Did cancer rates "quadruple" in Smederevo, Serbia due to a Chinese steel mill?
Flaws and omissions in a Reuters report
Some of you may have found that the March 19 Pekingnology post is no longer available on the Web. That’s because I took it down in hours, after being politely approached and kindly reminded that copyright issues may be at hand. I explained that on Twitter the next day but forgot to address it on Pekingnology - so here it is, with apologies to both you and Die Zeit.
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It’s been seven months since Pekingnology last posted what one reader used to call a “debunk” piece, which led to corrections on the opinion pages of the Wall Street Journal and the Washington Post, respectively.
Well, this is another one. As in the past, I respectfully wrote to the reporter and the editor of the criticized piece beforehand - in this case, twice. Unfortunately, I haven’t heard back.
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On November 9, 2021, Reuters reported from Belgrade, Serbia that "cancer rates have quadrupled in under a decade" in the city of Smederevo - hosting a Chinese-owned steel mill - "the municipality of around 100,000 people reported 6,866 cancer cases in 2019, up from 1,738 in 2011."
Repeated in its video report and highlighted in several tweets, those were the only set of numbers in the story, which was also picked up by The Telegraph and South China Morning Post.
This newsletter is an argument with that only set of numbers in the report.
I want to emphasize this is not an attempt to question the description of the local environment, but just the numbers, plus a bit of history
Cancer rates have quadrupled in under a decade…
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According to data from the Smederevo public health body, which a watchdog called Tvrdjava obtained through a freedom of information request and shared with Reuters, the municipality of around 100,000 people reported 6,866 cancer cases in 2019, up from 1,738 in 2011.
China's biggest steelmaker, Hesteel, bought it from the Serbian state for 46 million euros ($53 million) five years ago.
The Reuters report did not furnish the raw data - it isn’t obliged to, though.
Upon some research, it is found that Tvrdjava, which shared the numbers with Reuters, posted a table on its Facebook page days before the report, in October 2021
(The post was in Serbian, and the English version is auto-translated by Facebook.)
So this is the table that the Reuters report apparently relied upon - the number at the last line from 2019 is 6,866 and the number from 2011 is 1,738, matching the numbers in the report.
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First of all, and this is the easiest one, a Chinese company took over the ailing steel mill only on July 1, 2016. This is actually in the report
China's biggest steelmaker, Hesteel, bought it from the Serbian state for 46 million euros ($53 million) five years ago.
But the dominant message of the report, as reflected in the titles and the tweets, compared the numbers in 2011 and 2019.
The table put the morbidity numbers for 2015 at 4,160 and for 2016 at 4,370. So about half of the “quadruple” - which will be further challenged - simply cannot be linked with Chinese involvement. The Chinese weren’t even there, by the report’s own admission.
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Secondly, the numbers cited by the Reuters report, as shown in the table, inflate what’s internationally recognized as cancer numbers.
According to the International Statistical Classification of Diseases and Related Health Problems 10th Revision (ICD-10)-WHO Version, C00-C97 are used to identify malignant neoplasms, D00-D09 are in situ neoplasms, D10-D36 are benign neoplasms, and D37-D48 are neoplasms of uncertain or unknown behavior.
The international practice is counting only malignant neoplasms (C00-C97) as cancer:
The officially-approved Canadian Cancer Statistics count only C00-C97.
The official Australian statistics count "All cancers combined incorporates ICD-10 cancer codes C00–C96 (Malignant neoplasms of specific sites)".
The official UK statistics also count only C00-C97: "only malignant neoplasms, C00 to C97 excluding C44, have been included in this bulletin…".
In summary, only C00-C97 are cancer codes, internationally.
But
But the table and thus the Reuters-reported numbers expands beyond cancer codes to include also D00-D48.
Then both numbers - "6,866 cancer cases in 2019, up from 1,738 in 2011" are not “cancer cases” by international standards.
