I’m thrilled you enjoyed the post. Thank you for directing me to this wonderful book.

There must be something in the air. Just yesterday the Guardian blog posted a parallel and fantastic piece by Mike Marqusee:
“I don’t need a war to fight my cancer. I need empowering as a patient” Using the martial metaphor for something as complex as cancer makes the disease ripe for political and financial exploitation.

Here are 2 paragraphs, which I found exceptionally clear:

Many cancer therapies are blunt instruments. They attack not only cancer cells but everything else in sight. This is one reason people fear cancer: the treatment can be brutal. Making it less brutal would be a huge stride forwards for people with cancer. And that requires not a top-down military strategy, with its win or lose approach, but greater access to information, wider participation in decision-making (across hierarchies and disciplines) and empowerment of the patient.

Cancer treatment involves extensive interaction with institutions (hospitals, clinics, social services, the NHS itself). Even in the best hospitals, the loss of freedom and dependence on anonymous forces can be oppressive. Many cancer patients find themselves involved in a long and taxing struggle for autonomy – a rarely acknowledged reality of the war on cancer, in which the generals call the shots from afar.

As an aside I would be thrilled to discuss with you and your fantastic organization, both as an individual and as a founder of the Society for Participatory Medicine, the possibility to develop programs to raise the public awareness about the great benefits (necessity?) of becoming informed e-patients.

This is a terrific piece. Realize I’m coming late to this discussion and see comments here responding to many of your themes. Would like to also follow up on your good observations about the “war-on-cancer” metaphor and its impact, which deserve another nod.

“War” is a potent metaphor, as you note. Its use in framing the dialogue around cancer has had some positive effects (helping draw attention to the issue and probably making it more accessible), but clearly some negative ones (feeding new fears, narrowing discussion and limiting perceived options).

I think it’s mind blowing how a simple metaphor can have so much sway in directing our thoughts and actions. If you’re interested, there’s a wonderful paper (though maybe a bit academic) by Don Schon, which covers this topic beautifully. It can be found at: http://bit.ly/5X2G0u in the book Metaphor and Thought. When you get to the landing page for the book, just click the “contents” tab and then the chapter “A perspective on problem setting,” which starts on p. 137.

An example of the power of metaphor that has stuck with me begins on p. 144. Will summarize it here for folks that may not have time to read it. Schon describes how, several decades ago, the metaphor “urban blight” was used to characterize inner city “slum” areas and to support the need to eliminate and redesign them from the ground up…from homes to schools to parks and shopping and community centers. As Schon notes, “In this way it was hoped that the cycle of decay could be controlled and the birth of future slums prevented.” The metaphor of “Blight” fit this story well – blight is a plant disease that easily infects other plants if not fully eradicated. It suggests that slums, like blight, needed to be eradicated or they would spread. Piecemeal efforts to address the problems wouldn’t do.

But the blight metaphor also minimizes and draws attention away from another equally valid way to frame the issue. That is, despite their many problems, “slums” are also neighborhoods with vibrant communities. They are a nexus for social ties, support systems and other key benefits that residents rely on. When these communities are pulled apart, as they were when early renewal projects uprooted and moved them to new housing projects in the name of urban redesign, the systems they support are also destroyed and often prove difficult to rebuild.

In sum, many of the “solutions” that flowed from the logic of the blight metaphor made matters worse…much like the war on cancer analogy. Of course, these problems were discovered too late for many communities. I don’t think we can or should avoid metaphor but need to do what you and others suggest, which is to look for and challenge the limitations they may convey and to realize that these limitations may not be immediately obvious.

you are giving the USPSTF a role it doesn’t have! Have you ever looked at their mandate? Here it is:

The Task Force makes its recommendations on the basis of explicit criteria. Recommendations issued by the USPSTF are intended for use in the primary care setting.

Their job is not to look at best centers but to come up with recommendations for the entire population, based on the reality on the ground and the best scientific evidence available at the time of their “evolving” recommendations.

You say “some completely convincing study showed that mammography saves X number of lives”. That is EXACTLY the issue. There are conflicting studies and the studies in use have conflicted methodologies with both sides attacking the way data was collected and analyzed. For an understanding to “SOME” of the historical elements, read the mammography controversy, an article from Colin Begg in 2002. A summary: “The appropriateness of screening mammography has emerged once again as a contentious issue. This report brings readers up-to-date with the latest developments in this long-running controversy.”

+ ca change + c’est la meme chose!