Social History of Medicine Advance Access originally published online on February 14, 2009
Social History of Medicine 2009 22(1):204-206; doi:10.1093/shm/hkn101
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Book Reviews |
Cancer in the Twentieth Century
David Cantor (ed.), Cancer in the Twentieth Century, Baltimore: Johns Hopkins University Press, 2008. Pp. vi + 350. $25.00. ISBN 978 0 8028 8867 0.David Cantor has edited a fine collection of papers that consider the development of efforts to control cancer in the last century. Together they formed a special issue of The Bulletin of the History of Medicine in 2007 reporting a conference held at the National Institutes of Health in 2004. The collection is divided into three sections, covering education and marketing, therapeutics and notions of prevention and risk respectively, thus drawing our attention to the key loci of countries' attempts to limit the damage wrought on populations by cancer. Authors predominantly focus on the histories of America and Britain, demonstrating many historical differences in approach and outcome and doing much to explain why cancer treatments vary so greatly between the two today. While few directly compare even these countries, this book nonetheless serves as an excellent illustration of both the difficulty of, and the necessity for, comparative history when considering the emergence of complex healthcare systems in the developed world.
The first section sheds light on the cloudy history of state (and charity and clinic) interest in informing citizens about cancer, asking what made the disease sometimes highly attractive for education drives, sometimes impossible to publicly address. Elizabeth Toon's study of cancer education in Britain in the first years after the foundation of the NHS demonstrates that fear of increased demand for GP time led the focus to be on educating not the public but doctors about the early signs and symptoms of cancer as neither the government nor the medical establishment wanted waiting rooms packed with the worried well. This is in stark contrast to the history of public education programmes staged in America, which stressed a message of ‘do not delay’, as presented by David Cantor here and by others in recent publications (see, for example, Robert A. Aronowitz, Unnatural History: Breast Cancer and American Society, New York: Cambridge University Press, 2007). Papers in this section also consider the blurring of the boundary between sharing cancer information and advertising cancer services. Gretchen Krueger shows, for example, that images of children receiving cancer treatment, used in fund raising efforts by specialist hospitals and by the American Cancer Society, typically ‘masked or downplayed the physical manifestations of cancer in photographs, yet paired ... sentimental images with provocative headlines ... to amplify their impact’ (p. 76).
Authors writing about the history of cancer therapeutics attend to different viewpoints on treatment. Ornella Moscucci's careful reading of debates in the early part of the twentieth century over the rival merits of surgery and radiotherapy in the treatment of cervical cancer concludes that radiotherapy was of particular interest to women surgeons as it offered them a means to circumvent the barriers to professional advancement their sex placed in their way. She focuses on battles for professional status waged under the banner of contesting therapies. John Pickstone traces history at the level of nationwide policies and trends. Peter Keating and Alberto Cambrosio look at the emergence of a new style of biomedical practice, thus following developments from the perspective of the cooperative group administering clinical trials programmes. Baron Lerner stays closer to the level of illness experience, examining the role of an individual patient, Rose Kuchner, who, working as an advocate, helped shape which therapies were made available to others.
The final section of the book tries to combine two interests, but risk and prevention do not seem to speak to one another here and the four papers do not gel as convincingly as in the other sections. Two authors analyse the emergence of the notion of ‘embodied risk’ in hereditary cancers (Ilana Löwy and Paul Necochea), two utilise rich archival sources to show how lung cancer came to be seen as less a disease to treat and more one to prevent (Virginia Berridge and Carsten Timmermann). In his introduction to the collection, Cantor characterises the 1960s and 1970s as a time when there was a ‘reinvention’ of interest in the role of environmental, occupational and, what we now call, lifestyle factors in causing cancer (p. 23). Yet none of the authors, in this section or elsewhere, attend to the earlier history of research into cancer prevention, and nor do they ask why prevention was chronically under-funded for the middle decades of the century. To discover the extent of the discrepancy in state and voluntary funding of research into prevention versus treatment, and the political reasons behind it, one must turn to Devra Davis's recent book which spotlights the ‘revolving door of industrial and government cancer experts’ that operated since the 1930s (Devra Davis, The Secret History of the War on Cancer, New York: Basic Books, 2007).
Cancer patients are largely silent in this collection, with the exception of papers by Krueger and Lerner. But they are by no means absent. For the concerned doctors studied by Toon, patients are potential hoards clogging up surgeries. For the disappointed chest surgeons discussed by Timmermann, patients are inoperable cases that must become the last of their kind. For Moscucci's feminists, they are the subjects of cruel vivisection experiments. For Keating and Cambrosio, patients are data flowing around the protocol charts. For Löwy and Necochea's agents, they are the carriers of genes. In each case, control is sought as much of patients as it is of cancer itself: these papers show medical practitioners and researchers striving to control the number of patients presenting themselves for examination, access to patients as trial participants, and definitions of who counts as a patient.
This paperback book would make a stimulating addition to any reading list for advanced undergraduate courses examining the history of chronic disease or the economics of healthcare systems. Papers by Ilana Löwy and John Pickstone in particular would also be of enormous value as a supplement to the studies of any medical student or practising cancer physician. Löwy puzzles over the meaning of the phrase ‘molecular lesion’—apparently an oxymoron, yet used frequently to describe cancer-causing mutations in genes—to make sense of the emergence of routinised predictive imaging of bodies perceived to be carrying risk within them, in this case women at risk of breast cancer. Pickstone surveys a century of development in cancer therapeutics over two continents to explore the reasons behind the divergent configurations of cancer services seen at the close of the last century, and in the process repeatedly highlights the role played by centralised funding in reshaping cancer therapy policies and practices. The history of cancer services has been largely forgotten by those who dictate their present form, an amnesia this collection could begin to correct.
Royal Holloway, University of London
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