Mostrando entradas con la etiqueta ciencia. Mostrar todas las entradas
Mostrando entradas con la etiqueta ciencia. Mostrar todas las entradas

lunes, 22 de febrero de 2016

We Aren’t the World

http://www.psmag.com/books-and-culture/joe-henrich-weird-ultimatum-game-shaking-up-psychology-economics-53135

Joe Henrich and his colleagues are shaking the foundations of psychology and economics—and hoping to change the way social scientists think about human behavior and culture.

(Illustration: Mark McGinnis)
(Illustration: Mark McGinnis)
In the Summer of 1995, a young graduate student in anthropology at UCLA named Joe Henrich traveled to Peru to carry out some fieldwork among the Machiguenga, an indigenous people who live north of Machu Picchu in the Amazon basin. The Machiguenga had traditionally been horticulturalists who lived in single-family, thatch-roofed houses in small hamlets composed of clusters of extended families. For sustenance, they relied on local game and produce from small-scale farming. They shared with their kin but rarely traded with outside groups.
While the setting was fairly typical for an anthropologist, Henrich’s research was not. Rather than practice traditional ethnography, he decided to run a behavioral experiment that had been developed by economists. Henrich used a “game”—along the lines of the famous prisoner’s dilemma—to see whether isolated cultures shared with the West the same basic instinct for fairness. In doing so, Henrich expected to confirm one of the foundational assumptions underlying such experiments, and indeed underpinning the entire fields of economics and psychology: that humans all share the same cognitive machinery—the same evolved rational and psychological hardwiring.
The test that Henrich introduced to the Machiguenga was called the ultimatum game. The rules are simple: in each game there are two players who remain anonymous to each other. The first player is given an amount of money, say $100, and told that he has to offer some of the cash, in an amount of his choosing, to the other subject. The second player can accept or refuse the split. But there’s a hitch: players know that if the recipient refuses the offer, both leave empty-handed. North Americans, who are the most common subjects for such experiments, usually offer a 50-50 split when on the giving end. When on the receiving end, they show an eagerness to punish the other player for uneven splits at their own expense. In short, Americans show the tendency to be equitable with strangers—and to punish those who are not.
Among the Machiguenga, word quickly spread of the young, square-jawed visitor from America giving away money. The stakes Henrich used in the game with the Machiguenga were not insubstantial—roughly equivalent to the few days’ wages they sometimes earned from episodic work with logging or oil companies. So Henrich had no problem finding volunteers. What he had great difficulty with, however, was explaining the rules, as the game struck the Machiguenga as deeply odd.
When he began to run the game it became immediately clear that Machiguengan behavior was dramatically different from that of the average North American. To begin with, the offers from the first player were much lower. In addition, when on the receiving end of the game, the Machiguenga rarely refused even the lowest possible amount. "It just seemed ridiculous to the Machiguenga that you would reject an offer of free money," says Henrich. "They just didn’t understand why anyone would sacrifice money to punish someone who had the good luck of getting to play the other role in the game."
Joe Henrich and research assistant administer the Third Party Punishment Game in the village of Teci on Fiji's Yasawa Island.
Joe Henrich and research assistant administer the Third Party Punishment Game in the village of Teci on Fiji's Yasawa Island.
The potential implications of the unexpected results were quickly apparent to Henrich. He knew that a vast amount of scholarly literature in the social sciences—particularly in economics and psychology—relied on the ultimatum game and similar experiments. At the heart of most of that research was the implicit assumption that the results revealed evolved psychological traits common to all humans, never mind that the test subjects were nearly always from the industrialized West. Henrich realized that if the Machiguenga results stood up, and if similar differences could be measured across other populations, this assumption of universality would have to be challenged.
Henrich had thought he would be adding a small branch to an established tree of knowledge. It turned out he was sawing at the very trunk. He began to wonder: What other certainties about "human nature" in social science research would need to be reconsidered when tested across diverse populations?
Henrich soon landed a grant from the MacArthur Foundation to take his fairness games on the road. With the help of a dozen other colleagues he led a study of 14 other small-scale societies, in locales from Tanzania to Indonesia. Differences abounded in the behavior of both players in the ultimatum game. In no society did he find people who were purely selfish (that is, who always offered the lowest amount, and never refused a split), but average offers from place to place varied widely and, in some societies—ones where gift-giving is heavily used to curry favor or gain allegiance—the first player would often make overly generous offers in excess of 60 percent, and the second player would often reject them, behaviors almost never observed among Americans.
The research established Henrich as an up-and-coming scholar. In 2004, he was given the U.S. Presidential Early Career Award for young scientists at the White House. But his work also made him a controversial figure. When he presented his research to the anthropology department at the University of British Columbia during a job interview a year later, he recalls a hostile reception. Anthropology is the social science most interested in cultural differences, but the young scholar’s methods of using games and statistics to test and compare cultures with the West seemed heavy-handed and invasive to some. "Professors from the anthropology department suggested it was a bad thing that I was doing," Henrich remembers. "The word 'unethical' came up."
So instead of toeing the line, he switched teams. A few well-placed people at the University of British Columbia saw great promise in Henrich’s work and created a position for him, split between the economics department and the psychology department. It was in the psychology department that he found two kindred spirits in Steven Heine and Ara Norenzayan. Together the three set about writing a paper that they hoped would fundamentally challenge the way social scientists thought about human behavior, cognition, and culture.
A modern liberal arts education gives lots of lip service to the idea of cultural diversity. It’s generally agreed that all of us see the world in ways that are sometimes socially and culturally constructed, that pluralism is good, and that ethnocentrism is bad. But beyond that the ideas get muddy. That we should welcome and celebrate people of all backgrounds seems obvious, but the implied corollary—that people from different ethno-cultural origins have particular attributes that add spice to the body politic—becomes more problematic. To avoid stereotyping, it is rarely stated bluntly just exactly what those culturally derived qualities might be. Challenge liberal arts graduates on their appreciation of cultural diversity and you’ll often find them retreating to the anodyne notion that under the skin everyone is really alike.
If you take a broad look at the social science curriculum of the last few decades, it becomes a little more clear why modern graduates are so unmoored. The last generation or two of undergraduates have largely been taught by a cohort of social scientists busily doing penance for the racism and Eurocentrism of their predecessors, albeit in different ways. Many anthropologists took to the navel gazing of postmodernism and swore off attempts at rationality and science, which were disparaged as weapons of cultural imperialism.
Economists and psychologists, for their part, did an end run around the issue with the convenient assumption that their job was to study the human mind stripped of culture. The human brain is genetically comparable around the globe, it was agreed, so human hardwiring for much behavior, perception, and cognition should be similarly universal. No need, in that case, to look beyond the convenient population of undergraduates for test subjects. A 2008 survey of the top six psychology journals dramatically shows how common that assumption was: more than 96 percent of the subjects tested in psychological studies from 2003 to 2007 were Westerners—with nearly 70 percent from the United States alone. Put another way: 96 percent of human subjects in these studies came from countries that represent only 12 percent of the world’s population.
Henrich’s work with the ultimatum game was an example of a small but growing countertrend in the social sciences, one in which researchers look straight at the question of how deeply culture shapes human cognition. His new colleagues in the psychology department, Heine and Norenzayan, were also part of this trend. Heine focused on the different ways people in Western and Eastern cultures perceived the world, reasoned, and understood themselves in relationship to others. Norenzayan’s research focused on the ways religious belief influenced bonding and behavior. The three began to compile examples of cross-cultural research that, like Henrich’s work with the Machiguenga, challenged long-held assumptions of human psychological universality.
Some of that research went back a generation. It was in the 1960s, for instance, that researchers discovered that aspects of visual perception were different from place to place. One of the classics of the literature, the Müller-Lyer illusion, showed that where you grew up would determine to what degree you would fall prey to the illusion that these two lines are different in length:
Researchers found that Americans perceive the line with the ends feathered outward (B) as being longer than the line with the arrow tips (A). San foragers of the Kalahari, on the other hand, were more likely to see the lines as they are: equal in length. Subjects from more than a dozen cultures were tested, and Americans were at the far end of the distribution—seeing the illusion more dramatically than all others.
More recently psychologists had challenged the universality of research done in the 1950s by pioneering social psychologist Solomon Asch. Asch had discovered that test subjects were often willing to make incorrect judgments on simple perception tests to conform with group pressure. When the test was performed across 17 societies, however, it turned out that group pressure had a range of influence. Americans were again at the far end of the scale, in this case showing the least tendency to conform to group belief.
As Heine, Norenzayan, and Henrich furthered their search, they began to find research suggesting wide cultural differences almost everywhere they looked: in spatial reasoning, the way we infer the motivations of others, categorization, moral reasoning, the boundaries between the self and others, and other arenas. These differences, they believed, were not genetic. The distinct ways Americans and Machiguengans played the ultimatum game, for instance, wasn’t because they had differently evolved brains. Rather, Americans, without fully realizing it, were manifesting a psychological tendency shared with people in other industrialized countries that had been refined and handed down through thousands of generations in ever more complex market economies. When people are constantly doing business with strangers, it helps when they have the desire to go out of their way (with a lawsuit, a call to the Better Business Bureau, or a bad Yelp review) when they feel cheated. Because Machiguengan culture had a different history, their gut feeling about what was fair was distinctly their own. In the small-scale societies with a strong culture of gift-giving, yet another conception of fairness prevailed. There, generous financial offers were turned down because people’s minds had been shaped by a cultural norm that taught them that the acceptance of generous gifts brought burdensome obligations. Our economies hadn’t been shaped by our sense of fairness; it was the other way around.
The growing body of cross-cultural research that the three researchers were compiling suggested that the mind’s capacity to mold itself to cultural and environmental settings was far greater than had been assumed. The most interesting thing about cultures may not be in the observable things they do—the rituals, eating preferences, codes of behavior, and the like—but in the way they mold our most fundamental conscious and unconscious thinking and perception.
For instance, the different ways people perceive the Müller-Lyer illusion likely reflects lifetimes spent in different physical environments. American children, for the most part, grow up in box-shaped rooms of varying dimensions. Surrounded by carpentered corners, visual perception adapts to this strange new environment (strange and new in terms of human history, that is) by learning to perceive converging lines in three dimensions.
When unconsciously translated in three dimensions, the line with the outward-feathered ends (C) appears farther away and the brain therefore judges it to be longer. The more time one spends in natural environments, where there are no carpentered corners, the less one sees the illusion.
As the three continued their work, they noticed something else that was remarkable: again and again one group of people appeared to be particularly unusual when compared to other populations—with perceptions, behaviors, and motivations that were almost always sliding down one end of the human bell curve.
In the end they titled their paper “The Weirdest People in the World?” (pdf) By “weird” they meant both unusual and Western, Educated, Industrialized, Rich, and Democratic. It is not just our Western habits and cultural preferences that are different from the rest of the world, it appears. The very way we think about ourselves and others—and even the way we perceive reality—makes us distinct from other humans on the planet, not to mention from the vast majority of our ancestors. Among Westerners, the data showed that Americans were often the most unusual, leading the researchers to conclude that “American participants are exceptional even within the unusual population of Westerners—outliers among outliers.”
Given the data, they concluded that social scientists could not possibly have picked a worse population from which to draw broad generalizations. Researchers had been doing the equivalent of studying penguins while believing that they were learning insights applicable to all birds.
Not long ago I met Henrich, Heine, and Norenzayan for dinner at a small French restaurant in Vancouver, British Columbia, to hear about the reception of their weird paper, which was published in the prestigious journal Behavioral and Brain Sciences in 2010. The trio of researchers are young—as professors go—good-humored family men. They recalled that they were nervous as the publication time approached. The paper basically suggested that much of what social scientists thought they knew about fundamental aspects of human cognition was likely only true of one small slice of humanity. They were making such a broadside challenge to whole libraries of research that they steeled themselves to the possibility of becoming outcasts in their own fields.
“We were scared,” admitted Henrich. “We were warned that a lot of people were going to be upset.”
“We were told we were going to get spit on,” interjected Norenzayan.
