REVIEWS

S. Lochlann Jain
Malignant: How Cancer Becomes Us
Berkeley: University of California Press, 2013 (ISBN 978-0-520-27657-4)
Reviewed by Ada S. Jaarsma, 2014
Narrated by Theodra Bane

Malignant: How Cancer Becomes Us is a study of cancer culture: the policies, practices, and gruesome procedures that characterize the management of cancer in contemporary American society. "As the numbers stand now," S. Lochlann Jain writes, "one in two American men, and one in three American women, will be diagnosed with an invasive form of cancer during their lifetimes" (36). Yet, as the book explores with great care and precision, cancer is held out as an exceptional, rather than entirely ubiquitous, phenomenon. This paradox constitutes one of the animating concerns of the book: how can such an all-pervasive set of toxins and tumors continue to present itself as somehow not implicating each one of us? What is at stake in the evasions of cancer culture, and what kind of political consciousness becomes possible from the confrontation with cancer that Malignant proffers?

The book tracks a wide assortment of cancer debris. In one chapter, Jain examines the pamphlets handed out to recruit people to participate in cancer research trials, and in another chapter, scrutinizes the advertisements that invite young women to donate eggs in the name of advancing the fertility of others. Throughout each chapter, the stories by individuals, gathered together by Jain through years of ethnographic research, remind us of the sheer and unremitting pain of life with cancer. Whereas pathology reports translate between cells and physicians, the embodied life of cancer culture resists such abstractions. Malignant draws out such tensions between the objectifying mechanisms of for-profit medicine and the subjective experiences of patients, consumers, and even doctors. As the book's subtitle suggests, cancer somehow becomes us, as we navigate what Jain calls "the justifying logics of mortal lifespans in immortal systems" (51).

With its insistence that health cannot be understood apart from the normalizing forces of neo-liberal society, Malignant occupies a growing terrain of critical scholarly work. Described variously as critical temporality studies and affect studies, this work reflects the ongoing intellectual exchanges between queer theory and feminist analyses of biopower. One exemplary text of such exchanges is the co-edited volume Against Health (Metzl and Kirkland 2010), a collection of essays about the moralization of health to which Jain is a contributor. Malignant also resonates directly with texts by Elizabeth Povinelli, Lauren Berlant, and Mel Y. Chen (Berlant 2011; Povinelli 2011; Chen 2012)---books that bring social theory together with feminist and queer theory in order to provoke new attentiveness to debility, disability, and the chronic, systematic suffering of life in late capitalism.

This focus on the queer dynamics of health can be seen, for example, in Jain's demonstration of the sexed and gendered scripts of medical care. Especially vivid in chapter 3, "Cancer Butch," the means by which individuals negotiate the trajectory of cancer prognoses are caught up in the normative force of signifiers like hair (or lack of hair), breasts (or lack of breasts), and the use or nonuse of cosmetics. As we learn from Jain's analysis, cancer itself is characterized by sexed differences: cancers of female reproductive organs are less easily found and treated and have death rates nearly four times as high as men's cancers (81).

Such differences are taken up by cancer culture in highly prescriptive ways, as motifs of survival rely upon gendered norms without, at the same time, promoting recognition of disparities in survival rates. Pink-ribbon campaigns by BMW and assorted cosmetic companies, for example, bring together portraits of benign girlhood with a certain innocence of the disease itself, and Jain's analysis demonstrates how the ever-present "pink-washing" of breast-cancer campaigns sells femininity without the sex. Ads for early-detection campaigns hinge upon similarly normative ideologies about sex, reproduction, and over-determined valuations of life. One campaign, for example, represents survival as a moral duty for mothers, demonstrating what Jain calls the "ideology of the Child"; such ideology simulates, without actually promoting, concern for the value of life (65). As Jain explains, because of the exclusionary dynamics of capitalist society and despite the false promises of ad campaigns, "some lives are more worth living than others and some lifespans more worthy of completion (if only by proxy)" (66).

