Seth M. Holmes from University of California Berkeley and Molly Hales from University of California San Francisco and Berkeley review Malignant: How Cancer Becomes Us by S. Lochlann Jain.
Much as we might want to render cancer an external threat to be battled, it just is not so. Cancer is our history. Cancer has become us. Manifest within individual bodies—many, many bodies—it is also embedded within this country’s key industries, medicine not least among them. (p.8)
Cancer is widespread and devastating. It affects bodies, but it also affects economies, neighborhoods, populations, families, and loved ones. Cancer affects us all.
Author S. Lochlann Jain is not only an award-winning medical and cultural anthropologist, she is also a cancer survivor. Her book Malignant: How Cancer Becomes Us is therefore doubly relevant to practitioners of medicine and public health. Jain’s analysis unveils how cancer relates to institutions and industries, from agriculture to cosmetics to medical research. At the same time, her analysis of her own illness and treatment experiences illustrate the impact that cancer can have on an individual.
Jain begins the book with a simple premise: That the situation could be otherwise. It is not the biological disease itself that has made cancer so difficult to prevent, treat, and come to terms with. Rather, the way that we have approached cancer is the problem. The way that cancer circulates as a concept in society makes some aspects ubiquitous – and thus quotidian – while obscuring other crucial facts.
Jain points out relationships between cancer risk and economics, noting that, “Each of America’s iconic industries—agriculture, oil and gas, cosmetics, plastics, pesticides, tobacco, medicine, construction, military—has undoubtedly led to tens of millions of cancer deaths” (p.5). She shows how these industries benefit from the focus on individual risk that is so common in medicine. She also points out that this focus on individual risk tends to mask the differentially distributed threats that result from toxic waste, environmental destruction, and the widespread production and use of carcinogens. Jain traces how many carcinogenic products are sold by the same industries (e.g. cosmetics and automobile) that fund cancer awareness campaigns. These campaigns represent illness as an individual problem and not related to industrial toxins, thereby counteracting the possibility of political action for regulation.
In a similar way, Jain shows how clinical and epidemiological research plays into specific narratives in medicine. For example, narratives of self-sacrifice may underpin the desires of both clinicians and patients to participate in clinical research trials. Trial participants feel that they are sacrificing their own bodies for the benefit of future patients, even when the benefits and risks of these drugs are yet unknown. The survival charts and prognostic graphs that are so common in cancer research allow cancer survivors to compare themselves to those who have or will die of cancer, making them feel special, but also at times guilty.
Below Jain’s academic analysis of cancer lies another story – a deeply personal examination of the author’s experiences with breast cancer. This narrative is crucial for showing how the obfuscations surrounding cancer translate into experiences of fear and suffering for the human beings who “live in prognosis” – to use the author’s brilliant phrase.
One place in which this juxtaposition of big-picture analysis with personal experiences works especially well is Jain’s examination of stereotypes and assumptions around gender and sexuality. Jain describes the ways in which women with breast cancer are represented by a specific form of femininity, most famously the pink ribbon campaign. Through these representations, women with cancer are made to feel as though they need to meet very particular standards of beauty, for example the use of a wig or cosmetics, or the attention to breast size and appearance. Those who do not – or do not want to – meet these standards of feminine beauty are rarely represented. Jain critiques the fact that, “surgeons commonly suggest that women already considering a mastectomy consider a double mastectomy or additional cosmetic surgeries for the sake of ‘evenness.’ These surgeries have high complication rates” (p.176). Yet she also discusses her own decision to undergo a double mastectomy in order to achieve a balanced aesthetic that would allow her to “pass” without the need of a prosthesis. Here as elsewhere, the author’s candidness lends sensitivity and nuance to her arguments.
The impressive strength of Malignant is also its limitation: the sheer scope of the work. As Jain herself points out, cancer is not one disease but many. Her analyses are far-reaching, without offering easy answers. Yet, this is how it should be. Cancer brings many questions and does not, itself, have easy answers.
Malignant is a powerful analysis of cancer that moves between the broad and societal and the specific and personal. Malignant should be on the reading list of every clinician and clinical researcher who is interested in taking a more rigorous, and perhaps troubling, look at the many ways in which cancer affects and is affected by all of us.
Malignant: How Cancer Becomes Us by S. Lochlann Jain is published by University of California Press, Oakland, CA. ISBN: 9780520276574
Seth M. Holmes is Martin Sisters Assistant Professor of Public Health and Medical Anthropology at the University of California Berkeley; attending physician in Internal Medicie at the Alameda County Medical Center in Oakland, California; Co-Director of the MD/PhD Track in Medical Anthropology (UC Berkeley and San Francisco); and Director of the Berkeley Center for Social Medicine.
Molly Hales is an MD/PhD student in the Medical Scientist Training Program at the University of California San Francisco currently completing her PhD in Medical Anthropology at the University of California, San Francisco and Berkeley, and her MD at the University of California, San Francisco.