6

‘Slip! Slop! Slap!’ vs ‘Bronzez vite et sans danger’

The triage nurse just complimented me on my tan and asked me if I had some sun recently then rubbed my hand and I was like um I’m just Aboriginal, this is my skin

Nayuka Gorrie on Twitter¹

‘At times the scale of skin cancer is hard to comprehend. You think, “This is massive. Two-thirds of the population!”’ I’m having lunch with Professor Anand Deva, a renowned plastic surgeon. Laying his cards on the table, he declares, ‘I’ve got a lot to say about skin cancer.’ With good reason. Deva is in private and public practice, and makes a point of choosing difficult cases. Or, they choose him. I have to put down my fork as he recounts tales of neglected, invasive skin cancers, reportage straight from the operating theatre. As he describes corrugated foreheads, mottled scalps and worse, I think of sci-fi TV shows where the makeup department has gone to town. Or the disfigured survivors of trench warfare. I would hardly believe skin cancers are left to run riot over my fellow Australians were I not hearing it from this source.

We’re in the courtyard cafe of Sydney Hospital – Governor Lachlan Macquarie’s ‘rum hospital’, on the street named after him – talking about Australia’s epidemic of skin cancer. Anand Deva, now in his fifties, has always had a different perspective on skin cancer. ‘All through my career I have supported GPs, dermatologists and other colleagues when it’s a very complicated disaster: the cancer has spread everywhere, or it’s eaten off half of a patient’s face and they need reconstruction. When the doors open and my phone rings it’s usually something bad. Really bad.’ These are no run-of-the-mill, barn-door BCC removals like I have had, which he rightly calls ‘low-level stuff’. No, we’re talking about out-of-control basal or squamous cell carcinomas, melanomas, or rarer skin cancers that have been mistreated, ignored, or missed altogether.

But we’re not here outside Australia’s oldest hospital to discuss extreme surgery. Instead, Deva spooks me with a public health horror story. He’s an academic as well, able to step back to analyse patterns and systems, the epidemiology of skin cancer and the costs to the health system that treats it. He looks beyond the cells of a single carcinoma to consider a vast number of them peppered on the skin of millions of Australians, a cancerous welt across a sunbaked continent.

Mining the numbers, Deva tells me that depending on your genetic risk, skin cancer ‘tends to start in your forties, and then it picks up and keeps picking up. It’s exponential. So,’ he says to me, ‘by the time you’re in your late sixties or early seventies, chances are that someone with your skin type will have had not one but multiple skin cancers. Once you get one, the risk of a second one gets higher and it’s like a runaway steam train. You can’t stop it.’

Distracting myself from the path of epidermal doom ahead, I ask Deva about the financial impact on our sunny country’s coffers. ‘It’s a massive burden,’ he says. ‘But it’s a hidden cost. A lot of skin cancers don’t even make the cancer registry because actually they would destroy the cancer registry. So, they focus on lung, prostate, breast cancer – the more notifiable cancers. But one in four people over sixty has a BCC! Those don’t ever make it into the numbers. And their treatment is so fragmented.’

One reason for the scattergun care given to skin cancers is that there aren’t enough dermatologists in Australia. The shortage is global, particularly as demand for dermatology services grows. One UK dermatologist wrote that it is almost impossible to get an appointment to see a dermatologist in the National Health Service (NHS), using a case from her own in-demand outpatient clinic to illustrate the cost of unconscionable delays. A woman who had tried for six years with various GPs to work out what was causing her red, swollen face finally had an appointment with this particular dermatologist, who identified the cause immediately. The patient switched blood-pressure medications and her symptoms disappeared overnight. Her relief must have been great, but I imagine her fury over six ruined years would have been greater.² Skin cancer incidence is increasing in the United Kingdom too. Cancer Research UK reports that since the early 1990s, rates of melanoma skin cancer incidence have more than doubled.³ Skin cancer cases receive priority in the NHS, but as Dr Hélène du P. Menagé says, ‘Skin cancer is taking over dermatology.’

The shortage of dermatologists has a serious impact on how skin cancer treatment is delivered in Australia. Associate Professor David Francis, a Brisbane-based dermatologist, was president of the Australasian College of Dermatologists (ACD) until mid-2021. I put ten questions to him about the biggest issues facing the specialty. Number one on the list of detailed responses he emailed to me was workplace shortage, a situation that he said is getting worse. There are 550 practising dermatologists in Australia. That’s about one for every 46,000 people; fewer if you live in a regional or remote part of the country, because 90 per cent of all dermatologists are in cities.

