17 May 2011

Unhealthful News 137 - Colonoscopy and the the role of politics-of-identity in disease prevention

A recent study from the University of Texas found that many of those in the Medicare-aged population studied were getting colonoscopies more often than was recommended.  This is a technical result of interest because the observation could help with better containing excessive medical costs.  What is interesting about this is that readers treated it as being as technical and wonkishly boring as it was.  I looked at a few dozen of the news stories about it, and the reader comments were largely absent (most stories that allowed comments had none or none of substance) and were never particularly adamant.  Contrast this with reactions to anything written about mammography (which I covered recently, with follow-ups), where any hint that we should not be screening more often, earlier, and generally more aggressively is met with an outcry that makes it sound like someone proposed banning screening.  I could not find a single comment where someone said something like "I would not be alive to write this if I had not gotten screened sooner than those people recommend", whereas it is hard to find a story about mammography policy where comments can be posted in which the comments do not include such a statement.

What is the difference?  Colon cancer kills more people than breast cancer, after all.  (Fewer cases are diagnosed, but the difference may be less than the over-diagnosis rate caused by mammography, though, as I wrote about.)  The benefits of treating screen-detected future cases of disease is comparable. 

Part of the answer might be profits.  The colonoscopy industry is not as lucrative as the mammography industry: the practitioners sell other services, there are far fewer screens, and apparently the compensation for those doing the screening is far less impressive (I base the latter conclusions not on knowing the numbers but just from knowing that there does not seem to be a push from the practitioners to do more colonoscopies than are appropriate).  But that cannot really be most of it.  After all, there are a lot of pink ribbon  loop decorations out there, but not very many that are... hmm, I'll assume brown.  Your reaction to that might explain part of it – people like thinking and talking about breasts, but not colons.

But most of the explanation seems to be politics of identity.  People who survive or are dying from colon cancer got a terrible ugly disease, but those who survive or are dying from breast cancer are part of a community.  Part of that is the perception of being part of an underserved minority group (women), never mind that women are actually a majority and that spending on breast cancer research, prevention, and treatment is (when considered in proportion to the disease's total effects) enormously higher than for most diseases.  But the sisterhood transcends those pesky facts.  Even better, since so many non-threatening cases are diagnosed, there are a lot of survivors to form a community, unlike with lung or pancreas cancer.

Another interesting community identity phenomenon, one I write about, is that surrounding electronic cigarette use.  Though smokeless tobacco is still the most popular low-risk nicotine product, and is the reason we know that tobacco harm reduction works, it is pretty clear that e-cigarettes represent the future success of THR because a community has developed around them.  The major challenge they face, though is also backed by community identity.  Being opposed to all nicotine use, and especially anything that seems like smoking, is an identity issue for many people that is on par with nationalism (notice that it is drilled into schoolkids like the Pledge of Allegiance was in the 1950s).  A third example that comes to mind is the contrast between families dealing with autism and those dealing with any number of other mental diseases.  Autism is generating so much interest (i.e., funding) right now not so much because of technical reasons like the increase in diagnoses, I think, but because it now defines a community much more than being the family of a schizophrenic, let alone someone with depression.

I have no particular conclusions about this, other than it being useful to recognize that politics-of-identity drives a lot of the discussion about exposures and diseases that reaches most readers.  What might be interesting is to watch how this develops for the exploding topic of calorie control, the "obesity epidemic", anti-junk-food, etc.  Where will the identity communities form?  Will fat people assert a sense of community, or will they be convinced to agree they really are the problem (as most smokers have)?  Will healthy junk-food lovers defend their behavior (like e-cigarette users) or will they just accept that the attacks will continue and become semi-closeted (as most American users of smokeless tobacco)?  It is difficult to imagine that those campaigning against obesity could portray themselves as an oppressed minority fighting the Empire for the greater good, but it is amazing what people can convince themselves of.  Will those who have lost weight become a political force? 

If a political identity does emerge, I would like to be the first to suggest the ribbon be a donut as a loop with french fries as the tails.  And don't forget I suggested it!  I get so annoyed when someone tries to explain something to me that was originally my idea, which happens more often than you might think.

(P.S.  Actually I don't get annoyed.  There is something kind of poetic about it, actually.)

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