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Bone mineral density (BMD) testing : who needs it? who wants it? Kazanjian, Arminée, 1947-; Green, C. J. (Carolyn Joanne), 1956-; Bassett, Kenneth, 1952- May 31, 1997

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Centre for Health Servicesand Policy ResearchBONE MINERAL DENSITY (BMD) TESTING:WHO NEEDS IT? WHO WANTS IT?Arminee KazanjianCarolyn J. GreenKen BassettBCOHTA 97:3C MAY 1997B.C. Office of Health Technology AssessmentDiscussion Paper SeriesTHE UNIVERSITY OF BRITISH COLUMBIABone Mineral Density (BMD) Testing:WHO Needs it? WHO wants it?Kazanjian A, Green CJ, Bassett K.B.C. Office of Health Technology AssessmentCentre for Health Services and Policies ResearchS-184 Koerner Pavilion - 2211 Wesbrook MallThe University of British ColumbiaVancouver, B.C. V6T lZ3Tel.: (604) 822-7049Fax: (604) 822-7975PRESENTED AT THE 13TH ANNUAL MEETING OF THE INTERNATIONAL SOCIETYOF TECHNOLOGY ASSESSMENT IN HEALTH CARE HELD IN BARCELONA, SPAINMAY 25-28,1997.1The aim of BMD testing is the early detection and treatment of women prior toirreversible bone mineral loss. Large cohorts of peri- and post-menopausal women are beingoffered the test; unless they have retained the bone mineral density of a 20 or 30 year old, mostwill eventually be labelled with osteopenia or osteoporosis and be eligible for hormonereplacement therapy because "normal" bone mass is defmed in terms of the bone mineral densityof healthy women of reproductive agel.There is mounting evidence that BMD measures have a very low positive predictive value.A BMD measurement is a risk factor for, not the equivalent of, a clinical disorder. Most womeneligible for BMD testing will never suffer from symptomatic hip fractures'. Risk of hip fracture isdependent not just on bone mineral density, but also on proneness to falling and the ability toprotect oneself from injury from a fall. Factors such as limited physical activity, poor vision, fairor poor health, psychotropic drug use, being age 80 or over, and having a prior postmenopausalfracture, have been found to be stronger predictors of symptomatic hip fractures.Moreover, claims made by proponents of a positive effect on women's lives followingBMD testing are not supported by the research evidence. On the one hand, women who are pre­menopausal, those who do not identify themselves as members of the designated "high risk" ethnicgroups, and those who test normal for BMD, misguidedly may not take preventive measures toenhance their bone health. On the other hand, there is evidence that women identified as being athigh risk on the basis of BMD testing modify their lifestyle inappropriately by restricting theiractivity level; a strategy which could decrease BMD.Given that the evidence on effectiveness clearly does not support current patterns ofdiffusion, what are the forces driving BMD testing? WHOs interests are being served?This paper takes a critical approach to health technology assessment. Such an approachmakes central the social, economic and political contexts in which health technologies areembedded. The task of this paper is to make explicit the hidden assumptions about aging women'sbodies that drive the use of BMD testing. Primarily, it challenges the medical model of the agingfemale body as a diseased body, and questions the use of marketing strategies which create andcapitalize on women's fear of aging. Finally, the paper raises questions about the ethicalimplications of proliferating technologies for economic and political motives at the expense ofI WHO Study Group, 1994.~e greatest burden of suffering occurs in elderly postmenopausal women; it does not follow that allpostmenopausal women are at risk for hip fractures. 85% of white women age 50 with a lifeexpectancy of 80 years will not suffer a hip fracture.2women's own needs and interests.Critical health technology assessmentSince the mid-1970s, social studies of medicine have examined the social and politicalcontexts in which medical knowledge is produced and applied. Medical sociology, anthropologyand related disciplines have illustrated how medicine does not merely describe a pre-existingbiological reality, but reflects and perpetuates societal relations of power.' This does not meanthat medicine is unscientific; it means that medicine and science, like all beliefs and practices, bothreflect and support the cultural values of society at large.Further to this examination of biomedicine as a cultural system, insights from feministtheory have merged with critical studies of science to question the validity and appropriateness ofmany preventive technologies for women." There is a growing volume of evidence that thepromotion and use of preventive technologies may be driven primarily by economic motives,rather than the health care needs of women': the pharmaceutical industry, the medical devicesindustry manufacturers, and the researchers these engage, all depend for their incomes onexpanding the scope of medical intervention. These powerful commercial interests place heavyand continuing pressure on policy makers, caregivers and patients to routinely use technologieswhich are deemed preventive for large cohorts of women, despite the lack of demonstratedeffectiveness,"Increasingly, feminist critiques are challenging the ease with which life processes such asmenopause are being medicalized' and questioning women's placid acceptance of motives, which3See for example, Armstrong 1983; ComarofI 1985; Ehrenreich 1978; Frankenberg 1980, 1986;Foucault 1975, 1979; Latour and Woolgar 1979; Lock and Gordon 1988; Scheper-Hughes and Lock1987; Taussig, 1987; Wright and Treacher 1982; Young 1980, 1982,1983; 20la 1978.4See Casper Koenig (1996) and Franklin (1995) for recent reviews of this literature.5See for example, Haraway (1995), Martin (1994), Rapp (1995, 1996), Strathem (1992a, 1992b),Traweek (1993) and Wajcman (1991).6This has been shown for ultrasound (Rapp 1993), electronic fetal monitors (Bassett 1996, Kunisch1989), predictive genetic screening (Nelkin 1996, Nelkin and Tancredi 1994), and mammography(Gifford, 1986), among others. See Koenig (1988) for a clear introduction to these issues, andRatcliffe (1989) for a review of the early literature.7Beyene, 1989; Brown and Kerns 1985; Gifford, 1994;Lock, 1993.3don't relate to women's health needs, as the