Francis says, ‘There is a chronic lack of funding for dermatology consultants, as well as for training positions in public hospitals. Lack of funding results in lack of visibility – a vicious circle where a lack of presence constrains the College’s ability to advocate for an expansion of funding.’ Dermatology in Australia and elsewhere is an outpatient service, so it is not front and centre in major hospitals. Dermatology patients rarely take up acute-care beds. A friend who works as a GP in a regional city moaned with frustration and put her head in her hands when I asked her how long it takes for her patients, many of whom are Indigenous, to see a hospital dermatologist, even when their condition is desperate. Her physical response was all the answer I needed, but she added, ‘Six months. At least!’

Cynics argue that the doctors themselves control the supply. Like me, my friend Rodney Hanratty has handed over a lot of money to dermatologists over the years to treat his skin cancers – his BCCs, the melanoma that his dermatologist picked up with her sixth sense for them, Mohs surgery procedures. (Mohs is micrographic surgery, which means the margins of the excision are examined under a microscope as the operation progresses, until no cancerous cells remain.) He probably doesn’t begrudge a cent, but he’s right when he says, ‘Dermatologists are in the absolute sweet spot in the medical profession in the twenty-first century.’

Skin cancer alone could keep them in business forever: surveilling, excising, suturing. The range of conditions dermatologists manage in the young and old – and in those paying up big time to look younger – is overwhelming. They prescribe an impressive range of drugs – not just Roaccutane for acne, but biologics and steroids for numerous other conditions. They treat epidermolysis bullosa, the rare genetic condition that causes fragile skin, or the twenty kinds of ichthyosis that cause a scaly thickening of the skin. Many, though not all, do cosmetic procedures for which they can charge astronomical fees. One retired dermatologist griped that dermatologists were becoming glorified GPs, doing the skin checks that primary healthcare providers should manage themselves. Another complained that his well-trained colleagues were becoming high-priced beauty therapists, which undermines the reputation of the entire specialty.

I put this ‘overqualified GP/cosmetician’ assertion to David Francis. Ascertaining tone from an email can be tricky, but I thought I detected a resigned hint of ‘here we go again’ in his response. He explained that my sources were wrong and reminded me of dermatologists’ training: ‘Dermatologists are specialists, fully qualified medical doctors who have then undertaken a minimum of an additional four years’ training specifically in the diagnosis, treatment and management of all skin diseases, including skin cancer. In the same way cardiologists are the experts and specialists in heart health, dermatologists are the specialists in treating conditions of the skin, hair and nails.’ Shifting to advocacy mode, he said, ‘There needs to be more government funding for public clinics,’ adding, ‘The amount of sun damage and resulting long-term effects that are seen in the Australian population makes the practice of dermatology here quite unique.’

Faced with the expense of seeing a dermatologist in private practice and the frustration of waiting for one in the public system, many people rely on a particular kind of practice that has popped up around the country.

Skin cancer clinics are what you get when there aren’t enough dermatologists and GPs are overwhelmed. Some skin cancer clinics do good work, but many seem inclined to reach for their scalpels first and ask questions later. Samuel Zagarella tells me, ‘I see the effects of it all the time. A young woman will walk in for a mole check. I look at her back and she’s got ten scars there, ugly scars from benign moles that have been cut out unnecessarily. As soon as you walk into some skin cancer clinics they want to do a procedure on you and bulk bill you. That phenomenon is not good for people. But it fills that void for people who say, “I’m not going to wait six months to see a dermatologist and pay money when I can get it for free at a skin cancer clinic.” The public doesn’t know the difference between [the doctor at] a skin cancer clinic and a dermatologist. To them, they’re both just specialists.’ Patients experience negative outcomes as a result. ‘Skin cancers like BCCs around the eyes can be devastating and they’re not getting managed properly. Some skin cancer clinic doctors are getting better, they’ve had more training. But usually they’ve got a few weeks’ training, they know their Medicare item numbers [the codes used to bill the government] and off they go.’

Dr Zagarella, probably the most plain-speaking of all the dermatologists I met, maps out the health system’s structural flaws. He says, ‘The government’s happy because they perceive, wrongly, that [skin cancer clinics] are saving them money. But it’s actually costing them more money because of the Medicare rort going on. It’s more expensive for the government to pay for that than to pay for dermatologists. GPs aren’t happy either, because these patients are going straight to skin cancer clinics. The first port of call should be a GP, who does a skin check and says, “Oh, I’m not sure about that.” It’s not their fault, it’s just that GPs haven’t had enough dermatology training. In medical school they get three days on dermatology in a four-year course! Bugger-all training.’

David Francis sends me various studies proving that dermatologists are more accurate at diagnosing skin cancers than non-dermatologists.⁴ He explains, ‘This translates to a greater efficiency in skin cancer diagnosis and a reduction in the number of unnecessary biopsies and excisions and, as a result, fewer adverse effects associated with excision and wound repair. Their specialist training also means they have expertise in skin surgery techniques and the specific treatment approaches for different tumour types, resulting in improved skin cancer outcomes.’

