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Normal bone mass, aging bodies, marketing of fear : bone mineral density screening of well women Kazanjian, Arminée, 1947-; Green, C. J. (Carolyn Joanne), 1956-; Bassett, Kenneth, 1952- Sep 30, 1998

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Centre for Health Servicesand Policy ResearchNormal bone mass, agingbodies, marketing of fear:Bone mineral densityscreening of well womenBCOHTA 98:10C          September 1998British Columbia Office of Health Technology AssessmentU N I V E R S I T Y  O F  B R I T I S H  C O L U M B I ANormal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenNormal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenBritish Columbia Office of Health Technology Assessment 2Arminée Kazanjian  Dr SocAssociate ProfessorHealth Care and EpidemiologyPrincipal InvestigatorBC Office of Health Technology AssessmentUniversity of British ColumbiaCarolyn J Green  BHSc (PT) MScResearch Co-ordinatorBC Office of Health Technology AssessmentUniversity of British ColumbiaKen Bassett   MD PhDSenior Medical ConsultantBC Office of Health Technology AssessmentUniversity of British ColumbiaPresented at the 93 rd Annual Meeting of theAmerican Sociological AssociationSan Francisco  •  21-25 August 1998BC Office of Health Technology AssessmentCentre for Health Services and Policy ResearchUniversity of British Columbia429 - 2194 Health Sciences MallVancouver, British ColumbiaCanada  V6T 1Z3(604) 822-4810bcohta@chspr.ubc.cawww.chspr.ubc.caABSTRACTDefinitions of osteoporosis have become increasingly dependent on bone mineral density(BMD) measures.  However, there are major limitations with this type of approach whichpromotes a medical reductionist perspective, contributes to the medicalization of normally agingwomen, and supports technological determinism.  This paper takes a critical approach to needsNormal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenBritish Columbia Office of Health Technology Assessment 3assessment.  It examines the various interests being served through unchecked use of a diagnostictechnology, and asks: ‘who needs this technological service?’.Despite mounting evidence that BMD measures have a very low positive predictivevalue, entire cohorts of middle-aged and older women are labelled with their BMD measures.This is done for the sake of “early detection” and “better management” of “endocrine deficiencydisorder”.  The medicalization of yet another transition in the lives of women conforms to thebio-medical model and serves many private interests.Beyond the labelling of entire cohorts, the early (and hence of necessity, repeated) use ofthis technology is being presented as the only hope for preventing bone fractures.  The paperdiscusses serious ethical challenges in public health which remain to be identified and addressed.It is concluded that the recently heightened profile of women’s health issues, such asosteoporosis, is based more on economic premises than on sound evidence from technologyassessment.  When the evidence on effectiveness clearly does not support current patterns ofdiffusion, a critical approach to needs-based health technology assessment is required so as toprovide a broader perspective within which power relations and private interests can better beunderstood.Normal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenBritish Columbia Office of Health Technology Assessment 4INTRODUCTIONWhole population screening of women using densitometry has been widely discredited,1-3yet some still advocate bone mineral density (BMD) testing of all women at or near menopausepresumably to prevent fragility fractures 25-40 years later.  Technology assessment efforts to datehave focused primarily on clinical effectiveness debates, estimating when to screen and howmany fractures need to be prevented before the intervention is deemed to be cost-effective.4,5However, these studies do not explain why BMD testing may still seem appealing to both womenand their health care providers.In 1993, an industry-sponsored conference sanctioned by the World Health Organization(WHO) redefined osteoporosis strictly in terms of BMD thresholds.6  The WHO definitionestablishes four thresholds based on reference populations of healthy young women; these areused for diagnosing osteoporosis and determining intervention.  Unless women maintain bonemass at peak levels throughout their life span they will be labeled as ‘at risk’ or ‘diseased’.Using the WHO standards, 22% of all women over age 50 will be defined as having osteoporosisand 52% as having osteopenia.7  There is no epidemiological basis to support the cut-offs used bythe WHO study group; therefore the resulting epidemic observed in the last few years is moreapparent than real.8This paper examines issues beyond clinical effectiveness, the social, economic, andpolitical contexts within which BMD testing has emerged, and delineates the forces behind itsrapid diffusion in the western world.  