Kirsten Bell

Medicine, morality and mothering: public health discourses on foetal alcohol exposure, smoking around children and childhood overnutrition

Over the past few decades, three issues have emerged as threats to the health of infants and children in western, industrialised countries: the developmental impact of alcohol use in pregnancy (Foetal Alcohol Spectrum Disorder, or FASD), childrens exposure to second-hand smoke in the home, and childhood overnutrition and obesity. The definitive role of drinking during pregnancy, exposure to second-hand smoke and overnutrition on negative health outcomes in infants and children remains the subject of considerable debate. Nevertheless, all three issues have been medicalised and criminalised: framed as looming health emergencies that require immediate intervention and, increasingly, legislation. However, it is our contention that the alarm these health ‘threats’ currently generate has many of the characteristics of a moral panic. In this paper we unpack the discourses surrounding these three issues, and explore the common focus on maternal responsibility and the ways in which these movements serve to covertly marginalise and stigmatise particular groups of women.

Feminism and the invisible fat man

In this article we argue that the complex connections between gender and fatness have not been fully examined, particularly in so far as they relate to men. We consider the role of early feminist literature in establishing the idea that the fear of fatness is fundamentally tied up with patriarchy and the ways this also underwrites more recent examinations of fatness and gender. Moreover, we assert that popular feminist scholarship has actively produced the assumption that weight is not only a womens issue, but that it is tied up with the very construction of femininity. Through an examination of the cultural history of fatness we show that men have also been caught up in the drive to reshape the body over the last century. However, their concerns have remained largely hidden, framed as they often are in the lexicon of ‘fitness’ and ‘muscularity’. An examination of the limited published material on male concerns with fat reveals that for many men fatness is feminizing – and undermines normative forms of masculinity in threatening ways. We call for further research that considers both female and male experiences of fatness, given the limitations of approaches that focus merely on one or the other.

Cancer Survivorship: Why Labels Matter

Until relatively recently, the prevailing view was that a diagnosis of cancer was effectively a death sentence. However, the last 30 years have witnessed the transformation of cancer from a largely fatal disease to one in which a majority of those diagnosed receive treatments that result in long-term disease-free survivorship. This improvement in survival rates has been accompanied by a shift from talk of cancer victims to cancer survivors. The concept of cancer survivorship has been widely debated over the past few decades. In biomedical usage, the term survivor has a distinct clinical meaning, referring to individuals who have had a life-threatening disease but have remained disease free for a minimum of 5 years. However, in recent years, a variety of other definitions have been outlined. Proposed definitions differ primarily around the scope of populations covered; some refer only to those diagnosed with cancer, whereas others extend to family, friends, and caregivers. Complicating the picture is the distinction drawn between the terms cancer survivor and cancer survivorship. Although the former is used to encapsulate individuals throughout the cancer trajectory, the latter refers to a distinct phase in the cancer trajectory between primary treatment and cancer recurrence or end of life. Although each definition is an attempt to fully describe those who have been affected by cancer, their differences have contributed to ongoing confusion about who should be called a cancer survivor. Referring to the lack of consensus on how the cancer survivor is defined, Khan et al ask, “Does it really matter—is this debate trivial?” Continuing this discussion, we expand on the context in which the concept of the cancer survivor has developed, arguing that beneath what might seem like a trivial definitional debate lurks a more complicated concept structured by larger historical, social, cultural, and political forces. Most historical overviews of the concept of the cancer survivor generally attribute the first usage of the term to Fitzhugh Mullan, who argued against the dominant view that there are two different paths for people diagnosed with cancer: a path for those who are cured, and a separate path for those who are not. In his view, there was one path for people diagnosed with cancer: that of survival, dominated by dealing with the physical and psychological effects of diagnosis and treatment. He divided survival into three distinct seasons: acute survival, the period after diagnosis, when energies are focused on surviving treatment itself; extended survival, the period after completion of treatment, when the survivor’s energies are focused on dealing with the physical and psychological consequences of treatment; and permanent survival, the period when recurrence seems increasingly unlikely, although the survivor is continuing to deal with the long-term effects of treatment. Mullan’s dual status as a cancer survivor and a physician likely played no small role in the legitimacy accorded to the concept and the momentum his commentary generated for the nascent cancer survivor movement. The concept of the cancer survivor soon captured the imagination of those affected by and working in the field of cancer by drawing attention to the ongoing issues people with a history of cancer face after they have been successfully treated, many of which stem from the iatrogenic consequences of treatment itself. It also articulated the reality that people with a history of cancer do not just rejoin the land of the well when they are deemed cancer free. Rather, they live in the ambiguous space between the well and sick. In 1986, Mullan, along with representatives from 20 organizations, founded the National Coalition for Cancer Survivorship, a survivor-led advocacy organization seeking to change the focus from cancer victim to survivor. The National Coalition for Cancer Survivorship argued that “from the time of its discovery and for the balance of life, an individual diagnosed with cancer is a survivor.” Founded in 1996, the Office of Cancer Survivorship of the National Cancer Institute has retained the spirit of this definition while expanding it to suggest that “family members, friends, and care-givers are also impacted by the survivorship experience and are therefore included in this definition.” However, the Office of Cancer Survivorship also emphasizes the distinction between the concept of the cancer survivor and the cancer survivorship phase, choosing to focus its activities on the latter because of its relative neglect in advocacy, education, clinical practice, and research. These various definitions demonstrate that the concepts of the cancer survivor and cancer survivorship are far from neutral. They are not just attempts to describe something but to do something: to mobilize patients, oncologists, researchers, and all others affected by or invested in the experience of cancer. Although these developments are central to understanding debates about the term cancer survivor today, to fully understand the concept, we need to go back further in time, because the term survivor itself has been around for centuries—although its connotations have shifted over time. The oldest references appeared in the late 16th century and referred to a survivor in relation to the death of another/ others. For example, in 1594, Shakespeare made reference to “thy surviving husband” in his poem “The Rape of Lucrece,” reflecting its legal usage at the time, whereby the survivor of someone gained the rights/inheritance of the deceased. JOURNAL OF CLINICAL ONCOLOGY COMMENTS AND CONTROVERSIES VOLUME 31 NUMBER 4 FEBRUARY 1 2013