The costs of a fragmented system, where skin carcinomas are missed or not treated properly early on, are crushing. And they’re growing like, well, a cancer. As I talk to Anand Deva, the ambition of his project becomes clear. He wants to transform the way health care is delivered to skin cancer patients. He says, ‘The truth of the matter is that if people were properly trained and had an infrastructure around them where those questionable things were picked up early and treated on the spot, so to speak, and at an affordable price, we could make an impact on this disease.’

Deva has set up an Integrated Skin Cancer Clinic at Macquarie University Hospital in Sydney, one of six clinics established with the support of the New South Wales government health department. There, you can have a skin check with a GP and see a specialist if you need to – a dermatologist or a plastic surgeon – all under the same roof. This might not seem especially innovative unless you have had the experience of being a skin cancer patient who has devoted time and money to a protracted treatment process: getting a referral from a GP; having your skin checked by a dermatologist weeks or months later; waiting for a pathology result and then booking an appointment to have your damn spot excised by the dermatologist or a plastic surgeon.

Speed is a bonus of Deva’s integrated process – average waiting times between consultation, diagnosis and excision are much shorter than elsewhere – but quality is the main component of the clinic’s offering. I had always assumed that before hanging out a FREE SKIN CHECKS HERE sign, a GP must have had extensive specialised training in skin cancer, but again I learn this is not necessarily so. Deva applies the teaching hospital approach to his clinics. He signs up practising GPs already interested in skin cancer and, rather than offering online tutorials or a weekend course, brings them in-house for six months. Put through their paces, they do written tests and build up clinical skills, and are paired with dermatologists and plastic surgeons to learn operating skills in theatre that ensure their standard of stitching is reasonable. You don’t have to be an exacting plastic surgeon to comment, as Deva does, that ‘No one wants to be left with a horrible scar.’

A central part of the program measures trainees’ skills so they know how good they are. Deva explains, ‘So, if they think it’s a BCC, [we] cross-check the clinical diagnosis with the pathology. Then you can say, “Oh, you get it right 90 per cent of the time, your score rate is really good.”’ A more expert GP can look at a naevus with a dermatoscope and have greater certainty about what the pathology will show. They are more confident, so when next confronted with a BCC, if they know their strike rate is, say, 93 per cent, they might skip the biopsy. ‘We’ll take it straight to surgery. But all that takes practice, it takes mentoring, it takes ongoing learning with actual patients,’ says Deva.

A GP working in one of Anand Deva’s integrated clinics is called a GP Plus. Deva doesn’t hide his admiration for GPs’ ability to identify ailments that narrowly focused specialists can train themselves out of seeing. ‘They pick up depression. One GP said, “I think you’ve got diabetes,” and, sure enough, the patient had diabetes. He came in for a skin cancer check!’ Deva admits to being as competitive and ego-driven as the next surgeon, but says, ‘Being openly collaborative disarms a lot of that behaviour.’

‘Because I’m funded partly by the state government and because of the volume of work, we’re generating all this Medicare revenue [pooled by the clinic], so people pay nothing. When they walk in, they hand over their Medicare card and get the GP Plus skin check. If they see a specialist on the same day, there is no additional charge for me to see that patient. It’s not a full consult. It’s all been worked out. I’ve got faith in the GP Pluses that the only cases that are going to bother me are the bad ones. So why would I charge an out-of-pocket cost for that?’

Deva asks me how many melanomas I reckon they pick up weekly in each of their non-profit clinics.

‘One?’ I venture.

‘Four a week,’ he says. ‘These are mainly melanomas that have been missed by the system,’ he points out, adding that this is another ‘super-disruptive’ aspect of his model. Apart from being potentially deadly, melanoma presents in different ways and can be very aggressive, so breakthroughs in finding it earlier matter.

I recall the eye-opening conversation I had with Angela Betheras. She has stage-four metastatic melanoma. Her tone was so upbeat and matter of fact that it was only when I transcribed our conversation that I grasped how harrowing her journey has been. Before I called her, I knew she was a Saori-style weaver and a clothes designer. By the time I hung up, I no longer thought of her as an easygoing alpaca farmer and shop proprietor from rural Victoria – more a force of nature.

Betheras is a former international supply-chain manager for Australia’s biggest retailing group. She managed teams in Melbourne, Hong Kong and Shanghai, and tells me that in her old job they were basically ‘bringing in a whole ship every week’. Before she turned forty, she decided to return to West Gippsland in Victoria, near where she grew up. She was running a thriving business there when she discovered a lump on her back, ‘spherical like a golf ball’. When another lump popped up on her thigh she went to the doctor.

