Cancer in the Community

Cancer in the Community: Class and Medical Authority by Martha Balshem

Introduction:

Clashes due to cultural differences occur all over the world due to increasing globalization. These cultural clashes arise due to a lack of understanding and communication between different cultural perspectives. In particular, a broad spectrum of values and beliefs in the US exist due to its immense immigrant history.  It is important to pay attention to these cultural differences so that potential misunderstandings and poor communication do not cause problems between different social groups. In her ethnography, Cancer in the Community: Class and Medical Authority, Martha Balshem examines the problems that arise between two different social groups, the working class and medical authority, regarding the health education about cancer causation.  

 In her ethnography, Balshem mentions the issue of power and authority between the doctor and patient. She states that due to their occasional lack of cultural sensitivity, medical professionals fail to understand their patients and therefore are unable to establish an essential relationship. I agree with this statement because if there is mutual cultural understanding between both the patient and medical professional, then a healthy relationship can occur. This complex social issue is explained in great detail using many examples from the study community, which allows the reader to fully understand the author’s point. Overall, I agree with the ideas and points the anthropologist brings up in this ethnography.

At the start of the ethnography, Balshem opens with a question regarding whether one should change his or her lifestyle in order to reduce their risk of cancer. She questions why it feels wrong to do so if it is morally acceptable. Through many different examples such as interviews with the working class, excerpts from focus groups, print media, and in depth case study, Balshem creates a deeper understanding of the community. Balshem concludes her ethnography by stating that the problem lies in the judgmental perspective of medical professionals.  In order to solve the root problem of power in medical authority, the physicians, scientists, and health educators must not use a judgmental perspective. Her conclusion follows a logical sequence of ideas and examples from her field work and analysis.

The ethnography, Cancer in the Community: Class and Medical Authority by Martha Balshem, takes place in a working class neighborhood north of Philadelphia. Balshem refers to this neighborhood as Tannerstown in order to protect the actual identity of the community. This enclosed community has been known as a cancer “hot spot” due the high amount of cancer deaths in comparison to other parts of Philadelphia. The focus of the ethnographic research in this setting was to explore the beliefs of the Tannerstown residents behind cancer causality.  Many residents of Tannerstown believe that the polluted environment they live in and the factor of fate are the causes behind the high cancer rates, and not their personal lifestyles. The ethnographer does an outstanding job describing the social context of the community before beginning the analysis through exact quotes from residents, demographics, print media, and other sources.

The social class barrier between the residents of Tannerstown and the medical community caused an unfavorable environment for health education. Project CAN-DO entered the community with a five year plan to educate the residents about the importance of lifestyle choices in order to reduce their cancer risks (Balshem 1993:23). The distrust of the residents of Tannerstown created noncompliance with the health educators, which caused difficulties for the educators to change the cancer causation beliefs of the residents. The complexities of this project required the use of an anthropologist which is when the ethnographer joined the project. The ethnographer worked not only as an anthropologist, but also as a health educator. At times, Balshem struggled with separating her very different roles when performing her field work and analyzing her work. The lack of “felt experience” when performing her work took away a chance at further analysis of the ethnography, which caused a less thorough development of some ideas and experiences.

The ethnographer used the perspectives of many different Tannerstown residents in this ethnography. She included excerpts from one on one interviews, focus groups, print media, and her personal experiences and observations of her time working in Tannerstown. From her research and observations she came to make several conclusions regarding the ethics behind medical authority and social class. Martha Balshem’s final overall conclusion was that we need to change the victim and thus change ourselves, before we try to transform the lives of others (Balshem 1993:147). She stated the importance of not using a judgmental perspective when assuming authority. The main problem between the relationships of doctor and patient and community and medicine lies in the power of medicine. Scientists, physicians and health educators assume an authoritative and superior role in the patient-physician relationship and ignore the differences in health beliefs and cultural backgrounds, which results in the noncompliance of the patients because of their lack of acceptance to the health information delivered.