The objective of this paper is to make explicit theassumptions about aging women’s bodies that drive the use of BMD testing, and to identifymarketing strategies which create and capitalize on women’s fear of aging.Normal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenBritish Columbia Office of Health Technology Assessment 5METHODSA comprehensive evaluation framework for investigative technologies was developed,extending previous work in this area 9 which incorporates the assessment of clinical research onscreening tests with the epidemiological, economic and social contexts of technologicaldiffusion.  The framework provides a template within which evidence arising from a number ofacademic disciplines can be assembled and assessed.3Literature on the social and political contexts is reviewed and conditions under which theBMD test emerged and became accepted is examined.  In particular, we examine the powerfulcommercial interests which place heavy and continuing pressure on healthcare providers andwomen to focus on biological, rather than social, determinants of health.Critical health technology assessment starts from a premise that clinical care does notsimply reflect scientifically proven diagnostic and treatment protocols; clinical medicine isembedded in, and shaped by, specific social, economic, and political contexts.  Medicine doesnot merely describe a pre-existing biological reality, but reflects and perpetuates societal relationsof power.  Thus medicine and science, like all beliefs and practices, both reflect and support thecultural values of society at large.ANALYSISTwo approaches of interdisciplinary research provide critical analyses of technologiesrelated to women and aging:  feminist analysis demonstrates how technologies pertaining towomen’s health emerge out of, and perpetuate, popular ideas about women’s bodies andwomen’s roles in society;10-12 cross-cultural analysis documents variations in life-courseNormal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenBritish Columbia Office of Health Technology Assessment 6transitions, in particular the experience of menopause, and challenges the universality ofmenopausal symptoms.13-16These critiques in social studies challenge the ease with which life processes such asmenopause are being medicalized, and question women’s placid acceptance of commerciallymotivated interventions, which have no relationship to their health needs yet are emerging as themain determinant of technology diffusion.  This study shows that BMD testing has beeneffectively diffused because it is marketed and promoted in ways that draw on, and perpetuate,two trends in western popular culture: (a) the medical model of the aging female body; and, (b)the fear of aging and its association with disability, dependency and immobility.Aging and DiseaseSince the mid-nineteenth century, female life cycle transitions in Western societies havebeen increasingly medicalized; that is, interpreted by physicians as a series of events that shouldbe subject to medical management.15,17,18  Biological changes associated with aging are spokenabout in a language of decay and abnormality.  The biochemistry of women of reproductive ageis taken as the standard measure for what is normal and healthy; and aging women's bodies areunderstood in terms of "endocrine deficiency disorder", a hormone deficiency disease that is tobe treated with estrogen supplements.17-19  Al hough passage through the life cycle is both asocial and biological process, the focus of attention in medicine has been increasingly confined tobiological processes, such as ‘failing ovaries’.Popular magazine articles and books on menopause contain essentially the same message:the subject matter focuses on biological changes associated with menopause, and rarely putsmenopause into a larger context or discusses the subjective experience of individuals.15Normal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenBritish Columbia Office of Health Technology Assessment 7Aging is associated with a cluster of meanings involving emotional and physical losses.  Theselosses include declining social status and degradation of self-image, as the cultural ideal, youthfulfemininity, can no longer be met.  The social meanings associated with aging also include deeperfears of disability leading to loss of independence.20  Feath rstone andHepworth 21 have commented on the fear held for the aging body in contemporary Euro-American societies.  They refer to the 'mask of aging', the physical signs of 'decay' such aswrinkles and grey hair, from which women dissociate themselves.  As they note, such aconception of aging "sets great store on the belief that aging is a potentially curable disease."(emphasis in original).21Cross-cultural research has shown that the onset of menopause may bring increased socialstatus to women in many cultures.  The feedback loop between popular and scientific knowledgehas created and perpetuated the notion that the aging female body is a diseased body.  BMDtesting "works" in Euro-American societies because it has emerged out of, and in response to,culturally accepted norms about women's bodies and women's roles in society.  