the peritoneum (the lining of the abdominal cavity), the heart the pericardium (a sac that surrounds the heart or tunica vaginalis.
Most people who develop
mesothelioma have worked on jobs where they inhaled asbestos particles, or they have been exposed to asbestos dust and fiber in other ways. Washing the clothes of a family member who worked with asbestos can also put a person at risk for developing Mesothelioma Unlike lung cancer, there is no association between mesothelioma and smoking but smoking greatly increases risk of other asbestos induced cancer.Compensation via
Asbestos funds or lawsuits is an important issue in
mesothelioma The symptoms of
mesothelioma include shortness of breath due to pleural effusion (fluid between the lung and the chest wall or chest wall pain, and general symptoms such as weight loss. The diagnosis may be suspected with chest X-ray and CT scan and is confirmed with a biopsy (tissue sample) and microscopic examination. A thoracoscopy inserting a tube with a camera into the chest) can be used to take biopsies. It allows the introduction of substances such as talc to obliterate the pleural space (called pleurodesis, which prevents more fluid from accumulating and pressing on the lung. Despite treatment with chemotherapy, radiation therapy or sometimes surgery, the disease carries a poor prognosis. Research about screening tests for the early detection of mesothelioma is ongoing.
Symptoms of mesothelioma may not appear until 20 to 50 years after exposure to asbestos. Shortness of breath, cough, and pain in the chest due to an accumulation of fluid in the pleural space are often symptoms of pleural
mesotheliomaSymptoms of peritoneal
mesothelioma include weight loss and cachexia, abdominal swelling and pain due to ascites (a buildup of fluid in the abdominal cavity). Other symptoms of peritoneal
mesothelioma may include bowel obstruction, blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by
mesothelioma or by other, less serious conditions.
Mesothelioma that affects the pleura can cause these signs and symptoms:
chest wall pain
pleural effusion, or fluid surrounding the lung
shortness of breath
fatigue or anemia
wheezing, hoarseness, or cough
blood in the sputum (fluid) coughed up hemoptysis
In severe cases, the person may have many tumor masses. The individual may develop a pneumothorax, or collapse of the lung The disease may metastasize, or spread, to other parts of the body.
Tumors that affect the abdominal cavity often do not cause symptoms until they are at a late stage. Symptoms include:
abdominal pain
ascites, or an abnormal buildup of fluid in the abdomen
a mass in the abdomen
problems with bowel function
weight loss
In severe cases of the disease, the following signs and symptoms may be present:
blood clots in the veins, which may cause thrombophlebitis
disseminated intravascular coagulation a disorder causing severe bleeding in many body organs
jaundice, or yellowing of the eyes and skin
low blood sugar level
pleural effusion
pulmonary emboli, or blood clots in the arteries of the lungs
severe ascites
A
mesothelioma does not usually spread to the bone, brain, or adrenal glands. Pleural tumors are usually found only on one side of the lungs
Diagnosing
mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history. A history of exposure to asbestos may increase clinical suspicion for
mesothelioma A physical examination is performed, followed by chest X-ray and often lung function tests. The X-ray may reveal pleural thickening commonly seen after asbestos exposure and increases suspicion of
mesothelioma A CT (or CAT) scan or an MRI is usually performed. If a large amount of fluid is present, abnormal cells may be detected by cytology if this fluid is aspirated with a syringe. For pleural fluid this is done by a pleural tap or chest drain, in ascites with an paracentesis or ascitic drain and in a pericardial effusion with pericardiocentesis. While absence of malignant cells on cytology does not completely exclude
mesothelioma it makes it much more unlikely, especially if an alternative diagnosis can be made (e.g. tuberculosis, heart failure
If cytology is positive or a plaque is regarded as suspicious, a biopsy is needed to confirm a diagnosis of
mesothelioma A doctor removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples.
If the cancer is in the abdomen, the doctor may perform a laparoscopy. To obtain tissue for examination, the doctor makes a small incision in the abdomen and inserts a special instrument into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.
