REVIEW: Robert A. Aronowitz, Unnatural History: Breast Cancer and American Society

“Breast cancer is all around us.” This is how Robert Aronowitz, a medical doctor, opens his timely Unnatural History: Breast Cancer and American Society. We are all familiar with the truism that “one in eight American women” will develop invasive breast cancer over the course of her lifetime. The pink ribbon has come to symbolize both solidarity and hope. Mammograms and “Self-Breast Examination” have become part of women’s daily routine, if not a spectre haunting their daily lives. Yet the evidence remains contested and the therapeutic promise, the fear and hope associated with this “obstinate” disease as problematic as ever. Unnatural History weaves all these different elements, artifactual and natural, emotional and rational, vital and morbid, in the socio-historical narrative of breast cancer in the American context. In that sense, this is an “unnatural” history, a history of how “fear” and “risk” have been reshaping a disease, which continues to be as elusive as it was two centuries ago.


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We are all familiar with the truism that "one in eight American women" will develop invasive breast cancer over the course of her lifetime. The pink ribbon has come to symbolize both solidarity and hope. Mammograms and "Self-Breast Examination" have become part of women's daily routine, if not a spectre haunting their daily lives. Yet the evidence remains contested and the therapeutic promise, the fear and hope associated with this "obstinate" disease as problematic as ever. Unnatural History weaves all these different elements, artifactual and natural, emotional and rational, vital and morbid, in the socio-historical narrative of breast cancer in the American context. In that sense, this is an "unnatural" history, a history of how "fear" and "risk" have been reshaping a disease, which continues to be as elusive as it was two centuries ago.
Writing from different perspectives (biopolitical and feminist to sociohistorical and cultural), many scholars have recently explored the multifarious facets of this deadly disease. 1 Some have examined the broad historical contours of breast cancer, focusing on the controversial "radical" surgeries advocated by William Halsted and his followers. Others have looked at the experiences of women undergoing these mutilating mastectomies and the evolving nature of the patient-doctor relationship, in view of the emergence of patient activism, the self-help movement and "alternative medicine. " And still others have analyzed the idiosyncratic features of American culture and society as well as the rise of * Received 14 November 2010.
† Joelle M. Abi-Rached, MD, MSc., is currently currently a PhD student at the Department of the History of Science, Harvard University. Her research interests include contemporary developments in medicine, the "psy" sciences and "neuro" sciences. "evidence-based" medicine and how these have been reshaping the therapeutic rationale of breast cancer. Although Unnatural History explores some of these issues and shares a similar patient-based narrative with previous works, notably Leopold's A Darker Ribbon and Olson's Bathsheba's Breast, it offers some unique insights worth mentioning. At the very core of the book lies a persistent problem: the convoluted nature of the definition of a disease. What is breast cancer? Aronowitz convincingly shows how the discursive move from cancer in the breast to breast cancer is not a trivial linguistic mutation. Rather, it underlies significant epistemological and ontological tensions that are continuously shaped and refined by the socio-historical context in which they emerge. The focus on "fear, " "anxiety, " "uncertainty, " "promise, " and "hope" thus helps us understand the making of this dreaded disease; how it has been reorganized, how its therapeutic and clinical aspects have been reshaped, and how its societal concerns have been defined over time. Fear, Aronowitz argues, has been reconfigured since the nineteenth century, the period where the book starts: from private fears (that is, fears shared by the affected individual and her entourage), to collective and national fears (since Nixon's 1971 Cancer Act). But it is the combination of both "fear" and "risk, " of uncertainty and pessimism, of the personal and national burdens of this disease, of the rise of screening tests and the therapeutic promises of mammograms, that led to the eventual birth of a new ontological category, "the person at risk, " and the rise of the "surveillance" society.
Although Aronowitz speaks of the rise of the "life at risk" (chap. 5) and "women at risk for breast cancer" (p. 265; author's emphasis) rather than the broader category of the "person at risk" for developing any kind of disease, these two conceptual frameworks are symptomatic of a broader socio-political shi. We have become a society whereby risk has come to define our lives so pervasively. Consequently, the notion of mass surveillance through screening "susceptibilities" and potential risks becomes crucial, if problematic. In fact, Aronowitz argues that it is fear that has ultimately shaped national screening campaigns and other "preventive" measures that came to dominate much of the twentieth century: fear of potentially being at risk for cancer, fear of carrying a suspicious gene or feeling a suspicious lump, and fear of losing control over this dreaded disease. Because these new "life strategies" of managing fear and uncertainty, what sociologist Nikolas Rose aptly calls a "screen and intervene" rationale (Rose 2007;2008;2010), have become an imperative in current medical practice and policy-making, it is unfortunate that Aronowitz does not fully engage with the growing literature on the rise of the "risk society" (Beck 1992) and how risk has been reshaping biomedical practice beyond cancer (see e.g. Rose 2007).
Aronowitz highlights a further issue, that of responsibility and how the fluctuating shi in locating agency helped shape not only the notion of responsibility itself but also the patient-doctor relationship and medical practice more broadly speaking. For Aronowitz, the heightened responsibility of surgeons for breast cancer is key to understanding several developments; in specific, how surgeons established their authority through their commitment to extensive surgery and how this helped maintain an asymmetrical relationship between the male surgeon and the female patient. However, with the rise of new technological tools, such as X-rays and mammography, and the concomitant public campaigns to seek care without delay, responsibility shied gradually back to the patient. Not only did the rise of this new ethics of "caring" for one's health and one's body permeate medical practice, public health, and policy, but perhaps more interestingly societal perception as well. And because this "care of the self, " as Michel Foucault puts it, 2 has become so salient, it would have been useful had Aronowitz explored the self-help movement's role in shaping (for beer or worse) 3 patients' experiences of breast cancer and in contesting the boundaries of what counts as "health" and "disease. " Aronowitz writes with compassion and sensitivity but also with authority and a critical eye towards contemporary medical practice, which he considers deeply flawed. Despite advances in the understanding of breast cancer and the promotion of less aggressive treatments and beer preventive measures, one constant throughout the history of this disease has been its deadliness. Breast cancer still kills while new burdens are created. Notwithstanding the new category of the "person at risk" it reinforces, screening mammography carries its own pitfalls; heightened levels of anxiety and uncertainty, both of which could be avoided by a more judicious practice. One might argue that because Aronowitz does not provide medical practitioners with a solution, it leaves them in a murky zone. But precisely because the book is not prescriptive, it successfully achieves its goal, that of making us reconsider certain fundamental assumptions that lie behind therapeutic rationales and the understanding of diseases. And although Unnatural History focuses on the American context, it opens the possibility of dialogue not only across practices but also across cultures and sub-cultures, an openness that is more than needed in re-thinking the ways to manage and make sense of such an unyielding disease.