- Email: [email protected]
Pied piper
DISSECTING ROOM
Doctoring the risk society Risk factors
Pied piper
The rising incidence of breast cancer among young professional women has become the focus of considerable media attention. Needless to say, the facts that breast cancer is still very uncommon in women younger than 40 years, and that 80% of cases occur in women older than 50 years, have not received similar attention. Still, nobody knows why more younger women are getting breast cancer than ever before, nor has any method of prevention been shown to be effective. When scientists cannot find causes, epidemiologists identify associations. Though they call these “risk factors”, the late Petr Skrabanek suggested that “risk markers” would be more accurate. Such markers are of little use in elucidating causality and modifying them is of little preventive value. For breast cancer, having only one or two children late in life and breastfeeding them for only a few weeks or less, being overweight and unfit, and drinking alcohol have all been identified as risk factors (or markers). So what should a young woman on the verge of a career in business or the professions do to reduce her breast cancer risk factors? She should, according to a recent feature by the health editor of The Guardian, “have a first baby early— preferably before the age of 20”, “have more children”, and breastfeed them “for at least six months” (Jan 15, 2004). Furthermore, she is advised to follow a health regime: “don’t drink alcohol”, “stick to a low fat diet at least until you hit 50”, and “keep your weight down”. The list continues with instructions to “keep yourself fit”, “eat plenty of fruit and vegetables”, and to “add green tea and soy to your diet”. It would not be surprising to find that this austere and oppressive health promotion package meets with the approval of people who aspire to restore relations between the sexes to the state celebrated in the US cartoon The Flintstones (that is, the state that prevailed in middle-America in the 1950s). What is alarming is the fact that this advice seems to be popular among a growing body of women’s health activists. It seems that some women have become so disillusioned with trying to “have it all”, that they are instead advocating giving it all up and devoting the rest of their lives to trying to avoid death from breast cancer.
Mike Fitzpatrick e-mail: [email protected]
500
went back to see the Chief last year, on my yearly teaching visit to Africa. In the afternoon, I walked down the familiar paths along the edge of the southern vestiges of the Great Rift Valley. The Chief was sitting in front of his hut, legs stretched out, back at right angles, very straight, a shiny wheelchair proudly parked under the mango tree nearby. His femur had healed fairly well, after the makeshift traction I had set up for him during my last visit, but the collateral ligaments never really recovered from the fall and his knee was too unstable to walk on. His age and many years of liberal alcohol consumption have left him too unsteady to manage crutches, so we had arranged to get him a wheelchair. But there is not really anywhere to go in a wheelchair in the village. The paths are too narrow and the hills too steep, and so it stands next to his house, smartly polished but ineffectual. Despite being relegated to a sedentary existence, the power and prestige of the Chief remain enviable. In this democratic age, when first-year medical students routinely address their teachers by their first names, and you think yourself fortunate if your children are merely condescending, this elderly greatgrandfather wields absolute power in his village. In no way despotic or dictatorial, but calm and authoritative, the Chief is listened to by everyone when he speaks—perhaps because he has first listened to what everyone else has to say. He considers all sides of a dispute; since every dispute has many sides, this process cannot be hurried and can take days to complete. He will then deliberate, conferring sometimes with a colleague from a neighbouring village, or with a select group of elderly advisers, and pronounce a judgment that is final, and rarely appealed. Walking around these small villages, I cannot help wondering how I would
I
cope with such a life; with the constant shortage of food and lack of clean water, the mosquitoes, and the disease. I could deal with the hunger and discomfort I think, for a while, even the occasional accident and injury, but how do you cope with illness that is always present in one form or another? Malaria, schistosomiasis, hookworm infection, always there, smouldering under the surface, and now of course AIDS has been added to the list. I don’t think I could ever get used to losing that fine edge of full health that people in developed countries have begun to consider as almost being a right. Suddenly there is a commotion, for the kids have discovered I am here, and anything new in the village is worth checking out. Within minutes we are surrounded by 30 or 40 children— chattering, laughing, smiling, pointing, or just standing and watching. If your only toys consist of a football made from string-tied rags, and a miniature bicycle cunningly constructed from scraps of wire, almost any entertainment is good value. What is striking is their happiness. If life is uncertain you live for the moment, and it is only with increasing certainty that your future plans gradually, inexorably take on increasing importance until everything seems dominated by worries about specialisation, pension plans, investments, and so on. At a certain point, future gloom permeates present happiness like brackish water in an overused well. The children shrieked with delight when I showed them their faces on the minuscule screen of the camera. When I left, they followed me out of the village and so far along the road that I began to feel like an accidental pied piper, attracting with a different kind of digital magic a lengthening column of cheering children. Johannes Borgstein
THE LANCET • Vol 363 • February 7, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.