“Yes,” Henrich said. “That we’d go to conferences and no one was going to sit next to us at lunchtime.”
Interestingly, they seemed much less concerned that they had used the pejorative acronym WEIRD to describe a significant slice of humanity, although they did admit that they could only have done so to describe their own group. “Really,” said Henrich, “the only people we could have called weird are represented right here at this table.”
Still, I had to wonder whether describing the Western mind, and the American mind in particular, as weird suggested that our cognition is not just different but somehow malformed or twisted. In their paper the trio pointed out cross-cultural studies that suggest that the “weird” Western mind is the most self-aggrandizing and egotistical on the planet: we are more likely to promote ourselves as individuals versus advancing as a group. WEIRD minds are also more analytic, possessing the tendency to telescope in on an object of interest rather than understanding that object in the context of what is around it.
The WEIRD mind also appears to be unique in terms of how it comes to understand and interact with the natural world. Studies show that Western urban children grow up so closed off in man-made environments that their brains never form a deep or complex connection to the natural world. While studying children from the U.S., researchers have suggested a developmental timeline for what is called “folkbiological reasoning.” These studies posit that it is not until children are around 7 years old that they stop projecting human qualities onto animals and begin to understand that humans are one animal among many. Compared to Yucatec Maya communities in Mexico, however, Western urban children appear to be developmentally delayed in this regard. Children who grow up constantly interacting with the natural world are much less likely to anthropomorphize other living things into late childhood.
Given that people living in WEIRD societies don’t routinely encounter or interact with animals other than humans or pets, it’s not surprising that they end up with a rather cartoonish understanding of the natural world. “Indeed,” the report concluded, “studying the cognitive development of folkbiology in urban children would seem the equivalent of studying ‘normal’ physical growth in malnourished children.”
During our dinner, I admitted to Heine, Henrich, and Norenzayan that the idea that I can only perceive reality through a distorted cultural lens was unnerving. For me the notion raised all sorts of metaphysical questions: Is my thinking so strange that I have little hope of understanding people from other cultures? Can I mold my own psyche or the psyches of my children to be less WEIRD and more able to think like the rest of the world? If I did, would I be happier?
Henrich reacted with mild concern that I was taking this research so personally. He had not intended, he told me, for his work to be read as postmodern self-help advice. “I think we’re really interested in these questions for the questions’ sake,” he said.
The three insisted that their goal was not to say that one culturally shaped psychology was better or worse than another—only that we’ll never truly understand human behavior and cognition until we expand the sample pool beyond its current small slice of humanity. Despite these assurances, however, I found it hard not to read a message between the lines of their research. When they write, for example, that weird children develop their understanding of the natural world in a “culturally and experientially impoverished environment” and that they are in this way the equivalent of “malnourished children,” it’s difficult to see this as a good thing.
The turn that Henrich, Heine, and Norenzayan are asking social scientists to make is not an easy one: accounting for the influence of culture on cognition will be a herculean task. Cultures are not monolithic; they can be endlessly parsed. Ethnic backgrounds, religious beliefs, economic status, parenting styles, rural upbringing versus urban or suburban—there are hundreds of cultural differences that individually and in endless combinations influence our conceptions of fairness, how we categorize things, our method of judging and decision making, and our deeply held beliefs about the nature of the self, among other aspects of our psychological makeup.
We are just at the beginning of learning how these fine-grained cultural differences affect our thinking. Recent research has shown that people in “tight” cultures, those with strong norms and low tolerance for deviant behavior (think India, Malaysia, and Pakistan), develop higher impulse control and more self-monitoring abilities than those from other places. Men raised in the honor culture of the American South have been shown to experience much larger surges of testosterone after insults than do Northerners. Research published late last year suggested psychological differences at the city level too. Compared to San Franciscans, Bostonians’ internal sense of self-worth is more dependent on community status and financial and educational achievement. “A cultural difference doesn’t have to be big to be important,” Norenzayan said. “We’re not just talking about comparing New York yuppies to the Dani tribesmen of Papua New Guinea.”
As Norenzayan sees it, the last few generations of psychologists have suffered from “physics envy,” and they need to get over it. The job, experimental psychologists often assumed, was to push past the content of people’s thoughts and see the underlying universal hardware at work. “This is a deeply flawed way of studying human nature,” Norenzayan told me, “because the content of our thoughts and their process are intertwined.” In other words, if human cognition is shaped by cultural ideas and behavior, it can’t be studied without taking into account what those ideas and behaviors are and how they are different from place to place.
This new approach suggests the possibility of reverse-engineering psychological research: look at cultural content first; cognition and behavior second. Norenzayan’s recent work on religious belief is perhaps the best example of the intellectual landscape that is now open for study. When Norenzayan became a student of psychology in 1994, four years after his family had moved from Lebanon to America, he was excited to study the effect of religion on human psychology. “I remember opening textbook after textbook and turning to the index and looking for the word ‘religion,’ ” he told me, “Again and again the very word wouldn’t be listed. This was shocking. How could psychology be the science of human behavior and have nothing to say about religion? Where I grew up you’d have to be in a coma not to notice the importance of religion on how people perceive themselves and the world around them.”
Norenzayan became interested in how certain religious beliefs, handed down through generations, may have shaped human psychology to make possible the creation of large-scale societies. He has suggested that there may be a connection between the growth of religions that believe in “morally concerned deities”—that is, a god or gods who care if people are good or bad—and the evolution of large cities and nations. To be cooperative in large groups of relative strangers, in other words, might have required the shared belief that an all-powerful being was forever watching over your shoulder.
If religion was necessary in the development of large-scale societies, can large-scale societies survive without religion? Norenzayan points to parts of Scandinavia with atheist majorities that seem to be doing just fine. They may have climbed the ladder of religion and effectively kicked it away. Or perhaps, after a thousand years of religious belief, the idea of an unseen entity always watching your behavior remains in our culturally shaped thinking even after the belief in God dissipates or disappears.
Why, I asked Norenzayan, if religion might have been so central to human psychology, have researchers not delved into the topic? “Experimental psychologists are the weirdest of the weird,” said Norenzayan. “They are almost the least religious academics, next to biologists. And because academics mostly talk amongst themselves, they could look around and say, ‘No one who is important to me is religious, so this must not be very important.’” Indeed, almost every major theorist on human behavior in the last 100 years predicted that it was just a matter of time before religion was a vestige of the past. But the world persists in being a very religious place.
Henrich, Heine, and Norenzayan's fear of being ostracized after the publication of the WEIRD paper turned out to be misplaced. Response to the paper, both published and otherwise, has been nearly universally positive, with more than a few of their colleagues suggesting that the work will spark fundamental changes. “I have no doubt that this paper is going to change the social sciences,” said Richard Nisbett, an eminent psychologist at the University of Michigan. “It just puts it all in one place and makes such a bold statement.”
More remarkable still, after reading the paper, academics from other disciplines began to come forward with their own mea culpas. Commenting on the paper, two brain researchers from Northwestern University argued (pdf) that the nascent field of neuroimaging had made the same mistake as psychologists, noting that 90 percent of neuroimaging studies were performed in Western countries. Researchers in motor development similarly suggested that their discipline’s body of research ignored how different child-rearing practices around the world can dramatically influence states of development. Two psycholinguistics professors suggested that their colleagues had also made the same mistake: blithely assuming human homogeneity while focusing their research primarily on one rather small slice of humanity.
At its heart, the challenge of the WEIRD paper is not simply to the field of experimental human research (do more cross-cultural studies!); it is a challenge to our Western conception of human nature. For some time now, the most widely accepted answer to the question of why humans, among all animals, have so successfully adapted to environments across the globe is that we have big brains with the ability to learn, improvise, and problem-solve.
Henrich has challenged this “cognitive niche” hypothesis with the “cultural niche” hypothesis. He notes that the amount of knowledge in any culture is far greater than the capacity of individuals to learn or figure it all out on their own. He suggests that individuals tap that cultural storehouse of knowledge simply by mimicking (often unconsciously) the behavior and ways of thinking of those around them. We shape a tool in a certain manner, adhere to a food taboo, or think about fairness in a particular way, not because we individually have figured out that behavior’s adaptive value, but because we instinctively trust our culture to show us the way. When Henrich asked Fijian women why they avoided certain potentially toxic fish during pregnancy and breastfeeding, he found that many didn’t know or had fanciful reasons. Regardless of their personal understanding, by mimicking this culturally adaptive behavior they were protecting their offspring. The unique trick of human psychology, these researchers suggest, might be this: our big brains are evolved to let local culture lead us in life’s dance.
The applications of this new way of looking at the human mind are still in the offing. Henrich suggests that his research about fairness might first be applied to anyone working in international relations or development. People are not “plug and play,” as he puts it, and you cannot expect to drop a Western court system or form of government into another culture and expect it to work as it does back home. Those trying to use economic incentives to encourage sustainable land use will similarly need to understand local notions of fairness to have any chance of influencing behavior in predictable ways.
Because of our peculiarly Western way of thinking of ourselves as independent of others, this idea of the culturally shaped mind doesn’t go down very easily. Perhaps the richest and most established vein of cultural psychology—that which compares Western and Eastern concepts of the self—goes to the heart of this problem. Heine has spent much of his career following the lead of a seminal paper published in 1991 by Hazel Rose Markus, of Stanford University, and Shinobu Kitayama, who is now at the University of Michigan. Markus and Kitayama suggested that different cultures foster strikingly different views of the self, particularly along one axis: some cultures regard the self as independent from others; others see the self as interdependent. The interdependent self—which is more the norm in East Asian countries, including Japan and China—connects itself with others in a social group and favors social harmony over self-expression. The independent self—which is most prominent in America—focuses on individual attributes and preferences and thinks of the self as existing apart from the group.
The classic "rod and frame" task: Is the line in the center vertical?
That we in the West develop brains that are wired to see ourselves as separate from others may also be connected to differences in how we reason, Heine argues. Unlike the vast majority of the world, Westerners (and Americans in particular) tend to reason analytically as opposed to holistically. That is, the American mind strives to figure out the world by taking it apart and examining its pieces. Show a Japanese and an American the same cartoon of an aquarium, and the American will remember details mostly about the moving fish while the Japanese observer will likely later be able to describe the seaweed, the bubbles, and other objects in the background. Shown another way, in a different test analytic Americans will do better on something called the “rod and frame” task, where one has to judge whether a line is vertical even though the frame around it is skewed. Americans see the line as apart from the frame, just as they see themselves as apart from the group.
Heine and others suggest that such differences may be the echoes of cultural activities and trends going back thousands of years. Whether you think of yourself as interdependent or independent may depend on whether your distant ancestors farmed rice (which required a great deal of shared labor and group cooperation) or herded animals (which rewarded individualism and aggression). Heine points to Nisbett at Michigan, who has argued (pdf) that the analytic/holistic dichotomy in reasoning styles can be clearly seen, respectively, in Greek and Chinese philosophical writing dating back 2,500 years. These psychological trends and tendencies may echo down generations, hundreds of years after the activity or situation that brought them into existence has disappeared or fundamentally changed.
And here is the rub: the culturally shaped analytic/individualistic mind-sets may partly explain why Western researchers have so dramatically failed to take into account the interplay between culture and cognition. In the end, the goal of boiling down human psychology to hardwiring is not surprising given the type of mind that has been designing the studies. Taking an object (in this case the human mind) out of its context is, after all, what distinguishes the analytic reasoning style prevalent in the West. Similarly, we may have underestimated the impact of culture because the very ideas of being subject to the will of larger historical currents and of unconsciously mimicking the cognition of those around us challenges our Western conception of the self as independent and self-determined. The historical missteps of Western researchers, in other words, have been the predictable consequences of the WEIRD mind doing the thinking.