It took a while for various doctors to work out that she had cancer, and longer for them to work out what kind it was. She told me she didn’t learn of her diagnosis until ‘I went down with a friend to Peter Mac (the Peter MacCallum Cancer Centre in Melbourne) and I met the lovely lady who was head of the sarcoma team. She said, and I’ll never forget this, “Look, it’s lovely to meet you. But it’s not sarcoma, it’s melanoma. Would you like to meet the melanoma team?”’ Angela had never considered she might have melanoma. No culprit mole or freckle that might have triggered the disease has ever been found. It turns out that ‘melanoma of unknown primary’ (or MUP) accounts for about 20 per cent of all cases of metastatic melanoma. On a molecular level, MUP looks the same as a ‘known’ primary. One theory is that the melanoma cells have regressed or died off thanks to the immune system, except for a few that survived and spread. Like Michael Brady, Angela had surgery and is now having immunotherapy. But the ordeal of her melanoma treatment stuck in my mind.

After the surgery, but before the fortnightly, then monthly, immunotherapy, and the array of new, expensive drugs that she is now on, before the pneumonia, the radiation therapy, the collapsed lung and the numbness down half of her body, in late 2018 Angela Betheras met her oncologist, Damien Kee. She refers to him as her rock. Dr Kee is a specialist in rare cancers and skin cancers at The Alfred Hospital and the Peter MacCallum Cancer Centre in Melbourne. It’s a two-hour drive each way for Angela to attend appointments there. She says, reflecting on an early appointment, ‘When I looked back, I had had nineteen blood tests, PET scans, biopsies and hospital visits between August and November. So, when people asked me, “Have you had that scan before?” I’d say, I’m sure I’ve had it.’

I tell Angela she is one tough cookie. She responds by saying, ‘Well, you’ve got to put on your big-girl pants and say, “I can do this!”’ She deserves – and is getting – the best possible care any melanoma patient in Australia or the world could hope for. The new medical and immunotherapy treatment options for melanoma are a godsend, but they can be brutal, and Angela tells me she has heard of patients who have found themselves riddled with melanoma tumours. ‘Hundreds?’ I ask. ‘Thousands,’ she says, ‘the poor things.’ One person she knows of has had seventy immunotherapy treatments. She quoted her surgeon, prefacing his medical insights on melanoma with a warning to ‘excuse the French’: ‘It’s the most hideous little fucking disease, and they go wherever they fucking want . . .’

Melanoma is the big-ticket item in every sense, but the whole line-up of skin cancers must be managed better. Anand Deva is on a mission to do just that. Talking about his integrated clinics, he says, ‘This is the future.’ And not just for skin cancer but for other chronic conditions – obesity, joint issues, allergies. I ask him about the impact of public health campaigns on skin cancers. ‘What we’re doing to educate people today might have an impact in forty or fifty years, but it’s not going to stop the burden tomorrow, next month, next year or even in ten years. It’s going up. Exponentially. All the baby boomers are hitting the age where they are most at risk. We’re in the middle of it now but that wave is going to keep washing onto the shore for years. There’s been a threefold rise in melanoma over the past fifteen years. We’re on the start of that curve. It’s a worry.’

In 1981, Australia declared war on skin cancer. All citizens were potential conscripts, even those who thought themselves too old to serve. Child soldiers were conscripted in vast numbers. The enemy wasn’t so much the sun itself, but ignorance about its nefarious rays. In a battle for hearts and minds, campaigns were rolled out to persuade people, particularly the pale-skinned, to stop worshipping what was killing them. Fear wasn’t the main tactic; education, and protective clothing and substances, were. Campaign leaders insisted on vigilance, especially while outdoors. Today, it’s hard to say which side is winning this lifelong fight.

At this time the country was already waging a war against laziness. That campaign’s mascot was an everyman called Norm, a beer-drinking, cigarette-smoking slob in love with his lounge room, his couch and television essentially extensions of his self. The Monahan Dayman Adams advertising agency saw cartoon Norm get up from his lazy chair and star in the ‘Life. Be in it.’ campaign. Health-promotion operatives were busy persuading people to quit smoking, too, but they were about to launch a new front. This time a seagull called Sid, created by the same advertising house as Norm, issued a call to arms. His rallying cry was ‘Slip! Slop! Slap!’ Forty years later, sitting in front of a cumquat tree in his garden, David Hill, who worked at Cancer Council Victoria for thirty years and was CEO between 2002 and 2011, told me how it all came about.

