Cover of Risky Medicine
Risky Medicine Our Quest to Cure Fear and Uncertainty
by Robert Aronowitz
University of Chicago Press, 2015
Cloth: 978-0-226-04971-7 | Electronic: 978-0-226-04985-4
DOI: 10.7208/chicago/9780226049854.001.0001

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ABOUT THIS BOOKAUTHOR BIOGRAPHYREVIEWSTABLE OF CONTENTS

ABOUT THIS BOOK

Will ever-more sensitive screening tests for cancer lead to longer, better lives?  Will anticipating and trying to prevent the future complications of chronic disease lead to better health?  Not always, says Robert Aronowitz in Risky Medicine. In fact, it often is hurting us.  

Exploring the transformation of health care over the last several decades that has led doctors to become more attentive to treating risk than treating symptoms or curing disease, Aronowitz shows how many aspects of the health system and clinical practice are now aimed at risk reduction and risk control. He argues that this transformation has been driven in part by the pharmaceutical industry, which benefits by promoting its products to the larger percentage of the population at risk for a particular illness, rather than the smaller percentage who are actually affected by it. Meanwhile, for those suffering from chronic illness, the experience of risk and disease has been conflated by medical practitioners who focus on anticipatory treatment as much if not more than on relieving suffering caused by disease. Drawing on such controversial examples as HPV vaccines, cancer screening programs, and the cancer survivorship movement, Aronowitz argues that patients and their doctors have come to believe, perilously, that far too many medical interventions are worthwhile because they promise to control our fears and reduce uncertainty.   
 
Risky Medicine is a timely call for a skeptical response to medicine’s obsession with risk, as well as for higher standards of evidence for risk-reducing interventions and a rebalancing of health care to restore an emphasis on the actual curing of and caring for people suffering from disease.      

AUTHOR BIOGRAPHY

Robert Aronowitz is professor and chair of the history and sociology of science at the University of Pennsylvania; he earned his medical degree from Yale University. His books include Making Sense of Illness: Science, Society, and Disease and Unnatural History: Breast Cancer and American Society. He lives in Merion Station, Pennsylvania.

REVIEWS

“How did risk reduction become the mantra of modern medicine? Risky Medicine tells the important story of how disease and the risk of it have become collapsed to the point that it’s no longer always clear which one we’re actually treating. A physician and historian of medicine, Aronowitz surprises the reader with his counterintuitive arguments but never oversimplifies debates or caricatures the doctors, researchers, patients, and policy makers who figure in this compelling and incisive account. He shows us how medicine’s risk revolution matters, both for individuals who must manage their fears in the face of uncertainty and for societies intent on improving health outcomes while controlling costs.”
— Steven Epstein, author of Inclusion: The Politics of Difference in Medical Research

“An important, timely, and provocative analysis of our contemporary style of managing—and experiencing—disease. In today's world of ‘risky medicine’ we have come to diagnose and treat likelihoods—risk—as much as pain and incapacity, without evaluating the costs as well as benefits of this novel medical regime. Aronowitz’s forceful analysis makes clear the necessity for that critical evaluation; this book should be widely and enthusiastically reviewed.”
— Charles E. Rosenberg, author of Our Present Complaint: American Medicine, Then and Now

“In this important new book, Aronowitz shows us how all aspects of the US health system, from prevention to cure, hospital stays to outpatient visits, fee-for-service to managed care, have become entangled in a sprawling morass of ‘risky medicine’: a preoccupation with reducing and managing risks of future disease rather than treating present illness. Risky Medicine skillfully traces how it is that we came to think of health and disease in terms of risks instead of symptoms, demonstrates why our increasing concern with risk leads to more healthcare spending without necessarily improving quality of life, and offers keen analysis and concrete policy suggestions to rethink the role of risk in health policy and medical practice.  This should be required reading for anyone with a serious interest in the past, present, or future of health care in America.”
— Jeremy Greene, author of Generic: The Unbranding of Modern Medicine