Doctoring the risk society Risk factors
Pied piper
The rising incidence of breast cancer among young professional women has become the focus of considerable media attention. Needless to say, the facts that breast cancer is still very uncommon in women younger than 40 years, and that 80% of cases occur in women older than 50 years, have not received similar attention. Still, nobody knows why more younger women are getting breast cancer than ever before, nor has any method of prevention been shown to be effective. When scientists cannot find causes, epidemiologists identify associations. Though they call these “risk factors”, the late Petr Skrabanek suggested that “risk markers” would be more accurate. Such markers are of little use in elucidating causality and modifying them is of little preventive value. For breast cancer, having only one or two children late in life and breastfeeding them for only a few weeks or less, being overweight and unfit, and drinking alcohol have all been identified as risk factors (or markers). So what should a young woman on the verge of a career in business or the professions do to reduce her breast cancer risk factors? She should, according to a recent feature by the health editor of The Guardian, “have a first baby early— preferably before the age of 20”, “have more children”, and breastfeed them “for at least six months” (Jan 15, 2004). Furthermore, she is advised to follow a health regime: “don’t drink alcohol”, “stick to a low fat diet at least until you hit 50”, and “keep your weight down”. The list continues with instructions to “keep yourself fit”, “eat plenty of fruit and vegetables”, and to “add green tea and soy to your diet”. It would not be surprising to find that this austere and oppressive health promotion package meets with the approval of people who aspire to restore relations between the sexes to the state celebrated in the US cartoon The Flintstones (that is, the state that prevailed in middle-America in the 1950s). What is alarming is the fact that this advice seems to be popular among a growing body of women’s health activists. It seems that some women have become so disillusioned with trying to “have it all”, that they are instead advocating giving it all up and devoting the rest of their lives to trying to avoid death from breast cancer.
Mike Fitzpatrick e-mail: [email protected]
500
went back to see the Chief last year, on my yearly teaching visit to Africa. In the afternoon, I walked down the familiar paths along the edge of the southern vestiges of the Great Rift Valley. The Chief was sitting in front of his hut, legs stretched out, back at right angles, very straight, a shiny wheelchair proudly parked under the mango tree nearby. His femur had healed fairly well, after the makeshift traction I had set up for him during my last visit, but the collateral ligaments never really recovered from the fall and his knee was too unstable to walk on. His age and many years of liberal alcohol consumption have left him too unsteady to manage crutches, so we had arranged to get him a wheelchair. But there is not really anywhere to go in a wheelchair in the village. The paths are too narrow and the hills too steep, and so it stands next to his house, smartly polished but ineffectual. Despite being relegated to a sedentary existence, the power and prestige of the Chief remain enviable. In this democratic age, when first-year medical students routinely address their teachers by their first names, and you think yourself fortunate if your children are merely condescending, this elderly greatgrandfather wields absolute power in his village. In no way despotic or dictatorial, but calm and authoritative, the Chief is listened to by everyone when he speaks—perhaps because he has first listened to what everyone else has to say. He considers all sides of a dispute; since every dispute has many sides, this process cannot be hurried and can take days to complete. He will then deliberate, conferring sometimes with a colleague from a neighbouring village, or with a select group of elderly advisers, and pronounce a judgment that is final, and rarely appealed. Walking around these small villages, I cannot help wondering how I would
I
cope with such a life; with the constant shortage of food and lack of clean water, the mosquitoes, and the disease. I could deal with the hunger and discomfort I think, for a while, even the occasional accident and injury, but how do you cope with illness that is always present in one form or another? Malaria, schistosomiasis, hookworm infection, always there, smouldering under the surface, and now of course AIDS has been added to the list. I don’t think I could ever get used to losing that fine edge of full health that people in developed countries have begun to consider as almost being a right. Suddenly there is a commotion, for the kids have discovered I am here, and anything new in the village is worth checking out. Within minutes we are surrounded by 30 or 40 children— chattering, laughing, smiling, pointing, or just standing and watching. If your only toys consist of a football made from string-tied rags, and a miniature bicycle cunningly constructed from scraps of wire, almost any entertainment is good value. What is striking is their happiness. If life is uncertain you live for the moment, and it is only with increasing certainty that your future plans gradually, inexorably take on increasing importance until everything seems dominated by worries about specialisation, pension plans, investments, and so on. At a certain point, future gloom permeates present happiness like brackish water in an overused well. The children shrieked with delight when I showed them their faces on the minuscule screen of the camera. When I left, they followed me out of the village and so far along the road that I began to feel like an accidental pied piper, attracting with a different kind of digital magic a lengthening column of cheering children. Johannes Borgstein
THE LANCET • Vol 363 • February 7, 2004 • www.thelancet.com
For personal use. Only reproduce with permission from The Lancet.