One day in the early 1980s, Hill was in his office at what was then called the Anti-Cancer Council in Melbourne. ‘I could hear this noisy car – a Maserati. I don’t like noisy cars, but I like nice cars. I noted it and went back to work. About five minutes later I got a call from the switchboard saying, “There’s a gentleman here who wants to talk about anti-cancer advertising.” So, Phillip came up and said, “I’d like to help.” We said, “Whacko! We want to do something on skin cancer.” That’s how it all started.’ Then advertising man, now ABC broadcaster Phillip Adams told me that the car would have been a red Ferrari, but otherwise the story is true. Adams went away and wrote the words to the jingle, signed up Alex Stitt to do the drawings and commissioned Peter Best to write the music. Hill says, ‘They all worked for nothing, no money changed hands. We had the best copywriter, the best animator and the best composer in the field, so it’s not surprising that [the ad] was really good.’ Better than good: what emerged was one of the most effective public health campaigns in history.

Sid the Seagull lisps his way endearingly through the ad, which aired on television for free as a public service announcement. ‘Skin cancer isn’t so hot’ exclaims the bird, and exhorts us to ‘Slip! Slop! Slap!’ The tune, three words and two notes, some half-spoken, has been stuck in my head since 1981. Slip on a shirt, slop on sunscreen, slap on a hat. More imperative sibilance has since been added: seek shade, slide on sunnies. The five S’s are a central part of Cancer Council Australia’s SunSmart message, prevention the organisation’s driving force.

While he was at the helm of the Cancer Council, David Hill did a PhD in the science and psychology of behaviour. He is passionate about measuring how routine behaviours can change, telling me about surveys the Cancer Council conducted to find out if their mass media campaigns were working. On Monday nights during summer, researchers would cold-call random numbers to ask people if they were sunburnt, cross-matching UV radiation levels from the previous weekend recorded in the area of the phone number against how respondents described the state of their skin. ‘By Monday [the sunburn] has turned up and people can describe the intensity of the burn if they had it. And sunburn is technically an intermediate marker for the carcinogenic effect of the sun’s rays.’

The data showed that the message was working – people weren’t getting so sunburnt. Gratifying to be sure, but even more so are the rates of incidence reported decades later, after years of tracking and ongoing campaigns. David Hill describes as ‘beautiful’ the latest figures showing that melanoma in Australians under forty is dropping.⁵ ‘If you think about that, it’s logical, because young people had the opportunity to be exposed to SunSmart campaigns early in their life. The older people, people like me, didn’t. It’s a scientific demonstration and strong evidence for the campaigns working.’

Craig Sinclair is the current head of prevention at Cancer Council Victoria. Over Zoom, I found myself asking if he has had skin cancer himself, given that most fair Australians I talk to who are over forty have clocked at least one. ‘Yes, I’ve had what I think was a BCC on my nose about twenty years ago. But my mother, brother and two sisters have had melanomas. That didn’t get me into the job, it’s all happened since. It puts me genetically into a high-risk zone. I’m cautious outside and I go to my local GP, who I trust, who is very thorough with regular skin checks. Two out of every three Australians up to the age of seventy [will get skin cancer], that’s what the data is telling us. So, your sample is reflective of what is going on out there.’

Looking back on the work he has done at the Cancer Council, Sinclair tells me, ‘One of my proudest achievements has been the introduction of the SunSmart Schools program. There is not a primary school in Victoria that doesn’t support “No hat, play in the shade”.’ The self-explanatory policy, ruthlessly enforced, exists nationwide. My friend Erin Shiel worked in health promotion for the Cancer Council in New South Wales in the 1990s, rolling out the SunSmart program to reduce sun exposure among primary-school children. In what must have been a boon to hat manufacturers, hats became a compulsory part of all school uniforms: No hat, no play became the rule in that era.

Hats were a gift to the national index of cuteness, too. Every single day you can see five-year-olds living their best outdoor lives under big hats, their names sharpied on the inside, thousands of hats waiting to be reclaimed from lost and found boxes at any given moment during school terms. The Cancer Council worked with state education departments to encourage the erection of shade structures in playgrounds. Erin told me that, up until then, often schools had been using their main shaded areas for teachers’ car parking.

Architecture’s function is to provide shelter, but wraparound verandahs and deep awnings, proper eaves and covered walkways had been removed from the design of new buildings since the 1920s. No longer dark and gloomy in the Victorian style, new Australian houses, far more pleasant to live in, had sunrooms and sundecks, and were more likely to face north.⁶ People might refer jokingly to the dark side of suburbia, but there may have been a little too much brightness: excessive sun exposure on shadeless quarter-acre housing blocks and wide, treeless streets leading up to them. Parasols, big hats and long sleeves were out of fashion too. Sunburnt skin was the result.