“Risky Medicine examines the tremendous implications of the collapsing of risk and disease in contemporary American biomedicine. Across a series of historical and contemporary cases, and with great acuity, clinician/historian Aronowitz explains how we have come to the point where much of our medical care, health policy, and patient experience is shaped less by illness itself than its potential threat. This immensely intelligent, bold, yet humane book offers vital insight into the problems of overtreatment as well as new dimensions of embodiment and anxiety that follow from our focus on risk.”
— Julie Livingston, author of Improvising Medicine: An African Oncology Ward in an Emerging Cancer Epidemic

“In Risky Medicine, Aronowitz brilliantly analyzes the essential ironies of contemporary biomedicine. In our efforts to reduce the risk of disease, we may augment those very risks. In our efforts to reduce uncertainties about our health, we introduce new uncertainties. The traditional medical dictum of ‘do no harm’ becomes virtually impossible in a technocentric medical world of monitoring, testing, and treatment.  Physicians, historians, policy makers, and patients will all benefit from this powerful precautionary tale.”
— Allan M. Brandt, author of The Cigarette Century

“Americans have the most advanced (and expensive) health care—but not the best health. Science and sociology historian Aronowitz suggests that our market-driven, risk management-focused health care culture has led to excessive tests and overdiagnosis. The cure? Reforming how we think about health and how it’s practiced.”
— Discover

“Aronowitz poses useful questions about how societies should decide which innovations to adopt and how much people should choose to know about what is happening inside their bodies.”
— Financial Times

“With approaches from multiple disciplines such as sociology, anthropology and history, and drawing on personal experiences as a physician, Aronowitz’s book offers a critical perspective of the expanding centrality of risk in medicine and its effects on public health systems, clinical practice and disease experience. In this sense, Aronowitz’s work is part of emerging scholarship on the centrality of risk in science and medicine. . . . The book is, therefore, both relevant and an important read for historians of medicine and science, economists, public health policy makers and medical practitioners.”
 
— Medical History

"The rise of medical statistics has not just changed the way physicians evaluate therapies. It has also fundamentally changed our understanding of health and disease. As physician and historian Robert Aronowitz argues in Risky Medicine: Our Quest to Cure Fear and Uncertainty, it is no longer necessary to feel ill in order to be ill. A patient may feel fine and yet be treated as sick because her indicators point to elevated risk of disease or premature death. The experience of being “at risk” has, Aronowitz contends, converged with the experience of disease itself."
— Boston Review

"In Risky Medicine: Our Quest to Cure Fear and Uncertainty, physician and leading medical historian Robert Aronowitz maps the historical emergence of the risk paradigm in health: the notion that the task of medicine is to reduce and  manage the probability of future illness rather than treating present disease."
— American Sociological Association

"Aronowitz explores the transition from a time when medical encounters were primarily dealt with the management of felt bodily experience and physical signs to highly probabilistic risk knowledge that increasingly generated by medically-directed surveillance and probing. In tracing this transformation, Aronowitz aims to contribute to the history and sociology of medicine, in particular the study of disease and the disease experience as well as to our thinking about policy choices."
— Economic Record

TABLE OF CONTENTS

I


DOI: 10.7208/chicago/9780226049854.003.0001
[risk, prevention, screening, health policy, chronic illness, efficacy, medicalization, consumers, consumption]
This chapter gives an overview of the book's argument and structure. The experience of ill health is in increasingly dominated by the psychological aspects of risk and the work of risk reduction. Public health, medical interventions, and consumer products are increasingly risk-reducing rather than aimed at treating symptoms or curing disease. Three drivers of risk-centered medicine are introduced: the market-driven expansion of risk interventions; the converged experience of risk and disease; and the risk-reducing efficacy of many medical interventions, which often involves social and psychological work. This chapter gives rationales for the subsequent essays, distinguishing the book from medicalization studies. It also introduces the idea that changes in the built environment and other material aspects of modern life have led to new risks entering the body and being linked to ill-health, especially risks from consumer behavior. It concludes by connecting risk-centered medicine to broader trends, values, and interests within Western societies. (pages 3 - 20)


