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Editorial by Wes Wood

Effectiveness (and therefore the justification) of infection control regulations is meaningful when it is demonstrated (statistically) that a decrease in infection rates has coincided with the application of the regulations.
-- this is a Public Health policy goal.

After two decades of modern tattoo regulation the effectiveness, the goal of tattoo and piercing (T&P) infection control regulation has been completely forgotten because there is no evaluation step in the process of administering Public Health Policy. There is no concern or interest in reducing infection rates.

The effectiveness that is demonstrated for regulations is: how effective the regulations are at being enforced, not their effect on infection rates.  Once regulations are passed the enforcement becomes the effort as if it were a cause and effect, as if an increase in effective Tattoo/Piercing monitoring for standards practice results in a corresponding decrease in infection rates.  But this correlation lacks supporting evidence and to my knowledge has never been evaluated.

If there were a cause and effect link between tattoo/piercing application and infection rates, we would expect, though not require, a dosage link: the more tattoos the greater the number of infections. However, the opposite seems to be true.

What we have seen recently, that some outbreaks of Hep C are a result of tattooing, were all by non-licensed tattooists. This has an encouraging aspect. It looks like an umbrella effect of having regulations generally across the country (since these clusters were in different states) and does indicate that regulations should not be abandoned even though there is no evaluation of the results.

Other encouraging items for the state of tattooing today.

A recent study, 1999, concluded there was no statistical reason to believe there were any more medically related problems with tattoo/piercing healing than the general population wound healing. Piercing wound healing problems were not greater than the general public wound healing and tattoo had an even lower rate than piercing. This is quite astonishing: there are fewer wound healing problems as a result of getting a tattoo than the general public is at healing non-tattoo wounds. Why this would be so is a matter of conjecture.

A doctor we have cooperated with at Lenox Hospital Trauma Center in the Bronx, one of the busiest in the nation, stated that nearly all the piercing related problems that come in are caused by individuals piercing themselves, and mostly in unusual inappropriate places and only one, in all those years, he said, may have had an infection, being treated as an infection even though the evidence was not laboratory verified.

The typical argument for regulating body art is based on a fallacy: the Fallacy of Argument, called  post hoc ergo prompter hoc, (after this therefore caused by this).  
The argument runs like this: some tattoos/piercings became infected.  Tattooing was antecedent to the tattoo and therefore caused the infection. Regulating tattooing will decrease the infection rate.  This fallacy is easily exposed by remembering Bertrand Russell's famous illustration: every time the rooster crows the sun rises, therefore the rooster's crowing caused the sun to rise.

Do you recall hearing this kind of sloppy thinking:
"...you can get an infection or a life threatening disease from getting a tattoo"

"Tattooing is not considered a source for the spread of blood borne diseases. Poor home aftercare is implicated for superficial easily treated skin infections."

In my opinion, DOHs would make a great contribution to our profession, to our knowledge and understanding, and to the safety of body art procedures if they could spare some resources to study the subject.  But this is unlikely because the rate of infection is too low to justify the expense of a study because only isolated cases are available. Isolated cases that don't result in morbidity or mortality are not a justification or cause for community based Public Health Policy.

Here is an obvious contradiction:
On the one hand there are not enough incidents in quantity or any severe enough to warrant a study and on the other hand a claim is made that extensive regulation is necessary to control and limit the harmful effects on the community.

Without a study, legislators use "intuition" and "feelings," anecdotal cases and hunches. 

Life experience in the body art world suggests a very different hypothesis:  clients rarely if ever become infected.  Universal Precautions, Single use needles, and fresh gloves have effectively eliminated infection. Practically speaking, there are no infection rates. 

Life experience suggests that our aftercare instructions are adequate; our procedures are free from contamination; our clients are more likely to care for their wound and are in fact healthier than the general population.

"Frequent" means an incident rate of at least 5% which is not found in our profession.  Infections are not frequent. Rare means 1%. Infections are less than rare. There is no percentage.  It is too low to measure. To have any priority whatsoever for community public health action the incident rate would have to approach 1% (rare) of the population and/or have a mortality and morbidity.  There isn't even a statistic about the morbidity or mortality of tattoo/piercing.  Life experience supports only a remote possibility of minor easily treated superficial skin infections which does not justify the elaborate Public Health policy considerations.

The question is: "Why all these elaborate regulations?"