There is no universally agreed protocol for screening people who have been exposed to
asbestosScreening tests might diagnose mesothelioma earlier than conventional methods thus improving the survival prospects for patients. The serum osteopontin level might be useful in screening asbestos-exposed people for
mesotheliomaThe level of soluble mesothelin-related protein is elevated in the serum of about 75% of patients at diagnosis and it has been suggested that it may be useful for screening. Doctors have begun testing the Mesomark assay which measures levels of soluble mesothelin-related proteins (SMRPs) released by diseased mesothelioma cells
Incidence
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. The incidence rate is approximately one per 1,000,000. The highest incidence is found in Britain, Australia and Belgium: 30 per 1,000,000 per year. For comparison, populations with high levels of smoking can have a lung cancer incidence of over 1,000 per 1,000,000. Incidence of malignant mesothelioma currently ranges from about 7 to 40 per 1,000,000 in industrialized Western nations, depending on the amount of asbestos exposure of the populations during the past several decades. It has been estimated that incidence may have peaked at 15 per 1,000,000 in the United States in 2004. Incidence is expected to continue increasing in other parts of the world. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age. Approximately one fifth to one third of all mesotheliomas are peritoneal.
Between 1940 and 1979, approximately 27.5 million people were occupationally exposed to asbestos in the United States.[ Between 1973 and 1984, there has been a threefold increase in the diagnosis of pleural mesothelioma in Caucasian males. From 1980 to the late 1990s, the death rate from mesothelioma in the USA increased from 2,000 per year to 3,000, with men four times more likely to acquire it than women. These rates may not be accurate, since it is possible that many cases of mesothelioma are misdiagnosed as adenocarcinoma of the lung, which is difficult to differentiate from mesothelioma.
Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure exists in almost all cases. However, mesothelioma has been reported in some individuals without any known exposure to asbestos. In rare cases, mesothelioma has also been associated with irradiation, intrapleural thorium dioxide (Thorotrast), and inhalation of other fibrous silicates, such as erionite.
asbestos
is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven.
asbestos
has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
The combination of smoking and
asbestos exposure significantly increases a person's risk of developing cancer of the airways (lung cancer bronchial carcinoma). The Kent brand of cigarettes used
mesothelioma in its filters for the first few years of production in the 1950s and some cases of
mesothelioma have resulted. Smoking modern cigarettes does not appear to increase the risk of mesothelioma.
Some studies suggest that simian virus 40 may act as a cofactor in the development of mesothelioma.
Asbestos was known in antiquity, but it wasn't mined and widely used commercially until the late 1800s. Its use greatly increased during World War II Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with
asbestos exposure were not publicly known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos mines and mills, producers of asbestos products, workers in the heating and construction industries, and other tradespeople. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of
asbestos exposure in the workplace, and created guidelines for engineering controls and respirators, protective clothing, exposure monitoring, hygiene facilities and practices, warning signs, labeling, recordkeeping, and medical exams. By contrast, the British Government's Health and Safety Executive (HSE) states formally that any threshold for
mesothelioma must be at a very low level and it is widely agreed that if any such threshold does exist at all, then it cannot currently be quantified. For practical purposes, therefore, HSE does not assume that any such threshold exists. People who work with
asbestos wear personal protective equipment to lower their risk of exposure. Recent findings have shown that a mineral called erionite has been known to cause genetically pre-dispositioned individuals to have malignant mesothelioma rates much higher than those not pre-dispositioned genetically. A study in Cappadocia, Turkey has shown that 3 villiages in Turkey have death rates of 51% attributed to erionite related
mesotheliomaExposure to
asbestos fibres has been recognised as an occupational health hazard since the early 1900s. Several epidemiological studies have associated exposure to asbestos with the development of lesions such as asbestos bodies in the sputum, pleural plaques, diffuse pleural thickening, asbestosis, carcinoma of the lung and larynx, gastrointestinal tumours, and diffuse mesothelioma of the pleura and peritoneum.
The documented presence of
asbestos fibres in water supplies and food products has fostered concerns about the possible impact of long-term and, as yet, unknown exposure of the general population to these fibres. Although many authorities consider brief or transient exposure to
asbestos fibres as inconsequential and an unlikely risk factor, some epidemiologists claim that there is no risk threshold. Cases of mesothelioma have been found in people whose only exposure was breathing the air through ventilation systems. Other cases had very minimal (3 months or less) direct exposure.
Commercial
asbestos mining at Wittenoom, Western Australia, occurred between 1945 and 1966. A cohort study of miners employed at the mine reported that while no deaths occurred within the first 10 years after crocidolite exposure, 85 deaths attributable to mesothelioma had occurred by 1985. By 1994, 539 reported deaths due to mesothelioma had been reported in Western Australia.
