Malignant: How Cancer Becomes Us by S. Lochlann Jain. Berkeley: University of California Press, 2013.
Reviewed by Mary Anglin, Department of Anthropology, University of Kentucky
At the age of thirty-six, Lochlann Jain embarked on a journey for which neither her anthropological training nor her upbringing as “a reticent Canadian” and the daughter of a physician could fully prepare her. Diagnosed with advanced breast cancer, but only after a protracted effort to have her health concerns taken seriously, Jain next undertook an aggressive course of treatment comprised of double mastectomy, radiation, and chemotherapy. Thereafter she sought healing and “new vocabulary” through her involvement in support groups and retreats, as well as a relentless succession of funerals that attested to cancer’s gravity and the significance of community. Nonetheless, it is the ordinariness of that experience which Jain has chosen to highlight through her account of how “cancer has become a central, silent, ubiquitous player in twentieth- and twenty-first century America” (2013:5).
Cancer’s iconic status in the United States, and that of breast cancer more specifically, is exemplified by such events and textual representations as the proliferation of first-person narratives, beginning with Rose Kushner’s Breast Cancer: A Personal History and an Investigative Report (1975) and Betty Rollin’s First, You Cry (1976); President Richard Nixon’s declaration of a “war on cancer” with the National Cancer Act of 1971; the maturation of sociological and anthropological analyses of cancer, as well as those of public health and clinical researchers; and, more recently, the tipping point of saturation by cultural/commercial imagery which Barron Lerner (2010) has dubbed “pink ribbon fatigue.” From the outset, journalists like Kushner and Rollins did more than connect the personal with the political, to borrow the phrasing of the time. They altered lay and professional understandings of the disease, and inspired generations of advocacy. In a quest to separate biopsy procedures from the surgical treatment of breast cancer, for example, Kushner challenged the singular authority of the physician and championed patients’ rights to informed consent. Ten years prior, electing not to disclose her own health status lest her research findings appear biased, Rachel Carson (1962) had called attention to the dominance of the chemicals industry, as well as the magnitude and range of effects from environmental contamination. Cancer etiology turned out to be a political, as well as a scientific, question.
Carson’s influence yet carries forth through the work of self-styled cancer activists as well as environmentalists, public health practitioners, anthropologists, etc., to explore the systemic implications of exposure to that toxic soup: among them, a rising tide of cancer diagnoses in the late twentieth century. American biomedicine’s continued emphasis on traditional or behaviorally focused risk factors to explain the incidence of cancer has also become a topic for public debate and scholarly attention, as has the evolution of a highly powerful, lucrative arm of health care centered around cancer detection/treatment and the politically charged matter of who has access to those services. Likewise, the promotion of pink ribbon culture has received popular and academic scrutiny—not only for its infantilizing logic, but equally its place in the profitable arena of cause marketing and the displacement of attention from uncertainties that still surround breast cancer as an object of knowledge and a diagnosis.
To these discussions, Lochlann Jain brings a distinctive outlook, part anthropological and part autobiographic, which she characterizes as “living in prognosis.” To live in prognosis is to be subjected, without bidding or control, to the “rifle’s spray of statistics” that establish the odds of survival for a given disease. It is a liminal space, summoned forth by the actuality of diagnosis, which Jain (2013:45) has compared to “walking before the firing squad. I am alive. No you are dead.” That vantage point allows no room for glib optimism or the idea of survivorship as a “moral calling” except insofar as health outcomes are inexorably tied to economic factors and social valuation (2013:30-1, 57). And, finally, it is a site for the production of knowledge, most notably about the relationships—“economic, sentimental, medical, personal, ethical, institutional, statistical”—that establish cancer as a social field (2013:4).
In this remarkably forthright book, Lochlann Jain recounts various aspects of her diagnosis with, and treatment for, breast cancer that made the experience depart so vividly from official narratives of biomedical expertise and success. From each “curl of feeling,” Jain “worked [her] way backward from the discomfort to the structures that organized it” (2013:22). Foremost is her anger at the physicians who refused to order a biopsy, since she was a young adult and deemed to be at minimal risk, and her reflections on the counterfactual. “What if” her tumors had been detected sooner and at an earlier stage of disease? Did Jain’s dark complexion and identity as a lesbian have some bearing on the delay? Why wouldn’t the doctors’ errors meet the legal threshold for a “lost chance at survival,” and what does this say about patients’ rights (2013:102)? How have doubt and the absence of definitive information come to be treated as forms of knowledge that justify contemporary economic, legal, and medical institutional arrangements? What are the effects, viewed in terms of the social production and normalizing of cancer—as something that just happens?
At times, Jain’s analysis verges on polemic, as with her description of the “pervasive social taboo” against recognizing the link between environmental pollutants and cancer (2013:190). She usefully points to vested commercial interests, along with the notable failure of U.S. regulatory agencies, as a part of that silence (2013: 5-6, 188-90). Jain’s argument is less persuasive about the complicity of “many Americans”—in supporting the U.S. economy over and against potential health concerns—or the inadequacies of cancer activism (2013:185, see also pp. 86-7). How does one step outside of capitalism? Moreover, little mention is made of the campaigns of women (and men) from New York, Massachusetts, California and across the U.S., sometimes in coalition with environmental justice organizations, to “stop cancer where it starts” by promoting the precautionary principle; providing public testimony; pressing for municipal and state regulation of synthetic chemicals; and conducting research in the public interest through “laboratories of their own,” as with the Silent Spring Institute named for Carson (http://bcaction.org/; http://silentspring.org/about-us; http://www.breastcancerfund.org/clear-science/). Yet these efforts have been significant and are clearly distinguishable from corporate strategies to market sports cars or foundation fundraising activities that “drown… breast cancer in a sea of pink” (2013:86, see also pp. 67-69, 78).
Still, in the finest sense of autoethnography, Jain has created a poetic, deeply resonant portrait of her journey from the view of cancer as an exceptional state, associated with a “different genre of person,” to reflections on the grief, heartbreak and loneliness of living with—and dying from—this disease (2013:216, 220). Through the communal spaces of retreat, Jain learned about the power of self-representation and of bearing witness to the suffering of others. As she observed, “Unlike academic work, which needs to be critiqued to gain credibility and meaning, this work needed only to be heard” (2013:218). Stepping outside the discursive strategies of official accounts, Lochlann Jain has found a way to place individual and collective experiences, with their acknowledgement of sorrow and pain, back into the cultural narrative of cancer. More than elegy or memoir, Malignant provides an incisive, necessary social critique.
References Cited
Rachel Carson, Silent Spring. New York: Houghton Mifflin, 1962.
Rose Kushner, Breast Cancer: A Personal History and an Investigative Report. New York: Harcourt Brace Jovanovich, 1975.
Barron H. Lerner, Pink Ribbon Fatigue, The New York Times, October 11, 2010. http://well.blogs.nytimes.com/2010/10/11/pink-ribbon-fatigue/comment-page-8/?_r=0
Betty Rollin, First, You Cry. New York: The New American Library, 1976.