DOI: 10.7208/chicago/9780226049854.003.0002
[risk, chronic disease, history of medicine, efficacy, medical decision making, medicalization, prevention, screening]
Chronic disease has become dominated by risk and risk-reducing interventions. This has occurred because of (1) interventions that have directly changed the natural history of disease; (2) greater biological, clinical, and epidemiological knowledge of risks associated with chronic disease; (3) recruitment of larger numbers of people into chronic disease diagnoses; (4) new ways of conceptualizing the efficacy of risk-reducing interventions; and (5) intense diagnostic testing and medical intervention. The converged experience of risk and disease has led to: (1) some puzzling trends in medical decision making, such as sharply increased numbers of prophylactic mastectomies; (2) a larger market for risk interventions and greater clout for disease advocates; (3) shifts in the perceived severity of the disease, with ripple effects on people's self-understanding of ill health; and (4) interventions that promise both to reduce the risk of disease and to treat its symptoms. (pages 21 - 44)


DOI: 10.7208/chicago/9780226049854.003.0003
[efficacy, risk, screening, clinical trials, epidemiology, HPV, Gardasil, therapeutics]
This chapter explores what we mean by efficacy, the power to have an effect, in interventions that reduce risk. Many risk reducing practices do social and psychological work such as providing reassurance, reducing fear, and signaling responsibility for health. The efficacy of risk reduction is perceived differently than symptomatic or curative therapies. This efficacy of risk intervention is accepted because of trust in the results of epidemiological or clinical research. We have also been persuaded that risk interventions work by social processes such as the use of clinical trials as marketing devices, the ways that compliance with risk reducing practices can be self-reinforcing, the use of half-way endpoints as witnessed evidence of efficacy, and by the ways risk stratification can give a rational veneer to extreme interventions. (pages 45 - 66)

II


DOI: 10.7208/chicago/9780226049854.003.0004
[Framingham, chronic disease, risk factors, history of medicine, epidemiology, coronary heart disease, cohort studies, prevention]
One reason for the ascendency of risky medicine has been the explosion in knowledge about health risks, whose seminal development was the Framingham heart study. Framingham is considered to be the first cohort study and the major impetus for recognizing coronary heart disease (CHD) risk factors. I show that the novel methodological aspects of the study emerged without a great deal of planning or agency. Beginning as a cardiac control program similar to older tuberculosis campaigns, Framingham investigators innovated in incremental steps in response to its changing institutional base, the needs of its various supporters and audiences, and new concepts and tools. While Framingham was crucial in uncovering CHD risk factors, the study was itself shaped by the same social influences which were leading to a more individualistic and quantitative style of understanding and intervening in CHD and other chronic diseases. (pages 69 - 94)


DOI: 10.7208/chicago/9780226049854.003.0005
[Gardasil, Cervarix, Human papilloma virus, vaccines, risk, history of medicine, cervical cancer, prevention, pharmaceutical industry]
I explore the details and implications of the new HPV vaccines' co-construction as vaccines against cancer and as proprietary drugs that promise to reduce and control individual risk. This dual identity explains these vaccines' architecture, perceived efficacy, cost, and marketing. HPV infection has been constructed as a risk state or experience. The vaccines promise not only efficacy against cervical cancer and other disease outcomes, but at evading this risk state. The HPV vaccines' differences with traditional vaccines may be difficult to appreciate because researchers, public health officials, drug manufacturers, and clinicians have blurred the border between risk and disease and have appropriated older rationales and the language of traditional clinical interventions and public health for new ends. (pages 95 - 110)


DOI: 10.7208/chicago/9780226049854.003.0006
[Lyme disease, Lyme disease vaccine, history of medicine, history of public health, vaccines, health policy, disease advocacy, efficacy, prevention, Food and Drug Administration]
Two vaccines against Lyme disease (LD) appeared in the 1990s. Despite evidence of their safety and efficacy, one vaccine was withdrawn before FDA approval and the other pulled after only three years on the market. The history of these vaccines illuminates the challenges faced by many new risk-reducing products and practices and the important role played by their social and psychological, as distinct from their biomedical or scientific, efficacy. Vaccine developers appealed to consumers' desire for protection and control and to their LD fears. LD advocates initially supported the vaccines but soon became critical opponents. Their opposition flipped the vaccines' social and psychological efficacy. Instead of restoring control and reducing fear, some advocates argued that the vaccines caused an LD-like syndrome. The brief history of LD vaccines suggests that policy makers need to understand, anticipate, and perhaps shape the potential social and psychological work of risk reducing interventions. (pages 111 - 136)