In the 1980s and 1990s, the various state Cancer Councils weaponised fashion and architecture to shield Australians from the sun. Erin was part of the small team that worked with trade unions to educate bare-headed, sleeveless outdoor workers about skin protection, and to remind employers that sun protection was an occupational health and safety issue. Elaine Henry, who was CEO of Cancer Council NSW from 1985 to 1997, sounded triumphant when she said of the protective clothing campaigns, ‘Even posties. We convinced them!’

One of my brothers circulated a photo of me on the family chat with the caption ‘Book cover? LOL’. A beaming toddler, I’m in a swimming pool being held up by our mother, who sports a fetching swimming cap. I wear nothing but ribbons in my pigtails, and a ‘healthy’ tan. I love it, but the photo makes Mum feel guilty. The freewheeling 1970s, I remind her, were different times. It was our destiny to be out in the blazing sun, breathing in second-hand menthol cigarette smoke, drinking lime-green GI cordial, snacking on Cheezels and fortified by Akta-Vite Drinking Chocolate. Mothers were exhorted to expose their babies and children to nourishing sunlight. Today, taking children to the beach without sunscreen, hats and rash-vests to cover their backs, shoulders and arms – sometimes a whole suit covering their little legs, too – would be seen as a form of child neglect.

Elaine Henry says that education and awareness about skin cancer prevention are great; however, ‘You can’t just go out and say to people, “This is the situation, and this is what you’ve got to do about it,” but do nothing to help them. The great success we had was in getting people not to be frightened.’ One way they did this was by helping to equip everyone with hats, sunglasses and sunscreen, and making top-to-toe lycra swimwear for kids readily available. And more affordable.

Sunscreen was a key technology in the arsenal. Cancer Council NSW, working with the Australasian College of Dermatologists, set up ‘battle station’ tents on beaches, pumping out gallons of sunscreen and encouraging beachgoers to Slip! Slop! Slap! and to have professional skin checks. Henry tells me that her organisation collaborated with the Western Australia Cancer Council to get Woolworths supermarkets to manufacture economical pump-packs of sunscreen, so families could act on the messages bombarding them. Sunscreen was overpriced, so the Cancer Council developed its own, more affordable brand. Erin could remember unpacking the first box of these branded sunscreens. Cancer Council shops that stocked hats, swimwear, sunglasses, umbrellas and portable beach cabanas began appearing in malls. Among the first social enterprises in Australia, these retail outlets are still going strong.

They were exciting times. Innovative and energetic public health experts transformed themselves into health propagandists and social entrepreneurs, getting their message out and making sure people could act on it. Elaine Henry says, ‘We had people who were a bit antsy about sunscreen at the beginning.’ I comment that some still are. She responds with a sigh and says, ‘Those anti-sunscreen people and anti-vaxxers, they’re all in the same thread of conspiracy. Anti-science.’ She’s talking to me from France, in the middle of a COVID lockdown, when public health responses were dominating news across the globe and provoking countervailing forces of misinformation and lies. But I think it likely Henry would make this observation at any time. Her comment dredged up a vague memory I had of a controversy about nanoparticles in sunscreen. But it prompted a more fundamental question, one I had never really thought about, even though I use it every day. How does sunscreen work?

Let’s hope it works, not least as by 2029, the global sunscreen market is supposed to be worth $24.4 billion.⁷ That is an awful lot of bottles, sprays, tubes, foams, gels, creams, oils and lotions. Inside them all is an emulsion of some kind designed to carry the active ingredient, whether you’re rolling it on, spraying it on, or rubbing it into your skin. The active ingredient in a sunscreen works by either absorbing or filtering UV rays, or by reflecting or scattering them. UV absorbers, including avobenzone, oxybenzone, octocrylene and 4-methylbenzylidene camphor, absorb UV rays (both UVA and UVB, in sunscreens labelled ‘broad spectrum’) and convert them into imperceptible levels of heat. They are organic or chemical. UV reflectors, such as zinc oxide and titanium dioxide, are inorganic and act as a kind of physical barrier and scatter the rays. They are marketed as sunblock.⁸ My household had a ready-made sample set of sunscreen products, so I could name-check most of these chemicals and oxides by looking in the bathroom cabinet.

Beach historians (yes, there’s such a thing) Lena Lenček and Gideon Bosker write that in the 1930s, chemists worked out that microscopic particles of zinc oxide and titanium dioxide formed an effective blocking barrier when mixed into a thick paste. Unfortunately, ‘its brilliant white colour was unattractive on bare skin – the areas on which it was spread remained completely white – and so it was used only by lifeguards and skin-cancer patients’.⁹ Later, these metal oxides would become ‘microfine powders’ and, now, nanoparticles so small that they are invisible, transparent and safe.¹⁰ Products marketed as ‘sunblock’ usually contain these inorganic mineral sunscreens.