Family members and others living with
asbestos workers have an increased risk of developing
mesothelioma and possibly other asbestos related diseases. This risk may be the result of exposure to
asbestos dust brought home on the clothing and hair of
asbestos workers. To reduce the chance of exposing family members to asbestosMany building materials used in both public and domestic premises prior to the banning of
asbestos may contain
asbestos Those performing renovation works or activities may expose themselves to asbestos dust. In the UK use of Chrysotile asbestos was banned at the end of 1999. Brown and blue
asbestos was banned in the UK around 1985. Buildings built or renovated prior to these dates may contain asbestos materials.
For patients with localized disease, and who can tolerate a radical surgery, radiation is often given post-operatively as a consolidative treatment. The entire hemi-thorax is treated with radiation therapy, often given simultaneously with chemotherapy. Delivering radiation and chemotherapy after a radical surgery has led to extended life expectancy in selected patient populations with some patients surviving more than 5 years. As part of a curative approach to
mesothelioma radiotherapy is also commonly applied to the sites of chest drain insertion, in order to prevent growth of the tumor along the track in the chest wall.
Although
mesothelioma is generally resistant to curative treatment with radiotherapy alone, palliative treatment regimens are sometimes used to relieve symptoms arising from tumor growth, such as obstruction of a major blood vessel.
Radiation Therapy when given alone with curative intent has never been shown to improve survival from
mesothelioma The necessary radiation dose to treat mesothelioma that has not been surgically removed would be very toxic.
Chemotherapy is the only treatment for
mesothelioma that has been proven to improve survival in randomised and controlled trials. The landmark study published in 2003 by Vogelzang and colleagues compared cisplatin chemotherapy alone with a combination of cisplatin and pemetrexed (brand name Alimta) chemotherapy) in patients who had not received chemotherapy for malignant pleural mesothelioma previously and were not candidates for more aggressive "curative" surgery. This trial was the first to report a survival advantage from chemotherapy in malignant pleural
mesothelioma showing a statistically significant improvement in median survival from 10 months in the patients treated with cisplatin alone to 13.3 months in the combination pemetrexed group in patients who received supplementation with folate and vitamin B12. Vitamin supplementation was given to most patients in the trial and pemetrexed related side effects were significantly less in patients receiving pemetrexed when they also received daily oral folate 500mcg and intramuscular vitamin B12 1000mcg every 9 weeks compared with patients receiving pemetrexed without vitamin supplementation. The objective response rate increased from 20% in the cisplatin group to 46% in the combination pemetrexed group. Some side effects such as nausea and vomiting, stomatitis, and diarrhoea were more common in the combination pemetrexed group but only affected a minority of patients and overall the combination of pemetrexed and cisplatin was well tolerated when patients received vitamin supplementation; both quality of life and lung function tests improved in the combination pemetrexed group. In February 2004, the United States Food and Drug Administration approved pemetrexed for treatment of malignant pleural mesothelioma. However, there are still unanswered questions about the optimal use of chemotherapy, including when to start treatment, and the optimal number of cycles to give.
Cisplatin in combination with raltitrexed has shown an improvement in survival similar to that reported for pemetrexed in combination with cisplatin, but raltitrexed is no longer commercially available for this indication. For patients unable to tolerate pemetrexed, cisplatin in combination with gemcitabine or vinorelbine is an alternative, although a survival benefit has not been shown for these drugs. For patients in whom cisplatin cannot be used, carboplatin can be substituted but non-randomised data have shown lower response rates and high rates of haematological toxicity for carboplatin-based combinations, albeit with similar survival figures to patients receiving cisplatin.
In January 2009, the United States FDA approved using conventional therapies such as surgery in combination with radiation and or chemotherapy on stage I or II Mesothelioma after research conducted by a nationwide study by Duke University concluded an almost 50 point increase in remission rates.