jueves, 4 de junio de 2015

La conexión entre la mente y el sistema inmune (o la psicología profunda de la enfermedad)

Tomado de: http://pijamasurf.com/2015/02/la-conexion-entre-la-mente-y-el-sistema-inmune-o-la-psicologia-profunda-de-la-enfermedad/

En los últimos años se ha gestado discretamente un cambio de paradigma dentro de la ciencia, de la visión cartesiana reduccionista que cortaba de tajo y dejaba prácticamente incomunicados al cuerpo y a la mente, a una visión más inclusiva que considera a la mente-cuerpo como un solo sistema, dando lugar a disciplinas como la psicobiología y la psiconeuroinmunología. Hoy sabemos que nuestro estado de ánimo y los estímulos del medio ambiente tienen efectos a nivel celular y son tanto o más importantes para nuestra salud que nuestros genes. “La vieja forma de pensar era que nuestros cuerpos eran entidades biológicas estables, fundamentalmente separadas del mundo externo”, dice Steven Cole, profesor de medicina en UCLA. “La nueva forma de pensar es que hay mucha más permeabilidad y fluidez… nuestro cuerpo es literalmente producto del ambiente”.
Cole, moviéndose entre la ciencia dura y aspectos más suaves relacionados con el problema mente-cuerpo, intenta determinar la relación entre la “felicidad” y el sistema inmune: cómo reaccionan nuestras células a lo que subjetivamente llamamos felicidad –acaso así haciendo tangible lo que es la felicidad, encontrando una respuesta a esta pregunta milenaria, aunque desde la perspectiva parcial del cuerpo. Su trabajo lo ha llevado a concluir que “no hay duda de que la mente y el sistema inmune están ligados”.
Entrevistado por The Atlantic, Cole explica que experiencias negativas como un diagnóstico de cáncer, la depresión, el estrés, el trauma o el bajo estatus socioeconómico pueden afectar el perfil inmunológico de una persona. Mientras que “las experiencias de felicidad y la percepción de esas experiencias en nuestro cuerpo” también producen cambios en nuestros mecanismos biológicos, en sentido opuesto. Cole cree que estas experiencias positivas son capaces de “remodelar nuestra composición celular”. La antigua división entre el cuerpo y la mente que ha acompañado a la ciencia en sus fundamentos por tantos años no se sostiene: es prácticamente imposible que lo que experimentamos mentalmente (la imaginación, la fantasía, el pensamiento, la preocupación, la relajación, etc.) no se reproduzca también en nuestro cuerpo. Nuestra salud no sólo es el cúmulo de todas las cosas que hemos ingerido, el ejercicio que hemos hecho y nuestros genes, es también el agregado de todos nuestros pensamientos y emociones (nuestro cuerpo no puede dejar de registrar todos nuestros estados mentales y reprogramar su funcionamiento a partir de ellos).
Lo anterior nos obliga a tomar responsabilidad por lo que ocurre en nuestra mente en cada momento, sabiendo que, si bien un pensamiento aislado o una emoción fugaz seguramente no debilitarán significativamente nuestra inmunidad, la reiteración de nuestras formas de pensamiento y reacciones ante el mundo van apilándose y forman los hábitos y patrones que llegan a determinar nuestro estado de salud general.  O, con mayor precisión: “La experiencia que tienes hoy afectará la composición de tu cuerpo por los siguientes 80 días, porque eso es el tiempo que tardan la mayoría de los procesos celulares”, dice Cole. ¿A cuántos ciclos de estrés de 80 días hemos sometido a nuestras células? 
“Una de las funciones principales de la mente es mantener a bajo nivel la presión o, mejor dicho, no permitir que la presión surja desde un inicio”, dijo Manly P. Hall hablando sobre el “simbolismo psíquico” de algunas enfermedades. La mente, que es el regulador metabólico de todos los procesos orgánicos y que tiene la capacidad compensar desequilibrios con su acción intencional. Hay diferentes formas de ver esto, si tenemos una tendencia a estresarnos fácilmente puede generar el efecto contrario al deseado. Este pensamiento de preocupación o de frustración o de odio, puede ser la semilla de una enfermedad. Tal vez puedas percibirlo como una presión extra sobre tu facultad mental. Esto es una forma de verlo. Por otro lado también puede ser un respiro: tu actitud, la forma en la que empleas tu mente y la forma en la que te relacionas con el mundo puede sanarte, puede afectar directamente tus células y mantenerlas, como una brigada de soldados contentos y comprometidos con la estrategia nacional, atacando a tus enemigos verdaderos (y no volteándose en tu contra).
El sistema inmune tiene dos funciones principales: luchar contra agentes infecciosos y causar inflamación. La primera función es la que consideramos generalmente como señal de que nuestro sistema inmune funciona adecuadamente, en equilibrio, dirigiendo sus esfuerzos contra las verdaderas amenazas que enfrenta nuestro cuerpo. La segunda función, la inflamación, es en muchos casos el resultado de una sobreexcitación, ya sea porque introducimos agentes tóxicos a nuestro cuerpo (o que nuestro cuerpo percibe como tóxicos, como es el caso de algunas intolerancias a alimentos que la mayoría de las personas toleran perfectamente bien) o porque el estrés hace que nuestro sistema inmune esté combatiendo permanentemente enemigos invisibles –ya no virus o bacterias, sino quimeras. Además de causar dolor, la inflamación puede también dañar el tejido y con el tiempo producir una cuantiosa serie de enfermedades (la mayoría de las enfermedades neurodegenerativas, por ejemplo, parecen estar ligadas a la inflamación).
Cole realizó un estudio con sus alumnos cuyos resultados nos ayudan a entender mejor cómo nuestra psicología profunda se refleja en nuestro sistema inmune. En el estudio se midió el perfil de expresión genética de un grupo de voluntarios y se relacionó con una evaluación de sus niveles de felicidad. Un mejor perfil de expresión genética significa una mayor respuesta antiviral  y una menor respuesta inflamatoria. La evaluación de la felicidad se dividió en la felicidad “hedonista” y la “felicidad eudaimónica”. “La felicidad hedonista es el estado de ánimo elevado que experimentamos después de un evento de vida externo, como comprar una casa”, la eudaimonia es “nuestro sentido de propósito y dirección en la vida, nuestro involucramiento con algo más grande que nosotros”, explica Cole. El estudio mostró una notable correlación entre la felicidad eudaimónica y un mejor funcionamiento del sistema inmune. 
El estrés crónico que reduce la felicidad eudaimónica, sugiere Cole, puede acortar la longitud de los telómeros, mientras que actividades como la meditación mantienen la longitud de estos extremos de los cromosomas que protegen el ADN e intervienen en el proceso de envejecimiento. En otras palabras, la disciplina mental es capaz de afectar la expresión genética y regular la función de nuestro ADN. Para quienes dudaban de los poderes mentales del ser humano.
Julio_Ruelas_-_Criticism_-_Google_Art_Project
Imagen de Julio Ruelas
La eudaimonia o el buen daimon