DOI: 10.7208/chicago/9780226049854.003.0007
[Cancer, cancer survivors, risk, secondary prevention, patient advocacy, history of medicine]
I explore the rapid growth and changing meaning of cancer survivorship, a prominent example of the converged experience of risk and disease. Long-term survivorhood is no longer a period of receding worry after cancer diagnosis and treatment. Knowledge of risks emanating from the natural history of cancer and previous cancer interventions has led to many new types of often intense surveillance and intervention as well as more funding for research and clinical initiatives. But there have been problematic consequences of this transformation. As more people become cancer survivors due to expansion of the diagnosis and creation of new pre-cancerous and at-risk conditions, people with difficult-to-treat cancer have less societal visibility. We have also valorized the cancer survivor without asking why or recognizing the downsides of this valorization. Some interventions "work" not so much to improve a survivor's life chances as to restore control and certainty to the risky survival experience. (pages 137 - 156)


DOI: 10.7208/chicago/9780226049854.003.0008
[risk, global health, prevention, HPV, HPV vaccines, cervical cancer, see and treat, Januvia, type II diabetes, screening]
This chapter explores the global interrelationships among risk reducing ideas and practices. I focus on the global circulation of screening and surveillance programs and drugs to reduce risk. Many of these drugs are poised for export around the globe because they have very low marginal production costs, are highly palatable, and easily transported. There is also great demand - and potential to create even more demand - for practices and products which promise to prevent disease, especially in societies in which the infrastructure, resources, and manpower to treat disease is absent or inadequate. But the social and economic conditions in rich countries which have shaped the identity and meaning of such globalizing risk-reducing practices and products can be profoundly different from conditions in poor countries. As a result, their export to poorer parts of the globe can result in a mismatch with the health problems on the ground. (pages 157 - 180)

III


DOI: 10.7208/chicago/9780226049854.003.0009
[health policy, prevention, hormone replacement therapy, menopause, risk, women's health initiative, medical decision making]
I argue that the disease prevention landscape has been radically transformed over the past half-century and yet our clinical and public health practices have not been based on an adequate knowledge of this transformation. Health risks dominate medical practice, yet are poorly acknowledged. There are tremendous market rewards for successful risk interventions, which may be used by entire populations for large fractions of their lifespans. Our disease prevention policy has been reactive and after-the-fact. I use the history of hormone replacement therapy to prevent chronic disease to illustrate the relevance of this way of thinking about health risks. I argue for "upstream" disease prevention policy that potentially intervenes in the discovery of health risks, the ways health risks are made visible to others, and in actions that create demand for specific interventions. (pages 183 - 200)


DOI: 10.7208/chicago/9780226049854.003.0010
[Alzheimer's disease, sleep apnea, prostate cancer, PSA screening, health policy, chronic illness, trust, iatrogenesis, health care costs, quality of care]
I summarize the different components of what I call a risk system and then recapitulate (1) the problematic "states of risk" that often create demand for more interventions, (2) the self-fulfilling and self-reinforcing features of many risk systems, (3) the (often ironic) interconnectedness of risk interventions, (4) the centrality of trust; and (5) and some clinical and policy implications of thinking about health risks systematically. We have hastily and with hubris named and created new health risks and devised and diffused risk-reducing interventions before knowing whether they were safe and efficacious in the long run. Appreciating the limits of what we know about health risks and risk interventions can be more systematically factored into how we respond as individuals and collectively. Understanding and recovering the history of how such a comprehensive risk system developed and is sustained is a first step towards wiser and more appropriate individual and collective responses. (pages 201 - 222)

Acknowledgments

Notes

Index

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