In my opinion, an unholy alliance of interest groups each with their own goals are using health and legislature regulatory power to foster and promote their own private agendas.

Ten years ago unjustifiable, unsupportable, effectively "anti-body art" model regulations were published by the National Environmental Health Association, Denver, CO. with their "Body Art: A Comprehensive Guidebook and Model Code" which looks like the front guard to bring all body artists under oversight  by one or a few tattoo and piercing organizations.  They were  endorsed by APT, APP, SPCE, ABAA, and Gauntlet, (some members who also contributed to the work. 
(And its existence kept hidden from the body art world, even Members of the Board of APT were kept in the dark and did not know about this effort.)

More than a decade ago The Institute of Medicine deplored non-evidence based regulations and made a call for "evidence-based" thinking and continuous quality improvement (CQI).  The Year 2000 was supposed to be the target goal for improving public health agencies so they would be in line with evidence based thinking and action.  

The NEHA publication lacked scientific evidence, lacked investigational efforts and lacked justification. I doubt the NEHA "signers" ever did anything more than read it and sign-off. It would be laughable except that it attempts to bring all body arts under one legislative proposal, sweeping everything into one head, - for one noose, in spite of the differences between the different body arts.  If you read the supporting documents that are published with the Code you would wonder how the code could come to so unjustified unsupported contradictory proposals.  So I wonder why, instead of opposing the Body Art Code, the writers who are self-proclaimed to best represent the industry,  endorse them, and enthusiastically.

Infection Rates

Concerning hepatitis, a recent study in 1999 mentioned earlier, by Silver AL, &etc., from Dept. of Emergency Medicine, Research Institute William Beaumont Hospital, Royal Oak, Michigan concluded: We find no evidence to support the observation that tattoos serve as a risk factor for chronic viral hepatitis.  This conclusion of course does not mean tattooing doesn't, only that this study found no evidence to believe it is a factor to consider as part of the chain that leads to the disease.  

As a precondition for cmmunity regulation, as the first step, before regulation, a study is made to identify if a problem exists that needs fixing.  This is the Assessment Step, a precondition for proposed regulation: identifying if a problem exists. This is not done for the body arts.
The Institute of Medicine had hoped to reverse this anti-public health policy-making more than a decade ago.  But old methods are alive and still going strong and this is a good example of public health policy gone bad.  

But who cares? 

Who takes body arts seriously?  The cultural dogmatists consider us lucky that we are allowed to exist at all.  Who wants tattoo/piercing in "their" community?  Send them to industrial sections with the sex shops. Make it hard for them, make them submit building plans and layouts and a host of hurdles, even make conventions a real nightmare. This reminds me of how  minorities are often treated. Because we have rights and a constitution we can demand our just and fair rights.

Don't we have a right to pursue our profession without un-justifiable interference. Remember the Boston Tea Party in American history, the voting rights act, civil rights. This is what our fight should be about.  And legal action should be taken.

Dr. Benjamin Mojica, Acting Commissioner of Health of the NYC Dept. of Health testified that following universal precautions by tattooists, using new sterile needles and wearing gloves has protected the health of the community in NYC.   Elaborate facility regulations is - in his words -

"a waste of taxpayer money having no effect on infection rates." 

 Tattooists should have training in sterilization and infection control and be required to demonstrate that knowledge.  After 40 years in NYC there has not emerged a problem that would require such drastic effort that is seen elsewhere. 
We would expect that in all the years of underground and non-sterile tattooing in NYC, disease would have been rampant, but no. Not then, not now.  Not because artists are so wonderfully clean, but by the nature of the skin, the nature of the body's reaction, the nature of tattooing, the ease of following precautions it very difficult to get anything into the skin at all, with everything oozing out. It is only fortunate for tattooists that particles of ink actually get stay at all.  And it is our good fortune and that of our clients. Our record is unmatched. We are indeed lucky.
  
The NYC DOHMH is not interested in wasting critically needed health care funds.  We salute them for asserting the facts and the truth, relying on evidence-based thinking, what life experience in tattoo has taught us - tattoo is not even remotely a threat to the health of the community.  Even the CDC on Hep. deliberately and specifically asserts that tattoo and piercing are not considered sources of Hep., that there is no evidence to believe it to be true.

And yet we find elaborate regulations and a waste of resources that borders on -- fanatic.  And it is fanatic - fanatic deliberate ignorance of tattoo/piercing - not wanting to know not wanting to even hear the full story. And so we see even medical professionals not using evidence-based thinking and research attacking our profession based on assumptions from their professions as if they were the same and that we are engaged in open exposed infection prone surgery. 