Personalmente, lo que me interesa más del trabajo de Cole es el énfasis en la eudaimonia. Su investigación sugiere que la salud humana y la felicidad misma es el resultado de un buen daimon (que es lo que significa la palabra eudaimonia). El daimon es, según se creía en la antigua Grecia, el genio o acompañante del alma (a veces usado como sinónimo mismo del alma o psique). “Ethos anthropos daimon“, escribió Heráclito, una frase que se traduce como “Carácter es destino” (daimon siendo destino en este caso). Quizás nos ayude más leer la frase de Heráclito, llamado a veces el primer psicólogo,  de esta forma: “El carácter del hombre es su daimon” y de aquí intentemos entender lo que es el daimon. 
Marsilio Ficino, el gran traductor de Platón y otros clásicos, eje del renacimiento cultural de la Florencia de los Medici, dijo sobre el daimon: “Quien descubre su propio genio a través de estos medios encontrará su trabajo natural y al mismo tiempo encontrará su estrella y su daimon. Siguiendo este camino obtendrá felicidad y bienestar”. Ficino, quien fuera conocido como “doctor del alma”, amplía aquí el sentido de la frase inscrita en Delfos “Conócete a ti mismo”; conocerse a sí mismo es conocer también a nuestro daimon, nuestro destino, ese espíritu que nos guarda y asedia, como “una estrella flotando sobre la tierra, conectada al alma”, según Plutarco. Patrick Harpur, quien ha relacionado al daimon con las apariciones numinosas de diferentes épocas –desde los ángeles y las hadas a los OVNIs- dice que una forma de imaginarlo es como “una manifestación personal de un dios impersonal”.
Jung en sus memorias dice “estoy consciente de que ‘mana’, ‘daimon’ y ‘dios’ son sinónimos del inconsciente -eso es otra forma de decir que sabemos tan poco de los primeros como del último”, y agrega que el inconsciente era un término “científico” y “racional” mientras que el “uso del lenguaje mítico”[el daimon] da “ímpetu a la imaginación”. Jung siempre quiso mantener legitimidad científica en su trabajo, por eso la predilección por el “inconsciente”. Aquí podemos también aplicar su máxima de “hacer consciente el inconsciente”, la clave de su psicología, lo que significaría en otras palabras familiarizarnos con nuestro daimon –para no ser inconscientemente víctima de su tiranía.
Quizá la fuente más reputada de lo que es el daimon es Platón, quien nos introduce al daimon de Sócrates, el cual lo encaminó a aceptar el destino de la cicuta y quien, relatando el mito de Er, señala que cada alma tiene asignada un daimon personal que se encarga de vigilar el cumplimiento de la “porción” entregada por las Moiras al nacer. El daimon es el encargado de administrar y atender ese destino que hilan las Moiras; un destino que no es del todo fatal, ya que fue elegido por nuestra alma. En cierta forma las Moiras (que son la porción misma que se entrega) se transpolan al daimon, que a su vez es el representante de Ananké, la diosa de la necesidad, madre de las Moiras. Por lo que podemos entender que nuestro destino es aquello necesario –lo que no podemos ceder, por eso el celo voraz del daimon.
En su libro The Soul’s Code, James Hillman argumenta que la enfermedad es una de las formas con las que el daimon –que participa en el arquetipo del trickster– nos obliga a reflexionar y recapacitar para que no nos desviemos del camino de nuestra necesidad interna, del llamado profundo de nuestra vida, acaso procrastinando por campos hedonistas o en la ambición de la materia (lo del ego es el principio del placer, lo del alma es el compromiso teleológico). En otra parte Hillman escribe: “Hasta que el alma no obtiene lo que quiere, nos enferma” (si estas inflamado no vayas al doctor, pregúntale al daimon). Manly P. Hall, el erudito fundador de la Philosophical Research Society, observa que la mayoría de las personas enfermas con las que ha tratado “no tienen una salida creativa”, como si el hecho de no estar creando, de no estar cumpliendo con su propia obra magna, cualquiera que sea (y muchas veces es el servir a alguien más), les restara fuerza vital (fuerza vital que que se alimenta de dar al mundo fuerza vital). “Negar la propia alma es ser separado de la fuente misma de la vida”, escribe Patrick Harpur, en El fuego secreto de los filósofos
Tiene sentido, las personas que manifiestan vivir una vida plena de significado –no de placer e indolencia– son también más sanas, no tienen un sistema inmune que lucha en su contra, activando tormentas inflamatorias con fuego cruzado. El sentido es la salud, el dao. Seguir el camino que marca el daimon, vivir en armonía con el pleito de nuestra alma, parece ser la clave de la salud. Todo lo demás son pequeñeces. Esto también hace eco de lo que descubrió Viktor Frankl en los campos de concentración de la Segunda Guerra Mundial: los hombres con sentido existencial no se desmoronaban ante las abyectas condiciones que enfrentaban. Howard Bloom, en su libro Global Brain, señala que los seres humanos somos “hipótesis que lanza la mente global” y aquellos hombres-hipótesis del devenir planetario que prueban ser valiosos para esta mente global, este superorganismo del cual somos como las células individuales, son recompensados, gratificando su sistema inmune con una cascada de dulces y relajantes drogas orgánicas: hormonas, neurotransmisores como dopamina, GABA, serotonina o el butirato (esa mantequilla de los dioses de la inmunidad); los otros, cuyas vidas no tienen significado para el colectivo, son inundados con cortisol y adrenalina y llevados a los ghettos y gulags de la inmunodeficiencia. 
¿Acaso es que la vida, ese misterioso hálito, es una dádiva, una bendición y una manda que es depositada en nosotros y que podemos perder en cualquier momento; que perdemos cuando nos alejamos de ese misterioso destino que nuestra alma eligió entre las estrellas?
Twitter del autor: @alepholo

lunes, 14 de julio de 2014

How Lies Live and Grow in the Brain - Op-Ed - NYTimes.com

How Lies Live and Grow in the Brain - Op-Ed - NYTimes.com



Este es un gran artículo (tiene ya unos añitos). Habla de algunos de los factores por los cuales podemos llegar a creer cosas que son evidentemente mentira (y no, no se trata de estrategias de propaganda... en este caso)

Nuestro cerebro reprocesa (modificándolos) los datos que guardamos en la memoria de corto plazo cada vez que los recordamos, y luego los transfiere a la memoria de largo plazo separándolos del contexto en el que fueron aprendidos. Esa separación ("olvido de la fuente") puede hacer que olvidemos si la fuente del dato era o no confiable, o incluso si el dato era presentado como cierto o falso. Además está nuestra fuerte tendencia a privilegiar los datos que coinciden con nuestras ideas y creencias o nos resultan emocionalmente agradables.

jueves, 5 de junio de 2014

An Apple a Day, and Other Myths - NYTimes.com

An Apple a Day, and Other Myths - NYTimes.com



La última reunión de la Asociación Americana para la Investigación del Cáncer ha hecho evidente que la ciencia actual no encuentra ninguna correlación entre la alimentación de una persona y su probabilidad de tener cáncer. Ninguna. Ni  los vegetales o frutas son protectores, menos aún la fibra, ni la carne roja es dañina. La razón por la que en los años 90 los estudios decían lo contrario es porque eran estudios con enormes márgenes de error reales, ya que se basaban en lo que las personas recordaban haber comido tiempo atrás. Estudios que siguen la alimentación real de las personas en un lapso de tiempo no confirmaron lo que los anteriores sugerían.