Granted, the table itself may include a discrepancy - it notes “Maligne Bolesti Šifrovane Pod Dijagnozama Maligniteta” which is translated by Google as "Malignant Diseases Encrypted Under Diagnosis Of Malignancy”, but also notes C00-D48, which according to ICD-10 includes the D codes - situ neoplasms, benign neoplasms, and neoplasms of uncertain or unknown behavior - that internationally aren’t included in cancer statistics.
It’s not apparent if either Tvrdjava or Reuters tried to clarify that with the source of the data. Neither said they tried to do that.
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Thirdly, setting aside that half of the numbers in the table are irrelevant to Chinese involvement, and that they are inflated by including non-malignant neoplasms, the numbers aren’t used to calculate cancer rates by international standards.
Why?
The table used the word morbidity (“MORBIDITET”).
According to Principles of Epidemiology in Public Health Practice, Third Edition, from the CDC in the United States, "Measures of morbidity frequency characterize the number of persons in a population who become ill (incidence) or are ill at a given time (prevalence)".
In my opinion, the Reuters report’s language was a bit vague
Cancer rates have quadrupled in under a decade…
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According to data from the Smederevo public health body, which a watchdog called Tvrdjava obtained through a freedom of information request and shared with Reuters, the municipality of around 100,000 people reported 6,866 cancer cases in 2019, up from 1,738 in 2011.
“Cancer rates” sound like incidence, if you check the literature on cancer, for example at the U.S. National Cancer Institute:
But according to an emailed explanation from the Smederevo public health body, the numbers in the table are for prevalence, because they include cases diagnosed from previous years.
Translated to English by Google
Also, the numbers just can’t be incidence numbers. The world's highest cancer incident rate is found in Australia - 452.4 per 100,000 people, according to the France-based International Agency for Cancer Research, part of the World Health Organization.
Thousands of new cancer cases every year in Smederevo, of around 100,000 people, are simply unimaginable.
So we have established, by both the source of the numbers and logic, that the numbers in the table are for prevalence.
Which is a problem. Internationally, incidence is used to calculate cancer rates.
The officially-approved Canadian Cancer Statistics features "incidence" 248 times throughout the report. Australian cancer statistics also feature incidence heavily.
I can go on but the fact is, internationally, incidence is used to calculate cancer rates.
That prevalence is internationally not used speaks for itself that it’s not a scientific measure. And the Smederevo public health body, upon being approached, said the table can not be used for analysis.
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The fourth point: are there any incidence numbers for cancer rates in Smederevo? If so, what picture does it paint? How do they compare to "cancer rates have quadrupled in under a decade" which is in fact based on prevalence?
Smederevo, as the Reuters report says, is a town of 100,000 people. It is part of the Danube (Podunavlje) District, of 200,000 people.
The Health statistical yearbook of the Republic of Serbia, which is available online, downloadable, and has an English-language version, via the Institute of Public Health of Serbia, shows that the latest available data are for the Year 2018, as included in the 2020 Yearbook.
It shows the standardized cancer incidence rate per 100,000 population in the Danube (Podunavlje) District, in which Smederevo is a part, was 283.2 among males and 236.4 among females in 2018, the latest year where numbers are available in the Health statistical yearbook of the Republic of Serbia.
Going back a decade to the Year 2011 - the year that the Reuters report picked - as included in Yearbook 2013, the standardized cancer incidence rate per 100,000 population in the Danube (Podunavlje) District was 276.8 among males and 231.0 among females.
So it’s like this:
Year 2011 2018
Males 276.8 283.2
Females 231 236.4
Again, these numbers are standardized cancer rates per 100,000 people for the Danube region.
Given that Smederevo is part of Danube and has half the population, this is a referenceable measure.
And it’s an increase, but it’s a far cry from "cancer rates have quadrupled in under a decade".
Put it another way, if Smederevo’s cancer rates had indeed quadrupled, and because it has half the population of Danube, the cancer rates for the Danube would have jumped bigly.