Tattoo/Piercing is not open exposed infection prone procedures.

We are a folk art with no history of spreading or causing disease.

And no one yells about this assault on us, no one defends our profession, and the organizations out there, instead of supporting us, support more and more restrictions and useless regulations.  What a disgrace.They are the enemies trying to get a stranglehold over the entire profession.

Another part of this un-holy alliance, established tattoo and piercing businesses themselves demanding more stringent regulations, higher fees and multiple licensing for the purpose of making it difficult to enter the profession.  This is even bragged about within tattoo circles.   Even New Jersey endorsed regulations that require 2,000 hours of supervised experience supported by tax documents for a tattoo license, and 1,000 hours for a piercing license, apprenticeship trainings, anatomy courses, lighting stipulations, wall, floor and ceiling regulations, square footage minimums for each artist and a host of minutia that will have no effect on infection rates whatsoever. "We've put a lot of work into this."  I was told from a high ranking author of a state plan. As if -- therefore -- it now must be done.  It's an assault on our profession and we shouldn't keep quiet.

Dever has pointed out that traditionally, citizens have had little opportunity to influence the decisions about the health of their communities, as well as other needs, priorities and services.  Citizen involvement has long been recognized as important but citizens are only allowed a few moments to state their views at public hearings held near the end of the process, when a decision has ( for all intents and purposes) already been made. This amounts to extremely limited citizen input rather than meaningful citizen involvement. (p10, Dever, GEA, Improving Outcomes in Public Health Practice, Strategy and Methods. Aspen Publishers, 1997)

If public participation is to be meaningful, citizens must be heard not only before a final decision is made but from the beginning to the end of the decision-making process.  Citizens must be able to influence the entire process, from defining the problem to developing alternative solutions and evaluating the alternatives to making the final decision. (i.e., doing the right things right) (p11, Dever)

Body Art businesses often want to create hurdles for newcomers to restrict entry into "their" market. These are the enemies of body-art because they believe the profession belongs to them. 

A basically bogus argument: that regulations are needed to prevent "scratchers" from spreading disease, misses the point by not distinguishing "scratchers" competing economically and bootleggers tattooing in the park with guitar strings and no. This year was the first cluster of cases examined by the CDC for just such bootleggers. 

Regulations are un-justifiable when no safety can be demonstrated.

If you have to get permission to do something you are not free and do not have a "right." To live by "permission" is not to live free because permission can be revoked. These types of regulations take your rights away - without evidence. 

Reasonable precautions and regulation should be required to protect the health of the community.  Precautions based on evidence should be adopted and enforced for all commercial tattoo or piercing. -- Based on evidence.

Another bogus argument claims that problems are "under-reported." 

This is in error on two counts: 

1) a study would have to be made to support this.  It cannot be asserted based on feelings and intuition or mental "It sounds reasonable." That is not evidence and not acceptable for academic consideration at all. Anything that just "makes sense" to someone or sounds reasonable is not evidence.
2) because of the explosion of tattoo and piercing throughout the entire spectrum of the population including the well educated we would expect the opposite -- much more reporting - this is obvious. If tattoos and piercing have exploded 1000% we would expect more reports of medical problems especially bin our litiginous age.  But we don't find such increases of reports. The lack of an increase supports the position that there is no increase but we are actually safer than ever before.

Every tattooist and piercer should vocally defend our industry and our record from the irresponsible, unscientific and unjustified attacks and set the record straight whenever they have the opportunity.  There is no risk for all intents and purposes. Even the Red Cross has lifted their ban on donating blood by recently tattooed people.

We should openly oppose those groups that operate within our profession who want to be our "spokes-persons" because their agenda is no agenda for our industry - no agenda except to pay their dues - they offer nothing of value and reading their various articles, they are too often wrong with their advice.

 There is even a requirement in the Model Body Art Code that you will have to demonstrate your abilities at your craft, most likely to the ghost writers who  positioning themselves to take up that heavy serious responsibility.  One noose around the neck of the profession and One Group holding the rope is the first step to disaster - belong or no license.

Except you and me -  who cares.  So instead of hearing cries of "Foul" by organizations out there, we see them cheering and bring it on. 

Then again, this is not unusual for "business" in America.

Comments are always welcome.

Thank you, Wes Wood