¿Significa que hay que comer cualquier cosa? No. Significa que tenemos muchas menos certezas que lo que solemos creer respecto a la forma en que nos conviene comer. Significa que no es ni prudente ni solidario cuestionar la forma en que se alimentan los demás en función a supuestos efectos sobre su salud. Y que es tiempo de bajar un poco el tono e intentar evitar el asustarnos y asustar a los demás.

jueves, 14 de noviembre de 2013

Joseph M. Fericgla: Dime qué droga tomas y te diré quién eres

Dime qué droga tomas y te diré quién eres Ǵ radio macondo

"Y luego descubrí algo en antropología que nunca se dice pero es capital la importancia que tiene, es el hecho de que 89% de sociedades no occidentales consumen sustancias psicoactivas, las que están prohibidas precisamente, y que se las acusa de ser fuente de marginación, de delincuencia, de psicopatologías, de trastornos sociales y personales… Resulta que estas 89% de sociedades, yo he hecho los cálculos, y son todo contrario, son fuente de virtuosismo, digamos, son origen de aglutinamiento social, se celebran ritos de cohesión social en torno al consumo de estas sustancias; se usan en ámbitos médicos, religiosos, chamánicos, de procesos de educación y socialización…"

" Cada sociedad ha crecido en función de una droga que la impregna. Occidente, por el alcohol (desde hace dos mil años) :el alcohol genera agresividad y egocentrismo. El islam, por el cannabis: Se sientan a la puerta de casa a esperar ver pasar por delante el cadáver de su enemigo. El budismo oriental está impregnado de opio, la droga del extatismo, de la estupefacción ante el universo. Los indios norteamericanos tabaco virgen, con mucha nicotina, neuroestimulante: guerreros y visionarios. Al chocar con el blanco agresivo, guerra segura. ¡Sólo exterminándolos los dominaron! Sobre los indios sudamericanos, conozco muy bien a los amazónicos. Hace nueve años que convivo largas temporadas con los “shuar”, conocidos aquí como jíbaros. Es la cultura de la ayahuasca, al tomarla, ven la selva llena de espíritus, de vida. Por ejemplo, toman ayahuasca para “visitar” a parientes lejanos. Es en lo que creen, porque los jíbaros sólo creen en aquello que ven, en nada más."

"Pero para mí la adicción no existe. Lo que realmente hay, en términos más estrictos desde el punto de vista descriptivo, son comportamientos compulsivos. O sea, comportamientos que a la persona algo le obliga a hacerlos incluso dándose cuenta de que van en contra de sus propios intereses.Y todo comportamiento compulsivo es lo mismo, en el fondo da igual si es al sexo, a las máquinas de echar monedas, alguna sustancia psicoactiva, el trabajo, una secta… Lo importante es el comportamiento compulsivo, no a la cosa a la que está enganchada la persona. Entonces todo comportamiento compulsivo lo que hace es estar llenando algún vacío interior de la persona, emocional, existencial, depende, algún vacío interior. La adicción lo que hace es llenar el espacio de este vacío interior, y lo que hay que hacer no es cortar con la adicción, sino que lo importante es descubrir qué es el vacío de cada persona, de dónde surgió el vacío. Entonces en cuanto la persona lo pueda llenar, automáticamente dejan el comportamiento compulsivo porque ya no tiene espacio."

"A las personas nos cortan la vida las promesas que nos hemos hecho cuando éramos pequeños. Si alguien nos humilla de niños prometemos que nunca más vamos a permitirlo; si sentimos que nos abandona alguien querido prometemos que nunca más nos van a abandonar y, por lo tanto, nunca más queremos a nadie para no volver a sentimos en manos de otra persona. Esas son las cosas que nos cierran a la vida. Por eso es delicado tomar enteógenos. Tampoco puede uno ir rompiendo su sistema cada dos por tres."   

viernes, 24 de mayo de 2013

Our Feel-Good War on Breast Cancer - NYTimes.com

Our Feel-Good War on Breast Cancer (Peggy Orenstein)


Es un artículo largo, pero vale totalmente la pena leerlo entero. La autora, que tuvo cancer de seno, explica por qué las campañas de detección temprana son contraproducentes.

Tenemos tan metida la idea de que detección temprana equivale a prevención que esto al comienzo suena a herejía. Sin embargo, los argumentos son claros: Cuando un cancer es de crecimiento rápido, la persona probablemente lo detectará ella misma antes de hacerse cualquier examen. La mamografía no suele detectar los tipos más letales en una fase tratable. En cambio, la mamografía identifica como cancer formaciones tumorales que podrían ser igualmente tratadas más adelante, o que incluso no tienen perspectiva de crecer y por lo tanto no revisten riesgos, o bien el examen arroja un "falso positivo"; pero las personas que obtienen estos resultados son sometidas a tratamientos agresivos que sí les afectan la salud, además de la carga psicológica que supone para la persona pensarse como "enferma de cáncer".

Incluso sin hablar de mamografías, hay estudios que muestran que las mujeres que han sido capacitadas para hacerse autoexámenes mensuales no tienen más posibilidades de detectar cáncer ni mejores tasas de supervivencia que aquellas que no han sido capacitadas. Con o sin capacitación, las mujeres identifican bastante bien cuando tienen un tumor. A cambio, el exceso de concientización sobre el tema está generando miedo y rechazo al propio cuerpo en muchas mujeres jóvenes.

Pero las fundaciones y organizaciones que trabajan sobre cancer siguen financiando campañas de concientización y examen temprano, mientras destinan presupuestos minúsculos a la investigación científica que podría encontrar mejores formas de detección, tratamiento y cura. La autora no abunda mucho sobre el tema de los intereses económicos detrás de esto (por lo que no se le puede acusar de conspiranoia), pero me parece que no hay que ser muy desconfiado para imaginarse que hay muchos a quienes les conviene esta situación.

(Nuevamente, no se fien de mi resumen, lean el artículo, a continuación copio el texto completo por si tienen problemas con la página de NY Times)

I used to believe that a mammogram saved my life. I even wrote that in the pages of this magazine. It was 1996, and I had just turned 35 when my doctor sent me for an initial screening — a relatively common practice at the time — that would serve as a base line when I began annual mammograms at 40. I had no family history of breast cancer, no particular risk factors for the disease.