A scientific breakthrough came in 1943 when chemists succeeded in synthesising – and patenting – a complex string of molecules called para-aminobenzoic acid (PABA), which was used as organic sunscreen. (Organic, in a chemical context, means a compound containing carbon molecules.) I used to look out for sunscreens labelled PABA-free because contact dermatitis from PABA is not uncommon. However, use of PABA has decreased dramatically, because of these skin irritations and other reasons, and is now replaced by other compounds. It is partially banned in Australia, where sunscreens are regulated by the Therapeutic Goods Administration, but not in the United States, where – unlike Europe, which classes sunscreen as a cosmetic – the US Food and Drug Administration (FDA) classes sunscreen as a drug. Fewer compounds are approved for use in American sunscreens than in Europe.

George Zaidan, in an article in Wired, became the source of my favourite explanation of how sunscreen works, because it made sense after a lot of incomprehensible (to me) chemistry diagrams: ‘Our species has engineered a creamy white splooge that you spread over your body to convert the potentially DNA-damaging energy from hundreds of million septillions of ultraviolet photons per second into mostly harmless heat.’¹¹ If you find sunscreen labelling as bewildering as I do, be assured you are not alone. Zaidan, author of Ingredients: The strange chemistry of what we put on us and in us, says, ‘Sunscreens bear the most incomprehensible labels you are likely to be presented with.’

A more cultural, less chemical, history of modern sunscreens can be told by way of four international brands that are still stocked on supermarket and pharmacy shelves, and four chemists who didn’t like getting sunburnt. The brand histories tend to be corporate rather than critical, so some dates and details are more fluid than, shall we say, water resistant. Hamilton, Ambre Solaire, Piz Buin and Coppertone all promised deep tanning without burning. Skin cancer protection was not part of the sell until the 1970s.

In 1932, Adelaide chemist Milton Blake set up Hamilton laboratories and started producing sunscreen, filling the first five hundred tubes by hand. On the face of it, Hamilton would seem to be the world’s first commercial sunscreen manufacturer. (Patriotic though it would be, I make no claim.) Hamilton sunscreens are sold in Australia and Aotearoa New Zealand, with a strong export market in Turkey,¹² but Hamilton does not dominate shelves now packed with a bewildering range of options, including Garnier’s Ambre Solaire.

The founder of French beauty brand L’Oréal (parent company of Garnier), Eugène Schueller, a fair-skinned chemist – our second – kept getting sunburnt while he was sailing. He entreated his laboratories to develop a sun protection solution, presumably in time for the next summer. Triumphant L’Oréal workers handed him a golden bottle of ‘sun oil’. Schueller named it Ambre Solaire and launched it as a commercial product on the French Riviera in 1936.¹³

In 1938, Swiss chemistry student Franz Greiter, pharmacist number three on our list, got sunburnt while climbing Mount Piz Buin in the Alps between Switzerland and Austria. One can imagine him swearing to develop a cream to prevent that ever happening again if it were the last thing he did. He succeeded, for in 1946 Greiter’s product, which he called Glacier Cream, was launched as Piz Buin. (As a child in the 1970s, I was intrigued by the unusual name and by Piz Buin’s magazine advertisements – leggy and of course tanned blondes wearing white swimming costumes. I confess I learnt that Piz Buin was a mountain only when I wrote this chapter. I also discovered that Piz Buin has a special alpine sunscreen with a Sound of Music ingredient – Edelweiss extract.¹⁴ Perfect for escaping over the alps from Austria to Switzerland.)

Pharmacist number four is Benjamin Green, who was a US airman fighting in the tropics during World War II. While serving, Green used ‘red vet pet’ (red veterinary petrolatum) on himself and others as sun protection. Greasy and smelly, it was unpleasant when smeared on the skin. However, when mixed with coconut oil and cocoa butter, as Green discovered after he was back home in Miami, it became more appealing. So much so that it became the global brand Coppertone. The 1953 drawing of a pigtailed blonde girl’s swimsuit pants being pulled down by a cheeky dog, revealing that one part of her is much whiter than the rest, is one of the most famous images in advertising history. The original accompanying slogan was ‘Don’t be a Paleface!’ Coppertone ads with a bikini-clad Annette Funicello, star of the 1965 film Beach Blanket Bingo, promised the ‘Fastest tan with maximum sunburn protection’. If you were to say this, or ‘Tan, don’t burn’ in French, it would pretty much be ‘Bronzez vite et sans danger’, which is how Coppertone translated it for that market.

