In May, 2013 actress Angelina Jolie announced that, diagnosed with a high risk of breast cancer, she had undergone a double mastectomy. Two years later, after a blood test showed a high probability of an early onset of ovarian cancer, she had her ovaries removed. Jolie’s announcements have elicited considerable media attention, in many of which she was portrayed as courageous in a ‘cancer battle’, and since then studies have appeared showing a ‘Jolie-effect’ on breast cancer screening and elective mastectomy in the UK and the US. The actress’s activism also drew critical voices, among them some that questioned Jolie’s status as a ‘hero’ and saw her story rather as one of privilege, because women’s access overall to costly preventive and reconstructive surgeries is very limited.
Robert Aronowitz’s book, Risky Medicine helps us make sense of such contemporary phenomena. The actress’s story in many ways embodies the complex underlying issues that the modern understanding of risk in medical interventions and health reveals. It raises questions of how risk assessment has blurred the boundaries of disease and health, of how complex cancer survivorship has become in the past century, and of the economic and social implications of risk interventions.
In this collection of essays, Aronowitz expands on these issues and explores how risk and attempts at its reduction have become central to the experience of health and disease both in individual and collective terms. Through an analysis of various diseases like cancer and heart disease, and of problematic preventive measures such as the HPV and Lyme Disease vaccines, Aronowitz argues that reducing risk is not merely a road to health, but it has become the definition of health itself. He identifies three key aspects of risky medicine: market-driven expansion of risk interventions, the converged experience of risk and disease, and the social and psychological work that public health interventions as risk-reducing procedures carry out.
As the author acknowledges, ‘Risky Medicine has had a long gestation’. The book contains five chapters that have been published elsewhere since 2006: three chapters appeared as journal articles, while two had been included in edited volumes. While the book reflects these varied origins in some inconsistencies and deficiencies (such as only some chapters having conclusions, and the lack of a bibliography), putting previously published essays together with new material gives the author the opportunity to examine the set of problems that risk in medicine poses from a range of perspectives and to track changes over time. Aronowitz takes up the economic implications of risk interventions, the embodiment of risk, the role of pharmaceutical companies in expanding definitions and understandings of disease through a risk-centred approach, and the effectiveness of risk-reducing measures.
Throughout the chapters Aronowitz repeatedly comes back to ‘risk states’: experience of being at risk for disease. As he puts it, it is at once ‘a state to be avoided and worthy of prevention itself’. Jolie’s story can be understood as an example of risk interventions aimed at preventing risk states. Furthermore, her activism can be seen as part of what Aronowitz terms as modern cancer survivorship, the complex and varied ways in which risk-reducing interventions have shaped personal and aggregate patient experiences, including previvorship, an effort to do away with risk altogether and return to a state of certainty.
Aronowitz is very clear on why all this matters and not only voices criticism of health policies, and pharmaceutical and clinical practices, but also puts forward alternative solutions. Among others, he suggests the establishment of new types of regulatory bodies that would more closely scrutinise research and screening technologies that might diffuse practices without proof of efficacy or evidence. While focusing on the United States in general, the book also engages with global health policies and practices by considering global circulation of risk interventions. Through a vaccine controversy involving an international NGO and the unexpected success of an HPV screening and treatment method in India, Aronowitz shows the tensions between risk interventions that are thought to be universal, and local health conditions, and economic and political conditions.
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, and complements recent publications on risk in the history of science such as Dan Bouk’s How our Days became Numbered. The book is, therefore, both relevant and an important read for historians of medicine and science, economists, public health policy makers and medical practitioners.