Readers’ Comments

Readers shared their thoughts on this article.
So when the radiologist found an odd, bicycle-spoke-like pattern on the film — not even a lump — and sent me for a biopsy, I wasn’t worried. After all, who got breast cancer at 35?
It turns out I did. Recalling the fear, confusion, anger and grief of that time is still painful. My only solace was that the system worked precisely as it should: the mammogram caught my tumor early, and I was treated with a lumpectomy and six weeks of radiation; I was going to survive.
By coincidence, just a week after my diagnosis, a panel convened by the National Institutes of Health made headlines when it declined to recommend universal screening for women in their 40s; evidence simply didn’t show it significantly decreased breast-cancer deaths in that age group. What’s more, because of their denser breast tissue, younger women were subject to disproportionate false positives — leading to unnecessary biopsies and worry — as well as false negatives, in which cancer was missed entirely.
Those conclusions hit me like a sucker punch. “I am the person whose life is officially not worth saving,” I wrote angrily. When the American Cancer Society as well as the newer Susan G. Komen foundation rejected the panel’s findings, saying mammography was still the best tool to decrease breast-cancer mortality, friends across the country called to congratulate me as if I’d scored a personal victory. I considered myself a loud-and-proud example of the benefits of early detection.
Sixteen years later, my thinking has changed. As study after study revealed the limits of screening — and the dangers of overtreatment — a thought niggled at my consciousness. How much had my mammogram really mattered? Would the outcome have been the same had I bumped into the cancer on my own years later? It’s hard to argue with a good result. After all, I am alive and grateful to be here. But I’ve watched friends whose breast cancers were detected “early” die anyway. I’ve sweated out what blessedly turned out to be false alarms with many others.
Recently, a survey of three decades of screening published in November in The New England Journal of Medicine found that mammography’s impact is decidedly mixed: it does reduce, by a small percentage, the number of women who are told they have late-stage cancer, but it is far more likely to result in overdiagnosis and unnecessary treatment, including surgery, weeks of radiation and potentially toxic drugs. And yet, mammography remains an unquestioned pillar of the pink-ribbon awareness movement. Just about everywhere I go — the supermarket, the dry cleaner, the gym, the gas pump, the movie theater, the airport, the florist, the bank, the mall — I see posters proclaiming that “early detection is the best protection” and “mammograms save lives.” But how many lives, exactly, are being “saved,” under what circumstances and at what cost? Raising the public profile of breast cancer, a disease once spoken of only in whispers, was at one time critically important, as was emphasizing the benefits of screening. But there are unintended consequences to ever-greater “awareness” — and they, too, affect women’s health.
Breast cancer in your breast doesn’t kill you; the disease becomes deadly when it metastasizes, spreading to other organs or the bones. Early detection is based on the theory, dating back to the late 19th century, that the disease progresses consistently, beginning with a single rogue cell, growing sequentially and at some invariable point making a lethal leap. Curing it, then, was assumed to be a matter of finding and cutting out a tumor before that metastasis happens.
The thing is, there was no evidence that the size of a tumor necessarily predicted whether it had spread. According to Robert Aronowitz, a professor of history and sociology of science at the University of Pennsylvania and the author of “Unnatural History: Breast Cancer and American Society,” physicians endorsed the idea anyway, partly out of wishful thinking, desperate to “do something” to stop a scourge against which they felt helpless. So in 1913, a group of them banded together, forming an organization (which eventually became the American Cancer Society) and alerting women, in a precursor of today’s mammography campaigns, that surviving cancer was within their power. By the late 1930s, they had mobilized a successful “Women’s Field Army” of more than 100,000 volunteers, dressed in khaki, who went door to door raising money for “the cause” and educating neighbors to seek immediate medical attention for “suspicious symptoms,” like lumps or irregular bleeding.
The campaign worked — sort of. More people did subsequently go to their doctors. More cancers were detected, more operations were performed and more patients survived their initial treatments. But the rates of women dying of breast cancer hardly budged. All those increased diagnoses were not translating into “saved lives.” That should have been a sign that some aspect of the early-detection theory was amiss. Instead, surgeons believed they just needed to find the disease even sooner.
Mammography promised to do just that. The first trials, begun in 1963, found that screening healthy women along with giving them clinical exams reduced breast-cancer death rates by about 25 percent. Although the decrease was almost entirely among women in their 50s, it seemed only logical that, eventually, screening younger (that is, finding cancer earlier) would yield even more impressive results. Cancer might even be cured.
That hopeful scenario could be realized, though, if women underwent annual mammography, and by the early 1980s, it is estimated that fewer than 20 percent of those eligible did. Nancy Brinker founded the Komen foundation in 1982 to boost those numbers, convinced that early detection and awareness of breast cancer could have saved her sister, Susan, who died of the disease at 36. Three years later, National Breast Cancer Awareness Month was born. The khaki-clad “soldiers” of the 1930s were soon displaced by millions of pink-garbed racers “for the cure” as well as legions of pink consumer products: pink buckets of chicken, pink yogurt lids, pink vacuum cleaners, pink dog leashes. Yet the message was essentially the same: breast cancer was a fearsome fate, but the good news was that through vigilance and early detection, surviving was within their control.
By the turn of the new century, the pink ribbon was inescapable, and about 70 percent of women over 40 were undergoing screening. The annual mammogram had become a near-sacred rite, so precious that in 2009, when another federally financed independent task force reiterated that for most women, screening should be started at age 50 and conducted every two years, the reaction was not relief but fury. After years of bombardment by early-detection campaigns (consider: “If you haven’t had a mammogram, you need more than your breasts examined”), women, surveys showed, seemed to think screening didn’t just find breast cancer but actually prevented it.
At the time, the debate in Congress over health care reform was at its peak. Rather than engaging in discussion about how to maximize the benefits of screening while minimizing its harms, Republicans seized on the panel’s recommendations as an attempt at health care rationing. The Obama administration was accused of indifference to the lives of America’s mothers, daughters, sisters and wives. Secretary Kathleen Sebelius of the Department of Health and Human Services immediately backpedaled, issuing a statement that the administration’s policies on screening “remain unchanged.”
PR Newswire, via Associated Press; Tom DiPace/Associated Press; Gabrielle Plucknette/The New York Times (apron, sunglasses, flip-flop); Simon Fergusson/Getty Images.
Even as American women embraced mammography, researchers’ understanding of breast cancer — including the role of early detection — was shifting. The disease, it has become clear, does not always behave in a uniform way. It’s not even one disease. There are at least four genetically distinct breast cancers. They may have different causes and definitely respond differently to treatment. Two related subtypes, luminal A and luminal B, involve tumors that feed on estrogen; they may respond to a five-year course of pills like tamoxifen or aromatase inhibitors, which block cells’ access to that hormone or reduce its levels. In addition, a third type of cancer, called HER2-positive, produces too much of a protein called human epidermal growth factor receptor 2; it may be treatable with a targeted immunotherapy called Herceptin. The final type, basal-like cancer (often called “triple negative” because its growth is not fueled by the most common biomarkers for breast cancer — estrogen, progesterone and HER2), is the most aggressive, accounting for up to 20 percent of breast cancers. More prevalent among young and African-American women, it is genetically closer to ovarian cancer. Within those classifications, there are, doubtless, further distinctions, subtypes that may someday yield a wider variety of drugs that can isolate specific tumor characteristics, allowing for more effective treatment. But that is still years away.
Those early mammography trials were conducted before variations in cancer were recognized — before Herceptin, before hormonal therapy, even before the widespread use of chemotherapy. Improved treatment has offset some of the advantage of screening, though how much remains contentious. There has been about a 25 percent drop in breast-cancer death rates since 1990, and some researchers argue that treatment — not mammograms — may be chiefly responsible for that decline. They point to a study of three pairs of European countries with similar health care services and levels of risk: In each pair, mammograms were introduced in one country 10 to 15 years earlier than in the other. Yet the mortality data are virtually identical. Mammography didn’t seem to affect outcomes. In the United States, some researchers credit screening with a death-rate reduction of 15 percent — which holds steady even when screening is reduced to every other year. Gilbert Welch, a professor of medicine at the Dartmouth Institute for Health Policy and Clinical Practice and co-author of last November’s New England Journal of Medicine study of screening-induced overtreatment, estimates that only 3 to 13 percent of women whose cancer was detected by mammograms actually benefited from the test.
If Welch is right, the test helps between 4,000 and 18,000 women annually. Not an insignificant number, particularly if one of them is you, yet perhaps less than expected given the 138,000 whose cancer has been diagnosed each year through screening. Why didn’t early detection work for more of them? Mammograms, it turns out, are not so great at detecting the most lethal forms of disease — like triple negative — at a treatable phase. Aggressive tumors progress too quickly, often cropping up between mammograms. Even catching them “early,” while they are still small, can be too late: they have already metastasized. That may explain why there has been no decrease in the incidence of metastatic cancer since the introduction of screening.
At the other end of the spectrum, mammography readily finds tumors that could be equally treatable if found later by a woman or her doctor; it also finds those that are so slow-moving they might never metastasize. As improbable as it sounds, studies have suggested that about a quarter of screening-detected cancers might have gone away on their own. For an individual woman in her 50s, then, annual mammograms may catch breast cancer, but they reduce the risk of dying of the disease over the next 10 years by only .07 percentage points — from .53 percent to .46 percent. Reductions for women in their 40s are even smaller, from .35 percent to .3 percent.
If screening’s benefits have been overstated, its potential harms are little discussed. According to a survey of randomized clinical trials involving 600,000 women around the world, for every 2,000 women screened annually over 10 years, one life is prolonged but 10 healthy women are given diagnoses of breast cancer and unnecessarily treated, often with therapies that themselves have life-threatening side effects. (Tamoxifen, for instance, carries small risks of stroke, blood clots and uterine cancer; radiation and chemotherapy weaken the heart; surgery, of course, has its hazards.)
Many of those women are told they have something called ductal carcinoma in situ (D.C.I.S.), or “Stage Zero” cancer, in which abnormal cells are found in the lining of the milk-producing ducts. Before universal screening, D.C.I.S. was rare. Now D.C.I.S. and the less common lobular carcinoma in situ account for about a quarter of new breast-cancer cases — some 60,000 a year. In situ cancers are more prevalent among women in their 40s. By 2020, according to the National Institutes of Health’s estimate, more than one million American women will be living with a D.C.I.S. diagnosis.