The well-entrenched medicalized model of menopause has paved the way for the medicalization of bonemineral loss.Marketing of FearWhile natural phenomena become labelled as disease, anxiety is heightened as the generalpublic is inundated with media coverage about the "discovered" disease.14,22  Social studies ofmedicine have repeatedly demonstrated how market forces may create and capitalize on a climateof risk and reassurance, which then drives the use of health technologies regardless of whetherthey lead to improved health outcome.  This has been shown for prenatal ultrasound,23 electronicNormal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenBritish Columbia Office of Health Technology Assessment 8fetal monitors,24,25 predictive genetic and other screening,26,27 hormone therapy,28 andmammography,14,29 among others.30,31In the early 1980s, most women had never heard of osteoporosis.  Beginning in 1982,sponsored by a pharmaceutical company, an education campaign was launched to create publicawareness of osteoporosis as an important women's health issue.  The company clearly stood tobenefit from increased public awareness of osteoporosis, and women who sought advice fromphysicians about prevention might easily end up with a prescription for HT.32  The campaignincluded radio, television, and magazine coverage, such as various articles in V gue, McCall'sand Reader's Digest.  As Whatley and Worcester explain, by the mid-1980s, women had not onlyheard of osteoporosis, they had become frightened of the seeming inevitability ofpostmenopausal hip fractures and of a life of disability and dependency.20The market forces are appreciable.  In the time leading up to the WHO redefinition ofosteoporosis, drug companies were poised and waiting, recognizing that a massive potentialtarget population of “baby boomers” existed and was growing.  The economic implications oftesting and treating the female baby boomers from age 50 till they turn 85 is staggering.Once the fear of becoming diseased has been created, women are made to feel personallyaccountable for managing their risk of disease and for future illness, and are encouraged to takeappropriate measures to prevent such disease.10,14,27,30,33  Given that menopause has been definedin terms of hormone deficiency (and osteoporosis is increasingly defined in relation to thatdeficiency) any woman who wishes to avoid the "diseases" of aging will have to be tested forBMD and, if deficient, will have to take HT.Normal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenBritish Columbia Office of Health Technology Assessment 9CONCLUSIONThe implications of the 1993 redefinition of osteoporosis for the lives of women remainslargely unexamined by scientific research.  At the very least, testing and labelling large cohorts ofpre- and peri-menopausal women as “abnormal” in BMD is leading to increased dependency onBMD testing and associated interventions.  Repeat testing becomes necessary and HT would beadministered over many years in order to ensure that women retain “normal” levels of bonedensity.Psychological side effects of BMD testing resulting from being labelled as “at risk” willonly add to the anxiety caused by popular media coverage about a “new” disease.  Goffman’swork on labelling 34 provides an appreciation of the extent to which the identities and lifeexperiences of women so labelled will be altered - this, in the absence of physical symptoms ordisease.The very act of transposing probabilities of epidemiology into clinical practice as aconcept of risk means that this identified risk will be interpreted as something which the patientsuffers.  Being “at risk” has come to mean being “diseased”.  On-going medical intervention hasaccordingly come to be seen as necessary to prevent the body from aging.Normal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenBritish Columbia Office of Health Technology Assessment 10REFERENCES1. Barlow, D., Cooper, C., Reeve, J., Reid, D.  Department of Health is fair to patients with osteoporosis.British Medical Journal 1996 Feb;312:297-8.2. Coupland, D., Lentle, B., Aldrich, J., Connell, D. and Janzen, D.  Recommendations for themeasurement and quantification of bone mineral density.  British Columbia Medical Journal1996:38(5):265-8.3. Green, C.J., Bassett, K., Foerster, V. and Kazanjian, A.  Bone mineral density testing:  does theevidence support its selective use in well women?  British Columbia Office of Health TechnologyAssessment, 1997.4. Hailey, D., Sampietro-Colom, L., Marshall, D., Rico, P., Granados, A., Asua, J. et al.  Statement offindings. INAHATA project on the effectiveness of bone density measurement and associatedtreatments for prevention of fractures.  Edmonton, AB: Alberta Heritage Foundation for MedicalResearch; 1996.5. Marshall D., Sheldon T.A., Jonsson E.  Recommendations for the application of bone densitymeasurement: what can you believe?  International Journal of Technology Assessment in Health Care,13:3 (1997), 411-19.6. WHO Study Group.  Assessment of fracture risk and its application to screening for postmenopausalosteoporosis. Geneva,  Switzerland: World Health Organization, 1994.7. Ringertz H., Marshall D., Johansson C., Johnell O., Kullenberg R.J., Ljunghall S. et al.  