Treatment regimens involving immunotherapy have yielded variable results. For example, intrapleural inoculation of Bacillus Calmette-Guérin (BCG) in an attempt to boost the immune response, was found to be of no benefit to the patient (while it may benefit patients with bladder cancer.
mesothelioma cells proved susceptible to in vitro lysis by LAK cells following activation by interleukin-2 (IL-2), but patients undergoing this particular therapy experienced major side effects. Indeed, this trial was suspended in view of the unacceptably high levels of IL-2 toxicity and the severity of side effects such as fever and cachexia. Nonetheless, other trials involving interferon alpha have proved more encouraging with 20% of patients experiencing a greater than 50% reduction in tumor mass combined with minimal side effects.
A procedure known as heated intraoperative intraperitoneal chemotherapy was developed by at the Washington Cancer Institute. The surgeon removes as much of the tumor as possible followed by the direct administration of a chemotherapy agent, heated to between 40 and 48°C, in the abdomen. The fluid is perfused for 60 to 120 minutes and then drained.
This technique permits the administration of high concentrations of selected drugs into the abdominal and pelvic surfaces. Heating the chemotherapy treatment increases the penetration of the drugs into tissues. Also, heating itself damages the malignant cells more than the normal cells.

What is the mesothelium?
The mesothelium is a membrane that covers and protects most of the internal organs of the body. It is composed of two layers of cells: One layer immediately surrounds the organ; the other forms a sac around it. The mesothelium produces a lubricating fluid that is released between these layers, allowing moving organs (such as the beating heart and the expanding and contracting lungs to glide easily against adjacent structures.
The mesothelium has different names, depending on its location in the body. The peritoneum is the mesothelial tissue that covers most of the organs in the abdominal cavity. The pleura is the membrane that surrounds the lungs and lines the wall of the chest cavity. The pericardium covers and protects the heart. The
mesothelioma tissue surrounding the male internal reproductive organs is called the tunica vaginalis testis. The tunica serosa uteri covers the internal reproductive organs in women.
What is mesothelioma?
mesothelioma (cancer of the mesothelium) is a disease in which cells of the mesothelium become abnormal and divide without control or order. They can invade and damage nearby tissues and organs.
cancer cells can also metastasize (spread) from their original site to other parts of the body. Most cases of mesothelioma begin in the pleura or peritoneum.
How common is mesothelioma?
Although reported incidence rates have increased in the past 20 years, mesothelioma is still a relatively rare cancer. About 2,000 new cases of mesothelioma are diagnosed in the United States each year. Mesothelioma occurs more often in men than in women and risk increases with age, but this disease can appear in either men or women at any age.
What are the risk factors for mesothelioma?
Working with asbestos is the major risk factor for mesothelioma. A history of asbestos exposure at work is reported in about 70 percent to 80 percent of all cases. However, mesothelioma has been reported in some individuals without any known exposure to
Asbestos is the name of a group of minerals that occur naturally as masses of strong, flexible fibers that can be separated into thin threads and woven. asbestos has been widely used in many industrial products, including cement, brake linings, roof shingles, flooring products, textiles, and insulation. If tiny asbestos particles float in the air, especially during the manufacturing process, they may be inhaled or swallowed, and can cause serious health problems. In addition to mesothelioma, exposure to asbestos increases the risk of lung cancer, asbestosis (a noncancerous, chronic lung ailment), and other cancers, such as those of the larynx and kidney.
Smoking does not appear to increase the risk of mesothelioma. However, the combination of smoking and asbestos exposure significantly increases a person's risk of developing cancer of the air passageways in the lung.
Who is at increased risk for developing mesothelioma?
asbestos has been mined and used commercially since the late 1800s. Its use greatly increased during World War II. Since the early 1940s, millions of American workers have been exposed to asbestos dust. Initially, the risks associated with asbestos exposure were not known. However, an increased risk of developing mesothelioma was later found among shipyard workers, people who work in asbestos. Today, the U.S. Occupational Safety and Health Administration (OSHA) sets limits for acceptable levels of asbestos exposure in the workplace. People who work with asbestos wear personal protective equipment to lower their risk of exposure.
The risk o f asbestosrelated disease increases with heavier exposure to asbestos and longer exposure time. However, some individuals with only brief exposures have developed mesothelioma On the other hand, not all workers who are heavily exposed develop asbestos-related diseases.
There is some evidence that family members and others living with asbestos workers have an increased risk of developing mesothelioma, and possibly other asbestos-related diseases. This risk may be the result of exposure to
asbestos dust brought home on the clothing and hair of
asbestos workers. To reduce the chance of exposing family members to
asbestos fibers, asbestos workers are usually required to shower and change their clothing before leaving the workplace.