D.C.I.S. survivors are celebrated at pink-ribbon events as triumphs of early detection: theirs was an easily treatable disease with a nearly 100 percent 10-year survival rate. The thing is, in most cases (estimates vary widely between 50 and 80 percent) D.C.I.S. will stay right where it is — “in situ” means “in place.” Unless it develops into invasive cancer, D.C.I.S. lacks the capacity to spread beyond the breast, so it will not become lethal. Autopsies have shown that as many as 14 percent of women who died of something other than breast cancer unknowingly had D.C.I.S.
There is as yet no sure way to tell which D.C.I.S. will turn into invasive cancer, so every instance is treated as if it is potentially life-threatening. That needs to change, according to Laura Esserman, director of the Carol Franc Buck Breast Care Center at the University of California, San Francisco. Esserman is campaigning to rename D.C.I.S. by removing its big “C” in an attempt to put it in perspective and tamp down women’s fear. “D.C.I.S. is not cancer,” she explained. “It’s a risk factor. For many D.C.I.S. lesions, there is only a 5 percent chance of invasive cancer developing over 10 years. That’s like the average risk of a 62-year-old. We don’t do heart surgery when someone comes in with high cholesterol. What are we doing to these people?” In Britain, where women are screened every three years beginning at 50, the government recently decided to revise its brochure on mammography to include a more thorough discussion of overdiagnosis, something it previously dispatched with in one sentence. That may or may not change anyone’s mind about screening, but at least there is a fuller explanation of the trade-offs.
In this country, the huge jump in D.C.I.S. diagnoses potentially transforms some 50,000 healthy people a year into “cancer survivors " and contributes to the larger sense that breast cancer is “everywhere,” happening to “everyone.” That, in turn, stokes women’s anxiety about their personal vulnerability, increasing demand for screening — which, inevitably, results in even more diagnoses of D.C.I.S. Meanwhile, D.C.I.S. patients themselves are subject to the pain, mutilation, side effects and psychological trauma of anyone with cancer and may never think of themselves as fully healthy again.
Yet who among them would dare do things differently? Which of them would have skipped that fateful mammogram? As Robert Aronowitz, the medical historian, told me: “When you’ve oversold both the fear of cancer and the effectiveness of our prevention and treatment, even people harmed by the system will uphold it, saying, ‘It’s the only ritual we have, the only thing we can do to prevent ourselves from getting cancer.’ ”
What if I had skipped my first mammogram and found my tumor a few years later in the shower? It’s possible that by then I would have needed chemotherapy, an experience I’m profoundly thankful to have missed. Would waiting have affected my survival? Probably not, but I’ll never know for sure; no woman truly can. Either way, the odds were in my favor: my good fortune was not just that my cancer was caught early but also that it appeared to have been treatable.
Note that word “appeared”: one of breast cancer’s nastier traits is that even the lowest-grade caught-it-early variety can recur years — decades — after treatment. And mine did.
Patrick Hamilton/Newspix/Getty Images; Matt Born/The Star-News, via Associated Press; Gabrielle Plucknette/The New York Times; Sharpie, via Associated Press; U.S. Postal Service, via Associated Press.
Last summer, nine months after my most recent mammogram, while I was getting ready for bed and chatting with my husband, my fingers grazed something small and firm beneath the scar on my left breast. Just like that, I passed again through the invisible membrane that separates the healthy from the ill.
This latest tumor was as tiny and as pokey as before, unlikely to have spread. Obviously, though, it had to go. Since a lumpectomy requires radiation, and you can’t irradiate the same body part twice, my only option this round was a mastectomy. I was also prescribed tamoxifen to cut my risk of metastatic disease from 20 percent to 12. Again, that means I should survive, but there are no guarantees; I won’t know for sure whether I am cured until I die of something else — hopefully many decades from now, in my sleep, holding my husband’s hand, after a nice dinner with the grandchildren.
My first instinct this round was to have my other breast removed as well — I never wanted to go through this again. My oncologist argued against it. The tamoxifen would lower my risk of future disease to that of an average woman, he said. Would an average woman cut off her breasts? I could have preventive surgery if I wanted to, he added, but it would be a psychological decision, not a medical one.
I weighed the options as my hospital date approached. Average risk, after all, is not zero. Could I live with that? Part of me still wanted to extinguish all threat. I have a 9-year-old daughter; I would do anything — I need to do everything — to keep from dying. Yet, if death was the issue, the greatest danger wasn’t my other breast. It is that, despite treatment and a good prognosis, the cancer I’ve already had has metastasized. Preventive mastectomy wouldn’t change that; nor would it entirely eliminate the possibility of new disease, because there’s always some tissue left behind.
What did doing “everything” mean, anyway? There are days when I skip sunscreen. I don’t exercise as much as I should. I haven’t given up aged Gouda despite my latest cholesterol count; I don’t get enough calcium. And, oh, yeah, my house is six blocks from a fault line. Is living with a certain amount of breast-cancer risk really so different? I decided to take my doctor’s advice, to do only what had to be done.
I assumed my dilemma was unusual, specific to the anxiety of having been too often on the wrong side of statistics. But it turned out that thousands of women now consider double mastectomies after low-grade cancer diagnoses. According to Todd Tuttle, chief of the division of surgical oncology at the University of Minnesota and lead author of a study on prophylactic mastectomy published in The Journal of Clinical Oncology, there was a 188 percent jump between 1998 and 2005 among women given new diagnoses of D.C.I.S. in one breast — a risk factor for cancer — who opted to have both breasts removed just in case. Among women with early-stage invasive disease (like mine), the rates rose about 150 percent. Most of those women did not have a genetic predisposition to cancer. Tuttle speculated they were basing their decisions not on medical advice but on an exaggerated sense of their risk of getting a new cancer in the other breast. Women, according to another study, believed that risk to be more than 30 percent over 10 years when it was actually closer to 5 percent.
It wasn’t so long ago that women fought to keep their breasts after a cancer diagnosis, lobbying surgeons to forgo radical mastectomies for equally effective lumpectomies with radiation. Why had that flipped? I pondered the question as I browsed through the “Stories of Hope” on the American Cancer Society’s Web site. I came across an appealing woman in a pink T-shirt, smiling as she held out a white-frosted cupcake bedecked with a pink candle. In a first-person narrative, she said that she began screening in her mid-30s because she had fibrocystic breast disease. At 41, she was given a diagnosis of D.C.I.S., which was treated with lumpectomy and radiation. “I felt lucky to have caught it early,” she said, though she added that she was emotionally devastated by the experience. She continued screenings and went on to have multiple operations to remove benign cysts. By the time she learned she had breast cancer again, she was looking at a fifth operation on her breasts. So she opted to have both of them removed, a decision she said she believed to be both logical and proactive.
I found myself thinking of an alternative way to describe what happened. Fibrocystic breast disease does not predict cancer, though distinguishing between benign and malignant tumors can be difficult, increasing the potential for unnecessary biopsies. Starting screening in her 30s exposed this woman to years of excess medical radiation — one of the few known causes of breast cancer. Her D.C.I.S., a condition detected almost exclusively through mammography, quite likely never would become life-threatening, yet it transformed her into a cancer survivor, subjecting her to surgery and weeks of even more radiation. By the time of her second diagnosis, she was so distraught that she amputated both of her breasts to restore a sense of control.
Should this woman be hailed as a survivor or held up as a cautionary tale? Was she empowered by awareness or victimized by it? The fear of cancer is legitimate: how we manage that fear, I realized — our responses to it, our emotions around it — can be manipulated, packaged, marketed and sold, sometimes by the very forces that claim to support us. That can color everything from our perceptions of screening to our understanding of personal risk to our choices in treatment. “You could attribute the rise in mastectomies to a better understanding of genetics or better reconstruction techniques,” Tuttle said, “but those are available in Europe, and you don’t see that mastectomy craze there. There is so much ‘awareness’ about breast cancer in the U.S. I’ve called it breast-cancer overawareness. It’s everywhere. There are pink garbage trucks. Women are petrified.”
“Nearly 40,000 women and 400 men die every year of breast cancer,” Lynn Erdman, vice president of community health at Komen, told me. “Until that number dissipates, we don’t think there’s enough pink.”
I was sitting in a conference room at the headquarters of Susan G. Komen, near the Galleria mall in Dallas. Komen is not the country’s largest cancer charity — that would be the American Cancer Society. It is, however, the largest breast-cancer organization. And although Komen’s image was tarnished last year by its attempt to defund a Planned Parenthood screening program, its name remains virtually synonymous with breast-cancer advocacy. With its dozens of races “for the cure” and some 200 corporate partnerships, it may be the most successful charity ever at branding a disease; its relentless marketing has made the pink ribbon one of the most recognized logos of our time. The ribbon has come to symbolize both fear of the disease and the hope it can be defeated. It’s a badge of courage for the afflicted, an expression of solidarity by the concerned. It promises continual progress toward a cure through donations, races, volunteerism. It indicates community. And it offers corporations a seemingly fail-safe way to signal good will toward women, even if, in a practice critics call “pinkwashing,” the products they produce are linked to the disease or other threats to public health. Having football teams don rose-colored cleats, for instance, can counteract bad press over how the N.F.L. handles accusations against players of rape or domestic violence. Chevron’s donations to California Komen affiliates may help deflect what Cal OSHA called its “willful violations” of safety that led to a huge refinery fire last year in a Bay Area neighborhood.
More than anything else, though, the ribbon reminds women that every single one of us is vulnerable to breast cancer, and our best protection is annual screening. Despite the fact that Komen trademarked the phrase “for the cure,” only 16 percent of the $472 million raised in 2011, the most recent year for which financial reports are available, went toward research. At $75 million, that’s still enough to give credence to the claim that Komen has been involved in every major breast-cancer breakthrough for the past 29 years. Still, the sum is dwarfed by the $231 million the foundation spent on education and screening.
Though Komen now acknowledges the debate over screening on its Web site, the foundation has been repeatedly accused of overstating mammography’s benefits while dismissing its risks. Steve Woloshin, a colleague of Welch’s at Dartmouth and co-author of the Not So Stories column in The British Medical Journal, points to a recent Komen print ad that reads: “The five-year survival rate for breast cancer when caught early is 98 percent. When it’s not? It decreases to 23 percent.” Woloshin called that willfully deceptive. The numbers are accurate, but five-year survival rates are a misleading measure of success, skewed by screening itself. Mammography finds many cancers that never need treating and that are, by definition, survivable. Meanwhile, some women with lethal disease may seem to live longer because their cancer was found earlier, but in truth, it’s only their awareness of themselves as ill that has been extended. “Imagine a group of 100 women who received diagnoses of breast cancer because they felt a breast lump at age 67, all of whom die at age 70,” Woloshin said. “Five-year survival for this group is 0 percent. Now imagine the same women were screened, given their diagnosis three years earlier, at age 64, but treatment doesn’t work and they still die at age 70. Five-year survival is now 100 percent, even though no one lived a second longer.”