Analysis:

After an in depth description of a cancer death, the anthropologist brings up an important point regarding doctor patient relationships. Through this story, she showed the problems that arise between the two groups due to very different cultural backgrounds and perspectives. At many points a lack of communication existed between the doctor and the patient’s wife in the story. Both the patient and physician bring their own unique explanatory models in the clinical encounter resulting in a loss of communication when cultural sensitivity is not attempted. The author suggests that a solution to this problem is for the physician to treat not just the disease, a physical phenomenon, but also the illness, a cultural phenomenon (Balshem 1993:119). Illness is the subjective experience of suffering is strongly rooted in the cultural background and goes far beyond just the physical signs of disease (Nichter 2008). I agree that in order to ensure patient compliance, a strong line of communication and understanding needs to exist between both the patient and the doctor. This mutual understanding must start with the doctor being culturally sensitive during clinical practice. Social context is critical and must be included along with the concern of physical disease. Not only is it important to pay attention to the two different explanatory models in this complex relationship, but the author states that emotion is clearly an even more important factor. The patient’s wife in the story struggled with emotion throughout the story, particularly when faced with talking to rude doctors. The emotional state of a person allows us to understand the political and social context on a more personal scale. Emotion is the tie between social class and medical authority (Balshem 1993:121). Explanatory models alone cannot explain the problems that arise between the working class and professionals in the doctor-patient relationship. With just the use of EMs, perceptions and lived experiences are lost (Balshem 1993:124). The overall problem in the clinic is a problem of power, not of communication when considering both emotion and EMs.

I agree with the anthropologist’s point that a problem of power exists in the clinical setting resulting in a broken line of communication and a lack of patient compliance. Doctors often overlook the patient’s cultural background and emotions when treating the patient. They tend to pay attention solely to the physical disease and not the illness of the patient, although both are equally important when treating a person. Personally, I have witnessed this lack of social and emotional context used by doctors when treating patients. When my younger brother was being treated for Leukemia, we found out part way through his treatment that cranial radiation therapy would be necessary along with the chemotherapy he was already receiving. The doctor told my family of the high risks of cranial radiation quickly and authoritatively without thinking of the emotional impact it would have on the patient and my family. When my mother reacted negatively and questioned the need for such radical treatment, the doctor responded with annoyance. My mother felt that her concerns were ignored by the doctor and a loss of trust resulted from this emotion. The loss of trust created a loss of communication between my mother and the doctor because of the doctor’s belief of her superiority and power in her medical authority over my brother’s treatment. The doctor failed to attempt to understand the emotions and cultural beliefs of my mother resulting in this problem. From my personal experience, I have witnessed the importance of both the understanding of explanatory models and emotion in the doctor-patient relationship and I completely agree with the point the author makes regarding this issue. 

Another important idea illustrated by the ethnographer is the reason behind why many people of Tannerstown had difficulty believing and listening to the health educator’s information concerning cancer risk and prevention. This difficulty occurred due to the social beliefs that the residents already held about cancer risk and prevention. Social representations, such as the “defiant ancestor” were used to explain their cultural beliefs about cancer etiologies.  Many people brought up the “defiant ancestor” during interviews and focus group discussions as an explanation to combat the need for lifestyle changes to reduce cancer risks. The “defiant ancestor” is told to have “…smoked two packs of cigarettes a day, ate nothing but lard and bread, never went to the doctor, and lived to the age of ninety-three.“(Balshem 1993:81). The defiant ancestor did not live the prescribed healthy lifestyle that the health educators from Project CAN-DO deemed as necessary to reduce cancer risk, yet the defiant ancestor lived a long and healthy life. The people of Tannerstown attributed this to the positive attitude and hardworking ways of the defiant ancestor’s excellent health. They believe that if you ignore the symptoms, sickness will stay away (Balshem 1993:81).  The residents also strongly believe in the nocebo effect in regards to cancer causality. The people of Tannerstown believe that if one thinks they might have cancer, they will get it. They therefore do not acknowledge cancer prevention or symptoms because of their strong beliefs in the nocebo effect. The health educators in return refuse to familiarize themselves with the social beliefs regarding cancer causation, such as the nocebo effect, resulting in a greater difficulty when trying to educate the residents about cancer risks.

In my culture, beliefs in the nocebo effect are also taken very seriously similarly to the residents of Tannerstown. For instance, many people think that walking outside in the cold with inadequate warm clothing can cause a cold. This belief that you will get sick from being outside in cold weather results in the person actually getting sick. This belief reminds me of how the people in this ethnography believe that recognizing cancer symptoms and attempting to prevent it, will ultimately result in actually getting cancer. I agree with the ethnographer’s point that many Tannerstown residents ignore the information given to them about cancer prevention because they believe that dwelling on cancer prevention is foolish (Balshem 1993:83). The strong belief in the nocebo effect in this community is clear from the numerous quotes about the defiant ancestor and about the lack of control regarding getting cancer. Ultimately, the social beliefs cause these people to have strong beliefs behind the etiologies of cancer and the health educators are unable to change them due to their lack of trying to understand the culture of this community. 