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Inquisitive minds would ask: what if the Health statistical yearbook of the Republic of Serbia is unreliable?
Well, I don’t know. But the health yearbooks are published every year and publicly downloadable, and even available in English. That’s on the record. Something like that should be quoted, especially if it contradicts the storyline - it can be challenged, but not ignored.
In summary:
The key message - the “quadruple” - comes from comparing prevalence numbers in 2011 and 2019, but by the report’s own admission the Chinese weren’t even there before July 1, 2016.
The report failed to see that numbers in the table include cases that aren’t counted as numbers internationally.
The report failed to clearly identify that the numbers in the table are for prevalence, which is not the way to calculate cancer rates internationally. The international standard practice is to use incidence numbers.
The report failed to cite easily accessible incidence numbers, which paint a starkly different picture from the “quadruple”.
Fundamentally, the report cites a table already available on Facebook and quotes it without asking questions. There are no words in the report which showed the Smederevo public health body, the source of the table, had been approached to give further explanations, or third-party experts or numbers like the health yearbooks or had been consulted.
Let me stress again this is not an attempt to question the description of the local environment, but just the only set of numbers that feature prominently in the title, the tweets, and the video, plus a bit of history.
According to Tvrdjava’s Facebook post [Serbian], its project "Raising the Dust" against industrial pollution is part of the "Citizens Have the Power" initiative.
According to [Serbian] the coordinator of "Raising the Dust" and also an activist of Tvrdjava, who was writing on Serbian news site Danas [Serbian], the "Raising the Dust" project was implemented through the "Citizens Have the Power" initiative by the Serbian NGO CRTA in cooperation with USAID, the U.S. Agency for International Development. USAID granted two million U.S. dollars to CRTA from 2018 to 2022.
You may feel uncomfortable in including this link in reporting, which the Reuters story didn’t. But at a time when almost every possible China link is scrutinized to sniff out Chinese state influence, some reciprocity may not be inappropriate.
And while we are at reciprocity, let’s look back a few more years.
The Smederevo steel plant was under the control of U.S. Steel, the Pittsburgh, Pennsylvania-headquartered steel giant, from 2003 to 2012.
Serbian analysts recorded in an English-language paper published in 2013:
The number of malignant diseases is on the rise. The increase since 2001 and its holding until 2011 is particularly significant. The number of patients is alarmingly increased almost three times. This situation cannot be fully explained by environmental pollution, but some facts can lead to the problem of the environment. As a matter of fact, the Smederevo Steel Plant, previously known as "Sartid", was privatized in 2003 by the American company U.S. Steel. The production beat every record and grew to the historic record of 2.2 million tons per year, and that was the first time that both Blast Furnaces worked together. Since then only one Blast Furnace has been in operation, and the other has been repaired. This production was inevitably reflected in increased environmental pollution of the surroundings, which certainly had an effect on the health of the population.
In this observed period, Radinac, a village in the Steel Plant neighborhood, had the highest number of patients, which is clearly the result of environment violated at a large scale.
The City of Smederevo is a settlement with highly polluted environment. This conclusion especially applies to the polluted air, where the values of certain pollutants exceed limits several times. It is evident that there is a real risk of their seriously endangering human health. Without taking specific measures, we cannot expect significant improvement and enhancement of environmental quality
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The sad history is not to excuse future inaction but does bring an omitted but an important perspective: pollution was always there, especially regarding this sentence in the Reuters report
Activists say the plant is an example of Chinese-owned industrial firms ignoring pollution standards.
(I don’t speak Serbian. The email exchange with the Smederevo public health body was conducted by Nemanja Cabric, a Xinhua correspondent based in Belgrade. I thank Nemanja and his colleague Zhongyu Shi, also based in Belgrade, for their help in researching this matter.)
Thank you for the comprehensive research and good write up, you are doing very good work!
I hope Serbians can read this.