Malignant includes many in-depth analyses of these kinds of contradictions that characterize market-based health care. The cosmetics industry, for example, proffers programs for female cancer patients while spending millions on lobbying to prevent the regulation of carcinogens in their products. Another example is the "egg market" of in-vitro fertilization, in which the promise of fertility relies upon the use of hormones and the donation of eggs by young women whose own cancer rates are remarkably high.

Throughout discussions of such examples is a sustained reflection on one particular tension of cancer culture, one that is rendered poignant by Jain's deft combination of ethnography and memoir with social-science research. I'm referring to the dissonance between individuals who are living with cancer and the population-level aggregates that group individuals together as the basis for statistical analysis. In medical research, aggregates are required to translate cancer cases into statistically representable terms: numbers proffer equivalence across differences. Research trials construct disease categories, grouping patients together into aggregates, even as trials often exceed the lifespan of their participants.

However, of course, a particular individual's life or death can never square with population-based prognoses. As Jain puts it, statistics "at once describe and mask description. A single number implies both anyone (who could be the one with cancer) and everyone (in a culture and biology of culture)" (45). Despite the certainty that such abstractions hope to secure, a prognosis proffers a stark and irresolvable contradiction for the person being diagnosed. As Jain puts it: "I am alive. No, you are dead" (45).

Through ethnographic reflections on meetings sponsored by big science, Jain's book is especially instructive in its sustained demystification of the expert knowledge of oncology. The very trust in numbers that constitutes the basis for medical research, Jain points out, has had to be cultivated as a privileged evidentiary resource (116). In other words, the epistemologically contingent assumptions of medical research can be rendered explicit and, as Jain suggests throughout the book, can become open to critical questioning.

For example, the randomized control trial (RCT), rendered newly strange by Jain's reflections, consists of a method that is generally not discussed within scientific literature and yet "virtually defines oncology as a professional field" (113). Because RCTs require participants, corporations like Genentech invite people with cancer to not let their diseases go "uncounted," so as "not to miss an opportunity to donate to the higher cause" (118). This pitch is essential to the market-based promises of survival---the familiar promise that, someday, all cancers will one day be curable, given enough funding and enough participants in research trials (122). This pitch for participants also needs to be successful in light of capitalist imperatives, as cancer research underlies many highly profitable industries and economies.

Malignant also documents the misdiagnoses, suffering, and complications caused by treatment itself, as well as the traumas caused by both under-treatment and over-treatment due to the protocols of big medicine. Often invisible, deeply painful, and sometimes fatal, treatment injuries are excised from research trials but are essential to the practice of cancer research. As Jain grimly but resolutely explains, cancer research trials need and await the cancer recurrences and deaths of their participants. On these terms, survival makes sense as a calculus only because of the deaths of others.

The logic of cancer research disallows such insights because of the ways in which disease is instrumentalized in service to scientific inquiry. A person with cancer becomes "useful," in other words, as she or he becomes countable as data. As Jain puts it, the gap between the counter and the counted structures the asymmetry of doctor and patient. Jain admits, "I realized that my use, dead or alive, was as data---just like those who populated (maybe peopled is a better word) the trial reports I was reading" (115).

As this example evinces, the author's own body is proffered to the reader to be witnessed "as a material bearer of carcinogenic culture" (77) through Jain's narratives about her misdiagnosis, treatment, and recovery. "My patient self meets my anthropologist self here," Jain writes, "drifting downstream with the alligators" (94). This juncture of self-reflection with critical inquiry will be of interest to many feminist philosophers who search for ways to integrate the subjective aspects of embodiment with the rigors of theory and philosophy.

Also of interest to feminist philosophers will be the book's sustained exploration of the epistemology of ignorance at work within cancer culture. Ignorance, we learn, is constitutive of cancer. The "structural unknownness of cancer," Jain writes, elides the empirical methods of science and the vested interests of for-profit research (178). In addition to ongoing confusions about the efficacy of screening and treatment procedures, there is a virtual impossibility of securing causal links between environmental toxins and specific cases of cancer injuries. These examples underline one of the important insights of Jain's study: the fact that cancer is characterized by both "everywhere- and nowhereness" (184).