One final idea that the author brought up was the medicalization of fatalism in the working class. Many people in Tannerstown believe that fate, not smoking or other cancer risk factors, is the determining factor of cancer diagnosis and death. Despite the fact that many health educators from Project CAN-DO have conveyed to the community in many different ways that lifestyle changes play a critical role in preventing cancer, they still strongly held their previous beliefs. “Through a clinical gaze, the health educator may see those who do not follow scientific medical advice as being essentially sick. In the case described here, the diagnosis is fatalism.” (Balshem 1993:67). Since the residents do not believe what has been scientifically proven, the health educators from Project CAN-DO believe that they have a problem. Because the people in Tannerstown share what the health educators consider abnormal beliefs about cancer causality, they decided to diagnosis them with fatalism. The medicalization of a behavior due to lack of falling within what is socially normal is similar to the medicalization of other mental health diseases. Despite the fact the scientific evidence for some mental health diseases and disorders has not been found, the abnormal behaviors are given labels by the biomedical community. One such example is the medicalization of abnormal child behavior, ADHD, which we have talked about often during class over the past few weeks. Diagnosis can be difficult because it is purely subjective based on how the doctor interprets the patient’s behavior. Similarly, the people of Tannerstown have been diagnosed with fatalism due to the lack of cooperation with the health educators, a behavior with no scientific evidence to prove a diagnosis of a real biomedical disease.  

The consequences consist of a lack of understanding of the health educators of the beliefs of the community. It is difficult for the health educators to leave their worldview of biomedicine resulting in a lack of understanding the etiologies of the community members. Through the medicalization, the local cancer etiologies are seen merely as symptoms of fatalism and are not taken seriously. Also, the people themselves fail to believe the scientifically proven reasons given by the health educators. The vast divide in the health belief systems of the two groups create a social barrier and a lack of communication. A power struggle over whose beliefs should be thought of as correct ensues jeopardizing the health of a community. I don’t think the health educators should be labeling the community with a disease based off only the differences in beliefs concerning cancer etiology. This results in negative judgments of the patients and labels the entire working class with the problem of noncompliance. In truth, their noncompliance does not stem from their “fatalism”, but from a lack of social understanding between the medical authority and the working class.

Conclusion:

Overall, a clear divide stands between the working class and professionals, which include the medical professionals and health educators in this ethnographical work. The social barrier prevents communication and understanding of each other’s beliefs. Without communication, correct medical treatment cannot be delivered to patients who need it due to patient noncompliance. The root of the problem, though, is not communication, but the power of medical authority over the working class. This power stems from the professional sense of superiority because of a lack of understanding of each other’s explanatory models and emotions.

The applications of this ethnography extend beyond the health education efforts in Tannerstown. The issue of power within scientific medicine can be seen in all health fields across the United States and around the world. Clearly, this complex social issue can be labeled as a global health problem because of its widespread occurrence and its effect on health. The barrier between professionals and the working class is evident around the globe and often leads to inadequate health care due to similar issues identified by this work. Also, we learned that global health is about “a cacophony of voices” according to Paul Farmer during the first week of lecture (Farmer, lecture 9/26). This “cacophony” includes the complex relationship of the voices between the health care professionals and the patients.

The issue of the power in biomedicine can clearly be seen through this ethnographical work. Balshem does an excellent job depicting this complex social issue through the issue of cancer in Tannerstown. The overall conclusion made by Balshem can be applied not only to health education and oncology, but to all professions. Her final conclusion that the victim needs to be changed and judgmental perspective erased, in order to first change the professionals, before trying to transform others. In this ethnographic work, the health educators of Project CAN-DO should have addressed the problem of cancer risk education without a judgmental perspective and instead from a compassionate and socially accepting perspective in order to create a more mutually beneficial outcome.

-Allison Binkerd

Works Cited

Balshem, Martha

1993 Cancer in the Community: Class and Medical Authority. Washington: Smithsonian Institute Press.

Ceron, Alejandro, University of Washington, Seattle WA, October 24, 2012

Nichter, Mark. Global health: Why cultural perceptions, social representations, and biopolitics    matter. University of Arizona Press, 2008.