On the perils of invoking neoliberalism in public health critique

Read any issue of Critical Public Health and you’re more likely than not to see the concept of ‘neoliberalism’ invoked at some point. Inputting it as a keyword in the journal brings up 93 papers, and it features prominently in the title of three articles on our ‘most cited’ list: ‘Understanding health promotion in a neoliberal climate and the making of health conscious citizens’ (Ayo, 2012), ‘Neoliberalism, public health, and the moral perils of fatness’ (LeBesco, 2011) and ‘Aboriginal mothering, FAS prevention and the contestations of neoliberal citizenship’ (Salmon, 2011). The growing frequency with which the concept is invoked amongst authors publishing in CPH has led us to joke, on more than one occasion, that perhaps we should modify our name to Critical Public Health: the Negative Impacts of Neoliberalism. In light of the growing prominence accorded to the concept of neoliberalism in (and of course beyond) the journal, it therefore seems like a good time to take stock of our conceptual equipment to ensure that it does what we think it does and want it do. Reminded of Latour’s (2004) injunction to think critically about critique, in this editorial we simply want to do ‘what every good military officer, at regular periods, would do: retest the linkages between the new threats he or she has to face and the equipment and training he or she should have in order to meet them’ (p. 231). Indeed, we can’t help but notice that much like the concept of ‘society’ before it, when the term neoliberalism is invoked it is often used to

Cancer survivorship, mor(t)ality and lifestyle discourses on cancer prevention

Despite ongoing controversies regarding the impact of lifestyle factors such as body weight, diet and exercise on health, this framework has become increasingly prominent in understandings of cancer aetiology. To date, little consideration has been given to the impacts of such discourses on people with a history of cancer. Drawing on an ethnographic study of cancer survivors, I explore the constitutive dimensions of these discourses and the ways that they shape the subjectivities of women and men with a history of the disease. Overall, the study participants evidenced a complex and ambivalent engagement with such discourses. While they were generally unwilling to accept that their lifestyle had an impact on the development of their cancer, to varying degrees they endorsed the idea that weight, diet and exercise affected cancer progression. However, this acceptance was generally borne of an active desire to gain control over the uncertainty of living with the disease and was mediated by other aspects of the experience of surviving cancer.