Bone densitymeasurement: a systematic review.  A report from SBU, The Swedish Council on TechnologyAssessment in Health Care.  Journal of Internal Medicine 1997;241(suppl 739):i-iii, 1-60.8. Parsons, Talcott  The structure of social action:  a study in social theory with special reference to agroup of recent European writers, 2nd d. New York: Free Press; London: Collier-Macmillan, c1949(1967 printing).9. Kazanjian, A., Cardiff, K. and Pagliccia, N.  Design and development of a conceptual & quantitativeframework for health technology decisions:  A multi-project compendium of research underway.British Columbia Office of Health Technology Assessment, 1995.10. Hubbard, R.  The politics of women's biology. New Brunswick:  Rutgers University Press, 1990.11. Martin, E.  The egg and the sperm: how science has constructed a romance based on male and femaleroles.  Signs, 1991, 16, 3,  485-501.12. Shiva, V. and Moser, I.  Biopolitics: a feminist and ecological reader on biotechnology.  London;Atlantic Highlands, 1995.13. Brown, J. and Kerns, V.  In her prime: a new view of middle-aged women.  Massachusetts: Bergin andGarvey Publishers, 1985.14. Gifford, S.  The meaning of lumps: a case study of the ambiguities of risk.  In C.R. Janes, R. Stall andS.M. Gifford (eds.), Anthropology and Epidemiology: interdisciplinary approaches to the study ofhealth and disease.  Dordrecht: Reidel Publishers, 1986, 213-246.15. Lock, M.  Encounters with Aging: mythologies of menopause in Japan and North America. Berkeleyand Los Angeles: University of California Press, 1993.16. McKinlay, S., Brambilla, D. and Posner, J.  The normal menopausal transition.  Human Biology, 1992,4, 37-46.Normal Bone Mass, Aging Bodies, Marketing of Fear:Bone Mineral Density Screening of Well WomenBritish Columbia Office of Health Technology Assessment 1117. Kaufert, P.  Menopause as process or event: The creation of  definitions in biomedicine.  In M. Lockand D. Gordon (eds.), Biomedicine examined.  Dordrecht/Boston/London: Kluwer AcademicPublishers, 1988, 331-49.18. Kaufert, P. and Gilbert, P.  Women, menopause, and medicalization.  Culture, Medicine andPsychiatry, 1986, 10, 7-21.19. Kaufert, P. Myth and the menopause.  Sociology of Health and Illness, 1982, 4, 141-66.20. Whatley, M.H. and Worcester, N.  The role of technology in the co-optation of the women's healthmovement: the cases of osteoporosis and breast cancer.  In K. Strother Ratcliffe (ed.), Healingtechnology: feminist perspectives.  Ann Arbor: University of Michigan Press, 1989, 199-220.21. Featherstone, M. and Hepworth, M.  The mask of ageing and the postmodern life course.  In M.Featherstone, M. Hepworth, and B.S Turner (eds.), The body: social process and cultural theory.London: Sage, 1991, 371-389.22. Skrabanek, P.  False premises and false promises of breast cancer screening.  Lancet, 1985, 2, 316-320.23. Rapp, R.  Real time fetus: the role of the sonogram in the age of mechanical reproduction.  In G.L.Downey, J. Dumit and  S. Traweek (eds.), Cyborgs and citadels: anthropological interventions in theborderlands of technoscience.  Seattle: University of Washington Press, 1995, 32-64.24. Bassett, K.  Anthropology, clinical pathology and the electronic fetal monitor: lessons from the heart.Social Science and Medicine, 1996, 42, 2, 281-92.25. Kunisch, J.R.  Electronic fetal monitors: marketing forces and the resulting controversy.  In K. StrotherRatcliffe (ed.), Healing technology: feminist perspectives.  Ann Arbor: University of Michigan Press,1989, 41-60.26. Marshall, K. Prevention.  How much harm? How much benefit? 3. Physical, psychological and socialharm.  Canadian Medical Association Journal, 1996, 155, 2, 169-176.27. Nelkin, D.  The social dynamics of genetic testing: the case of Fragile-X.  Medical AnthropologyQuarterly, 1996, 10, 4, 537- 550.28. Haraway, D.  A manifesto for cyborgs: Science, technology, and socialist feminism in the 1980s.  InL.J. Nicholson (ed.),  Feminism/Postmodernism. London: Routledge, 1990, 65-107.29. Lock, M.  Social and cultural issues in connection with breast cancer testing and screening. Paperpresented at "Genetic testing for breast cancer susceptibility: the science, the ethics, the future".International Bioethics Conference, San Francisco, November 1996.30. Koenig, B.  The technological imperative in medical practice: the social creation of a "routine"treatment.  In M. Lock and D. Gordon (eds.), Biomedicine examined. Dordrecht/Boston/London:Kluwer Academic Publishers, 1988, 465-496.31. Strother Ratcliffe, K.  Health technologies for women: Whose health? Whose technology?  In K.Strother Ratcliffe (ed.), Healing technology: feminist perspectives.  Ann Arbor: University of MichiganPress, 1989, 173-198.32. Mintzes, B.  Blurring the boundaries: New trends in drug promotion.  Health Action International-Europe; 1998.33. Posner, T.  What's in a smear? Cervical screening, medical signs  and metaphors.  Science as Culture,1991, 2, 2, 167-87.34. Goffman, E.  Stigma: notes on the management of spoiled identity.  Englewood Cliffs, New Jersey:Prentice-Hall, 1963.

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