When I asked Chandini Portteus, vice president of research, evaluation and scientific programs at Komen, in January why the foundation continued to use that statistic, she didn’t so much explain as sidestep. “I don’t think Komen meant to mislead,” she said. “We know that mammography certainly isn’t perfect. We also know that it’s what we have and that it’s important in diagnosing breast cancer.” (The statistic was subsequently removed from its Web site.)
In “Pink Ribbon Blues,” Gayle Sulik, a sociologist and founder of the Breast Cancer Consortium, credits Komen (as well as the American Cancer Society and National Breast Cancer Awareness Month) with raising the profile of the disease, encouraging women to speak about their experience and transforming “victims” into “survivors.” Komen, she said, has also distributed more than $1 billion to research and support programs. At the same time, the function of pink-ribbon culture — and Komen in particular — has become less about eradication of breast cancer than self-perpetuation: maintaining the visibility of the disease and keeping the funds rolling in. “You have to look at the agenda for each program involved,” Sulik said. “If the goal is eradication of breast cancer, how close are we to that? Not very close at all. If the agenda is awareness, what is it making us aware of? That breast cancer exists? That it’s important? ‘Awareness’ has become narrowed until it just means ‘visibility.’ And that’s where the movement has failed. That’s where it’s lost its momentum to move further.”
Before the pink ribbon, awareness as an end in itself was not the default goal for health-related causes. Now you’d be hard-pressed to find a major illness without a logo, a wearable ornament and a roster of consumer-product tie-ins. Heart disease has its red dress, testicular cancer its yellow bracelet. During “Movember” — a portmanteau of “mustache” and “November” — men are urged to grow their facial hair to “spark conversation and raise awareness” of prostate cancer (another illness for which early detection has led to large-scale overtreatment) and testicular cancer. “These campaigns all have a similar superficiality in terms of the response they require from the public,” said Samantha King, associate professor of kinesiology and health at Queen’s University in Ontario and author of"Pink Ribbons, Inc.” “They’re divorced from any critique of health care policy or the politics of funding biomedical research. They reinforce a single-issue competitive model of fund-raising. And they whitewash illness: we’re made ‘aware’ of a disease yet totally removed from the challenging and often devastating realities of its sufferers.”
I recalled the dozens of news releases I received during last October’s National Breast Cancer Awareness Month, an occasion I observed in bed while recovering from my mastectomy. There was the one from Komen urging me to make a “curemitment” to ending breast cancer by sharing a “message about early detection or breast self-awareness that resonates with you”; the one about the town painting itself pink for “awareness”; the one from a Web site called Pornhub that would donate a penny to a breast-cancer charity for every 30 views of its “big-” or “small-breast” videos.
Then there are the groups going after the new hot “awareness” demographic: young women. “Barbells for Boobies” was sponsoring weight-lifting fund-raisers to pay for mammograms for women under 40. Keep A Breast (known for its sassy “I ♥ Boobies” bracelets) urges girls to perform monthly self-exams as soon as they begin menstruating. Though comparatively small, these charities raise millions of dollars a year — Keep A Breast alone raised $3.6 million in 2011. Such campaigns are often inspired by the same heartfelt impulse that motivated Nancy Brinker to start Komen: the belief that early detection could have saved a loved one, the desire to make meaning of a tragedy.
Yet there’s no reason for anyone — let alone young girls — to perform monthly self-exams. Many breast-cancer organizations stopped pushing it more than a decade ago, when a 12-year randomized study involving more than 266,000 Chinese women, published in The Journal of the National Cancer Institute, found no difference in the number of cancers discovered, the stage of disease or mortality rates between women who were given intensive instruction in monthly self-exams and women who were not, though the former group was subject to more biopsies. The upside was that women were pretty good at finding their own cancers either way.
Beyond misinformation and squandered millions, I wondered about the wisdom of educating girls to be aware of their breasts as precancerous organs. If decades of pink-ribboned early-detection campaigns have distorted the fears of middle-aged women, exaggerated their sense of personal risk, encouraged extreme responses to even low-level diagnoses, all without significantly changing outcomes, what will it mean to direct that message to a school-aged crowd?
Young women do get breast cancer — I was one of them. Even so, breast cancer among the young, especially the very young, is rare. The median age of diagnosis in this country is 61. The median age of death is 68. The chances of a 20-year-old woman getting breast cancer in the next 10 years is about .06 percent, roughly the same as for a man in his 70s. And no one is telling him to “check your boobies.”
“It’s tricky,” said Susan Love, a breast surgeon and president of the Dr. Susan Love Research Foundation. “Some young women get breast cancer, and you don’t want them to ignore it, but educating kids earlier — that bothers me. Here you are, especially in high school or junior high, just getting to know to your body. To do this search-and-destroy mission where your job is to find cancer that’s lurking even though the chance is minuscule to none. . . . It doesn’t serve anyone. And I don’t think it empowers girls. It scares them.”
Rather than offering blanket assurances that “mammograms save lives,” advocacy groups might try a more realistic campaign tag line. The researcher Gilbert Welch has suggested, “Mammography has both benefits and harms — that’s why it’s a personal decision.” That was also the message of the 2009 task force, which was derailed by politics: scientific evidence indicates that getting mammograms every other year if you are between the ages of 50 and 74 makes sense; if you fall outside that age group and still want to be screened, you should be fully informed of the downsides.
Gabrielle Plucknette/The New York Times; Adrian Keating/Associated Press
Women are now well aware of breast cancer. So what’s next? Eradicating the disease (or at least substantially reducing its incidence and devastation) may be less a matter of raising more money than allocating it more wisely. When I asked scientists and advocates how at least some of that awareness money could be spent differently, their answers were broad and varied. Many brought up the meager funding for work on prevention. In February, for instance, a Congressional panel made up of advocates, scientists and government officials called for increasing the share of resources spent studying environmental links to breast cancer. They defined the term liberally to include behaviors like alcohol consumption, exposure to chemicals, radiation and socioeconomic disparities.
Other researchers are excited about the prospect of fighting or preventing cancer by changing the “microenvironment” of the breast — the tissue surrounding a tumor that can stimulate or halt its growth. Susan Love likened it to the way living in a good or bad neighborhood might sway a potentially delinquent child. “It may well be,” she told me, “that by altering the ‘neighborhood,’ whether it’s the immune system or the local tissue, we can control or kill the cancer cells.” Taking hormone-replacement therapy during menopause, which was found to contribute to escalating rates of breast cancer, may have been the biological equivalent of letting meth dealers colonize a street corner. On the other hand, a vaccine, the current focus of some scientists and advocates, would be like putting more cops on the beat.
Nearly everyone agrees there is significant work to be done at both ends of the diagnostic spectrum: distinguishing which D.C.I.S. lesions will progress to invasive disease as well as figuring out the mechanisms of metastasis. According to a Fortune magazine analysis, only an estimated .5 percent of all National Cancer Institute grants since 1972 focus on metastasis; out of more than $2.2 billion dollars raised over the last six years, Komen has dedicated $79 million to such research — a lot of money, to be sure, but a mere 3.6 percent of its total budget during that period.
“A lot of people are under the notion that metastatic work is a waste of time,” said Danny Welch, chairman of the department of cancer biology at the University of Kansas Cancer Center, “because all we have to do is prevent cancer in the first place. The problem is, we still don’t even know what causes cancer. I’d prefer to prevent it completely too, but to put it crassly, that’s throwing a bunch of people under the bus right now.”
One hundred and eight American women die of breast cancer each day. Some can live for a decade or more with metastatic disease, but the median life span is 26 months. One afternoon I talked to Ann Silberman, author of the blog “Breast Cancer? But Doctor . . . I Hate Pink.” Silberman started writing it in 2009, at age 51, after finding a lump in her breast that turned out to be cancer — a Stage 2 tumor, which she was told gave her a survival rate of 70 percent. At the time she was a secretary at a school in Sacramento, happily married and the mother of two boys, ages 12 and 22. Over the next two years, she had surgery, did six rounds of chemo, took a trio of drugs including Herceptin and, finally, thought she was done.
Four months later, a backache and bloated belly sent her to the doctor; the cancer had spread to her liver. Why didn’t the treatment work? No one knows. “At this point, you know that you’re going to die, and you know it’s going to be in the next five years,” she told me. Her goal is to see her youngest son graduate from high school next June.
It isn’t easy to face someone with metastatic disease, especially if you’ve had cancer yourself. Silberman’s trajectory is my worst fear; the night after we spoke, I was haunted by dreams of cancer’s return. Perhaps for that reason, metastatic patients are notably absent from pink-ribbon campaigns, rarely on the speaker’s podium at fund-raisers or races. Last October, for the first time, Komen featured a woman with Stage 4 disease in its awareness-month ads, but the wording carefully emphasized the positive: “Although, today, she has tumors in her bones, her liver and her lungs, Bridget still has hope.” (Bridget died earlier this month.)
“All that awareness terminology isn’t about us,” Silberman said. “It’s about surviving, and we’re not going to survive. We’re going to get sick. We’re going to lose parts of our livers. We’re going to be on oxygen. We’re going to die. It’s not pretty, and it’s not hopeful. People want to believe in ‘the cure,’ and they want to believe that cure is early detection. But you know what? It’s just not true.”
Scientific progress is erratic, unpredictable. “We are all foundering around in the dark,” said Peter B. Bach, director of the Center for Health Policy and Outcomes at Memorial Sloan-Kettering Cancer Center. “The one thing I can tell you is some of that foundering has borne fruit.” There are the few therapies, he said — like tamoxifen and Herceptin — that target specific tumor characteristics, and newer tests that estimate the chance of recurrence in estrogen-positive cancers, allowing lower-risk women to skip chemotherapy. “That’s not curing cancer,” Bach said, “but it’s progress. And yes, it’s slow.”
The idea that there could be one solution to breast cancer — screening, early detection, some universal cure — is certainly appealing. All of us — those who fear the disease, those who live with it, our friends and families, the corporations who swathe themselves in pink — wish it were true. Wearing a bracelet, sporting a ribbon, running a race or buying a pink blender expresses our hopes, and that feels good, even virtuous. But making a difference is more complicated than that.
It has been four decades since the former first lady Betty Ford went public with her breast-cancer diagnosis, shattering the stigma of the disease. It has been three decades since the founding of Komen. Two decades since the introduction of the pink ribbon. Yet all that well-meaning awareness has ultimately made women less conscious of the facts: obscuring the limits of screening, conflating risk with disease, compromising our decisions about health care, celebrating “cancer survivors” who may have never required treating. And ultimately, it has come at the expense of those whose lives are most at risk.

Peggy Orenstein is a contributing writer for the magazine and the author, most recently, of  “Cinderella Ate My Daughter: Dispatches From the Front Lines of the New Girlie-Girl Culture.”
Editor: Ilena Silverman
This article has been revised to reflect the following correction:
Correction: April 28, 2013
An article on Page 36 this weekend about breast cancer awareness misidentifies the reduction in the chance that a woman in her 50s will die of breast cancer over the next 10 years if she undergoes screening. It is .07 percentage points, not .07 percent.