The breast-cancer-ization of cancer survivorship: Implications for experiences of the disease

Numerous observers have commented on the cultural prominence of breast cancer in North America. However, although popular and biomedical conceptions of cancer survivorship have been influenced to an inordinate degree by breast cancer, few researchers have examined the impact of dominant discourses on people diagnosed with other forms of cancer. Drawing on interviews with 32 Canadian men and women with a history of cancer conducted between 2010 and 2013, I demonstrate that breast cancer became central to their own experiences of cancer, providing an important lens through which to understand the effects of the disease. The effects of these comparisons were diverse, leading some participants to want to differentiate themselves from this implicit norm, leading others to downplay the seriousness of their own forms of suffering, and amplifying a sense of shame and stigma in yet others.

The impact of cancer on family relationships among Chinese patients.

This study examines the impact of cancer on family relationships among members of a Chinese cancer support group. A qualitative research design was used, including participant observation of 96 participants at group meetings over an 8-month period and in-depth interviews with seven group members. Findings indicated that family members were integral to the support group, constituting almost 40% of the participants. Patients in the group expressed concerns about family, with family members identified as having “equal suffering” when caring for patients. Notably, among both patients and family members, there was a strong emphasis on the need to conceal emotion, coupled with a focus on instrumental support in caregiving. Furthermore, patients’ anxiety about “burdening” their family appeared to inflate their own experience of distress, as patients and their family carers both sought to maintain a positive front. The findings highlight the need for practitioners to focus on the entire family when designing interventions to help patients cope with cancer. More important, interventions need to be culturally sensitive that will empower patients and family members in living with the illness.

Remaking the Self: Trauma, Teachable Moments, and the Biopolitics of Cancer Survivorship

As numerous scholars have noted, cancer survivorship is often represented in popular discourse as providing an opportunity for a physical, emotional, and spiritual makeover. However, this idea that cancer enables the self to be remade on all levels is also increasingly evoked in the field of psychosocial oncology. Exploring cancer survivorship as a biopolitical phenomenon, I focus on two concepts that have become central to understandings of the disease: the “teachable moment” and “post-traumatic growth.” Drawing primarily on representations of cancer survivorship in the clinical literature, I suggest that cancer is increasingly seen to present a unique opportunity to catalyze the patient’s physical and psychological development. In this framework, the patient can no longer be relied upon to transform him or herself: this change must be externally driven, with clinicians taking advantage of the trauma that cancer entails to kick-start the patient into action. Broadening my analysis to the concepts of “trauma” and “development” writ large, I go on to suggest that survivorship discourse seems to partake of a larger and relatively recent meta-narrative about development—both individual and societal—and the positive opportunity that trauma is seen to present to stimulate reconstruction on a grand scale.

Being ‘thick’ indicates you are eating, you are healthy and you have an attractive body shape: Perspectives on fatness and food choice amongst Black and White men and women in Canada

Abstract Despite recent critiques of contemporary obesity discourses that link ‘modern Western lifestyles’ to an ‘obesity epidemic’, the population’s weight remains a central concern of current dietary guidelines. Food choices that are considered beneficial to maintaining a certain weight are understood to play a key role in one’s health. This concern reflects medico-moral assumptions about the properties of food and what people should eat. However, the impact of obesity discourses on different individuals and social groups is rarely considered, although there is some evidence that people do generate, reflect and resist the norms and standards set for them, including those that relate to food/weight. In this paper, we will examine the perspectives on fatness and food choice amongst Black and White women and men living in Vancouver and Halifax, Canada. With this examination, we will challenge conventional assumptions about the singular ‘modern Western lifestyle’ that leads to obesity concerns by teasing out some of the social, cultural and political contexts within which people conceptualise issues regarding weight and make their food choices. By examining the experiences of both women and men we will also provide important insights into the gendered ways in which people engage with obesity discourses and the injunction to ‘eat healthily’ as a form of weight management.

Metastatic Cancer and Mothering: Being a Mother in the Face of a Contracted Future

For the majority of people diagnosed with metastatic cancer, there is little hope of a disease-free future. Drawing on ethnographic fieldwork at a support group for women with metastatic cancer, we examine the relationship between metastases and mothering. We argue that the experience of raising children while living with a terminal illness crystallizes cultural expectations about mothering based on an essentialist model of parenthood whereby the person best suited to raise children is their biological mother. These expectations create an irresolvable gap between discourse and experience that both increases the suffering of women raising children and generates an internal hierarchy of suffering among women with cancer metastases that hinges on the distinction between those who have dependent children and those who do not.