What are the symptoms of mesothelioma?
Symptoms of mesothelioma may not appear until 30 to 50 years after exposure to
asbestos Shortness of breath and pain in the chest due to an accumulation of fluid in the pleura are often symptoms of pleural mesothelioma. Symptoms of peritoneal mesothelioma include weight loss and abdominal pain and swelling due to a buildup of fluid in the abdomen. Other symptoms of peritoneal mesothelioma may include bowel obstruction blood clotting abnormalities, anemia, and fever. If the cancer has spread beyond the mesothelium to other parts of the body, symptoms may include pain, trouble swallowing, or swelling of the neck or face.
These symptoms may be caused by
mesothelioma or by other, less serious conditions. It is important to see a doctor about any of these symptoms. Only a doctor can make a diagnosis
How is
mesotheliomadiagnosed?
Diagnosing mesothelioma is often difficult, because the symptoms are similar to those of a number of other conditions. Diagnosis begins with a review of the patient's medical history, including any history of asbestos exposure. A complete physical examination may be performed, including x-rays of the chest or abdomen and lung function tests. A CT (or CAT) scan or an MRI may also be useful. A CT scan is a series of detailed pictures of areas inside the body created by a computer linked to an x-ray machine. In an MRI, a powerful magnet linked to a computer is used to make detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed.
A biopsy is needed to confirm a diagnosis of mesothelioma. In a biopsy, a surgeon or a medical oncologist (a doctor who specializes in diagnosing and treating cancer) removes a sample of tissue for examination under a microscope by a pathologist. A biopsy may be done in different ways, depending on where the abnormal area is located. If the
cancer is in the chest, the doctor may perform a thoracoscopy. In this procedure, the doctor makes a small cut through the chest wall and puts a thin, lighted tube called a thoracoscope into the chest between two ribs. Thoracoscopy allows the doctor to look inside the chest and obtain tissue samples. If the
cancer is in the abdomen, the doctor may perform a peritoneoscopy. To obtain tissue for examination, the doctor makes a small opening in the abdomen and inserts a special instrument called a peritoneoscope into the abdominal cavity. If these procedures do not yield enough tissue, more extensive diagnostic surgery may be necessary.
If the diagnosis is mesothelioma, the doctor will want to learn the stage (or extent) of the disease. Staging involves more tests in a careful attempt to find out whether the cancer has spread and, if so, to which parts of the body. Knowing the stage of the disease helps the doctor plan treatment.
Mesothelioma is described as localized if the cancer is found only on the membrane surface where it originated. It is classified as advanced if it has spread beyond the original membrane surface to other parts of the body, such as the lymph nodes, lungs, chest wall, or abdominal organs.
How is
mesotheliomatreated?
Treatment for mesothelioma depends on the location of the
cancerthe stage of the disease, and the patient's age and general health. Standard treatment options include surgery, radiation therapy, and chemotherapy. Sometimes, these treatments are combined.
Surgery is a common treatment for
mesotheliomaThe doctor may remove part of the lining of the chest or abdomen and some of the tissue around it. For cancer of the pleura (pleural
mesotheliomaa lung may be removed in an operation called a pneumonectomy. Sometimes part of the diaphragm, the muscle below the lungs that helps with breathing, is also removed.
Stereo Tactic Radiation Therapy also called radiotherapy, involves the use of high-energy rays to kill
cancercells and shrink tumors Radiation therapy affects the
cancercells only in the treated area. The radiation may come from a machine (external radiation) or from putting materials that produce radiation through thin plastic tubes into the area where the
cancercells are found (internal radiation therapy).
Chemotherapy is the use of anticancer drugs to kill cancer cells throughout the body. Most drugs used to treat
mesotheliomaare given by injection into a vein (intravenous, or IV). Doctors are also studying the effectiveness of putting chemotherapy directly into the chest or abdomen (intracavitary chemotherapy).
To relieve symptoms and control pain, the doctor may use a needle or a thin tube to drain fluid that has built up in the chest or abdomen. The procedure for removing fluid from the chest is called thoracentesis. Removal of fluid from the abdomen is called paracentesis. Drugs may be given through a tube in the chest to prevent more fluid from accumulating. Radiation Therapy and surgery may also be helpful in relieving symptoms.
 

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