Yet, of course, as Jain points out, "no data does not equal no effect" (160), so an examination of the ignorance at work within cancer culture means calling into question the startling paucity of research into procedures like in-vitro fertilization. There are currently no mechanisms in place to track the striking links between the hormones used in fertility treatments and egg-donation and cancer: "The dicey medical experiment of giving fertility hormones to the young, fertile women who are recruited to donate lays bare some of the mechanisms by which cancer remains shrouded in mystery," Jain concludes (130). This lack of research is all the more noteworthy when we learn that "one in forty-nine women under the age of thirty-nine is diagnosed with an invasive cancer. Unlike for children and for older adults, survival rates for young adults have not improved" (130).

Overall, the book enacts what Jain's own reflections invite: "refocusing attention on what we don't know---rather than trying to generate knowledge that obfuscates what we don't know" (156). As we discover through the book's wide-ranging research, the endemic injuries of cancer culture demand but also disallow effective knowledge-practices. Medicine, for example, looks to prognoses as the literal description of an aggregated chance. Medical malpractice law, in contrast, requires evidence of causation (like the mistake of a doctor) and the specifications of individual cases---specifics that belie the generalizations of statistical aggregates.

Rather than trying to mitigate such epistemological contradictions by appealing to the need for better environmental laws or more effective malpractice procedures, for example, Malignant ultimately opens up the affective dimensions of cancer culture that move us beyond liberal politics---most especially by affirming the importance of grief and mourning. Along these lines, Jasbir K. Puar's reading of Jain's work, especially its dual emphasis on temporality and grief, draws out the resultant queer politics that emerges from this deliberate cultivation of mourning (Puar 2009).

Likewise, Jain's conclusion to Malignant invokes the "elegiac politics" of living in prognosis, in which prognosis time demands the rethinking of subjectivity (I am alive. No, you are dead), of temporality (what is a natural timeline of a human life in prognosis time?), and of the exclusions and disparities that characterize life in capitalism. Disproportionate access to health care, differential proximities to the toxic environments that give rise to cancer clusters---these are structuring injustices of late liberalism. Although cancer is ubiquitous and nonexceptional, as Jain's study makes clear, cancer emerges and becomes the object of research, treatment, and advertising through brutally exclusionary mechanisms. By concluding with a reflection on elegiac politics, Malignant proffers a way to deepen our sense of responsibility for such injustices, while at the same time intensifying the uncertainties that characterize cancer culture.

References

Berlant, Lauren. 2011. Cruel optimism. Durham, N.C.: Duke University Press.

Chen, Mel Y. 2012. Animacies: Biopolitics, racial mattering, and queer affect. Durham, N.C.: Duke University Press.

Metzl, Jonathan M., and Anna Kirkland. 2010. Against health: How health became the new morality. New York: New York University Press.

Povinelli, Elizabeth A. 2011. Economies of abandonment: Social belonging and endurance in late liberalism. Durham, N.C.: Duke University Press.

Puar, Jasbir K. 2009. Prognosis time: Towards a geopolitics of affect, debility and capacity. Women & Performance: A Journal of Feminist Theory 19 (2): 161-72.

Ada S. Jaarsma is an associate professor of philosophy at Mount Royal University in Calgary, AB, where she works in continental philosophy, feminist philosophy, and critical theory.  Her current research reflects on the existential significance of recent evolutionary theory, particularly epigenetics, mobilizing Kierkegaard's existential texts (and interpretations of Kierkegaard by Habermas, Arendt, and Derrida) in order to explore the critical, queer and post-secular implications of evolutionary thought.

ajaarsma@mtroyal.ca

http://www.adajaarsma.com

"Also of interest to feminist philosophers will be the book's sustained exploration of the epistemology of ignorance at work within cancer culture. Ignorance, we learn, is constitutive of cancer."