Mountaineer–pharmacist Greiter’s further claim to fame is as the inventor of the sun protection factor (SPF) system. This happened in 1974, when awareness of skin cancer was finally searing into people’s minds as well as their skin. SPF measures how long it takes skin to burn when you’re wearing sunscreen compared to when you’re not. So, if burning with no protection takes ten minutes, SPF30 takes three hundred minutes. High SPF sunscreens are important, except they can give sun-lovers a false sense of confidence, making them so complacent that they forget to reapply. But you have to apply it in the first place to be in a position to reapply.

I asked Cathy Cameron Felder, who grew up in sunny Southern California but now lives in Napa in Northern California, if she remembered being told to wear sunscreen when she was a child. Cathy is my cousin and shares my Celtic skin: she has had five BCCs removed, including one her ophthalmologist found on her eyelid. She says, ‘I do not recall ever seeing anything about wearing sunscreen or hats on a national level. I remember Slip, Slop, Slap from when we visited Australia. It was such a cultural difference.’ Cathy says, ‘We would always make fun of Dad for saying, “Do you have sunscreen on?” when we left the house in high school, but that was after years of lying out with baby oil to tan our little freckled bodies. Yikes!’ A US Centers for Disease Control report on skin cancer prevention, published in 2019, pointed out that the amount of skin cancer education in American schools had actually decreased in the preceding years. The report also showed that 38 per cent of American schools recommend that their students wear hats or visors on sunny days; 0.5 per cent require it. Because some schools disallow FDA-regulated drugs (a category which includes sunscreen) on school grounds, sunscreen can only be applied at school in twenty-two American states, which have legislated that sunscreen is exempt.¹⁵ At least sunny California is one of them.

Some students might not be allowed to take sunscreen to school in the United States, but many are allowed to use indoor tanning beds; some states have no restrictions at all on indoor tanning for minors. A 2021 opinion piece in JAMA Dermatology reported that an estimated 419,245 American skin cancer cases each year are attributable to indoor tanning, and called for legislation to eliminate indoor tanning in all states. The authors noted indoor tanning’s popularity with adolescents and young people and, extraordinarily to me, said that approximately half of the top American colleges had indoor tanning facilities on campus or in off-campus housing.¹⁶

Solariums, the use of which increases dramatically a tanner’s risk of developing melanoma and other skin cancers, were banned in Australia in 2015, following their prohibition in Brazil in 2009. Shutting down solariums took long and often emotional campaigns by the Australian Cancer Councils and the Melanoma Institute Australia, bolstered by evidence that tanning beds transmitted five times the radiation of the sun.¹⁷ In 2014, a graphic UK campaign called ‘A Look to Die For’, sponsored by the NHS, Liverpool City Council (Liverpool was known as the sunbed capital of England) and St. Moriz fake tan, was rolled out alongside the hashtag #BinTheBeds.¹⁸ In images from the campaign, glamorous models are disfigured by notations of their tanning-salon history – dates and places – etched into their faces and backs. Some have real scars where malignant melanomas have been removed. In 2019, British MP Pauline Latham, who has had skin cancer herself, called tanning beds ‘killing machines’ and said they should be banned. Since the solarium ban came into effect, raids of illegal tanning salons in Australia show that tanning can be an addiction, and that the pursuit of a tan comes from the same part of being human that makes us think the cost of beauty can never be too high.

Adolescents, in spite of all this advocacy, still want to tan. Public health experts in Australia agree that all the good work of early childhood falls away when children become teenagers and discard forms of sun protection seen as uncool, which is pretty much all of them. In high school, broad-brimmed hats are replaced with less-effective caps, or nothing. The Cancer Council’s #OwnYourTone campaign encouraged teenagers to embrace their natural skin colour, rebuke tanning and see the sun as their ‘frenemy’.¹⁹ But it was up against a tsunami of other images generated by people with golden tans who aren’t called influencers for nothing. Craig Sinclair of the Cancer Council Victoria confirms, ‘All it takes is the transition to high school, and all the practice and policies are pretty much out the window. If there is an investment to be made – which there should be – it would be improving high-school campaigns.’

Prevention is an investment that pays off. Sinclair has worked in health promotion for his whole career, and is also the director of the World Health Organization’s Collaborating Centre for UV Radiation. ‘What baffles me here in Australia is we accept the significant costs and the burden to the public health system of treating skin cancer despite all the evidence that programs like SunSmart can prevent it. For every single dollar a government spends on skin cancer prevention, they can expect a $3.20 return on that investment. We know what works. We know what the recipe is to make a difference in changing behaviour. We know our efforts reduce prevalence. Why is it our national cancer – something uniquely related to living in Australia – is not addressed in terms of a national investment by the Commonwealth government? All they’re doing at the moment is mopping up the costs. No one’s there to build the fence at the cliff.’