main determinantof technologydiffusion.This research shows that BMD testing has been effectivelydiffused because it is marketedand promoted in ways that draw on, and reify, three trends in Euro-Americanpopular culture: (1)the medical model of the aging female body (2) the fear of aging and its association withdependencyand immobility; and (3) the healthpreventionconsciousness in North Americansociety.Aging and diseaseSince the mid-nineteenth century,female life cycle transitions in Euro-Americansocietyhave been increasingly medicalized, interpretedby physicians as a series of events that should besubject to medical managements.Biological changes associatedwith aging are spoken about in a language of decay andabnormality. The biochemistryof women of reproductiveage is taken as the standard measure forwhat is normal and healthy; and aging women'sbodies are understood in terms of disease,"endocrine deficiencydisorder", specifically a hormonedeficiencydisease that is to be treatedwith estrogen supplements. Popular magazinearticles and books on menopausecontain essentiallythe same message",The feedback loop between popular and scientificknowledge has created and perpetuatedthe notion that the aging female body is a diseasedbody. Aging is associatedwith a cluster ofmeanings involvingemotionaland physicallosses.These losses include declining social status anddegradationof self-image,as the cultural ideal (youthfulfemininity) can no longer be met. Thesocial meanings associatedwith aging also include deeperfears of disabilityleading to loss ofindependence.Interestingly, cross-culturalresearch indicates that the associationof aging with decay andloss is a specifically Euro-Americanphenomenon. In many societies, women expect to continue tobe well and gain increasing worth and even veneration as they age and become respected elders.10BMD testing "works" in Euro-American societiesbecause it has emerged out of, andresponds to, culturally accepted norms about women's bodies and women's roles in society. Thewell- entrenchedmedicalized model of aging has paved the way for the medicalization of boneS.Kaufert 1988; Kaufert and Gilbert 1986;Kaufert and McKinlay 1985;Lock 1993.9 Lock 1993:xxxv."Beyene, 1989; Brownand Kerns 1985; Lock 1993.4mineral 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!'. In the early 1980s,most women had never heard of osteoporosis. Beginning in 1982, an education campaign wassponsored by Ayerst laboratories to create public awareness of osteoporosis as an importantwomen's health issue. The company clearly stood to benefit from increased public awareness ofosteoporosis (Ayerst manufactured Premarin, a popular form of estrogen replacement therapy)and women who sought advice from physicians about prevention might easily end up with aprescription for ERT.The Ayerst campaign included radio, television, and magazine coverage, including articlesin Vogue, McCall's and Reader's Digest. As Whately and Worcester explain, by the mid-1980s, women have not only heard of osteoporosis, but they had become frightened of theseeming inevitability of postmenopausal hip fractures and of a life of disability and dependency"Burden of suffering statistics have been widely misused to "sell" the fear of osteoporosis,reported in ways that play on images of immobility, dependency, and even death. An Americantelevision advertisement for a calcium supplement shows a healthy thirty-year-old womantransformed to a stooped sixty-five-year-old in thirty seconds"A popular guide to preventingosteoporosis stateD:The consequences of hip fractures can be devastating. Fewer than one-half of allwomen who suffer a hip fracture regain normal function. Fifteen percent dieshortly after their injury, and nearly 30 percent die within a year".Once the fear of becoming disabled/diseased has been created, women are made to feelpersonally accountable for future illness and are encouraged to take appropriate measures toprevent such disease. ISPrevention consciousness11 Gifford, 1986; Nelkin 1996,Strabanek, 1985; Susman, 1994.12 Whately and Worcester 1991:203.13 Giges 1986.14 Notelovitz and Ware 1982.IS Nelkin, 1996; Whately and Worcester 1991.5In the United States and Canada, increasing emphasis is being placed on a particular modelof health promotion that emphasizes lifestyle change and individual responsibility. Patients areencouraged to take more control in the clinical encounter (for example, patients are encouragedto review their medical charts and x-rays; increasing emphasis is being placed on informedconsent) and individuals are being held accountable for behaviours which place them at risk forpoor health. Societal responsibility (for example, ensuring adequate nutrition and attention toenvironmental hazards), in stark contrast, receives much less".Along with diet, exercise, and stress reduction, BMD testing has been promoted andunderstood as part of the package of how to prevent the health problems associated with aging".By 1990, HRT had developed into a massive industry showing annual sales in the range of fourhundred sixty million dollars!8. In 1992, Ayerst's estrogen, Premarin, was reported to be thefourth most prescribed medication in the United States". In 1993, the World Health Organizationredefmed osteoporosis, making it dependent on bone mineral density measures. The redefmitionemerged from a four day meeting financed by Rorer Foundation, Sandoz Pharmaceuticals, andSmith Kline Beechanr",In the time leading up to the WHO redefinition, drug companies were poised and waiting,recognizing that a massive potential target population existed and was growing. Given that in1992 only an estimated 15% of the female population in America received some form of HRr!,the economic implications of the WHO redefinition are staggering. For example, in June, 1995the company Frost and Sullivan reported that Europe's osteoporosis market is growing, and thatthe growth was being fuelled by increased life expectancy and by the more widespread acceptanceof hormone replacement products by menopausal women". The company reported that in Europealone, the HRT treatment market was at $379 million in 1995; and will rise to $580.2 million by2000. The total market for osteoporosis treatment (comprising preventative as well as curativemeasures) in 1995 was valued at $1.05 billion, and forecast to reach $1.55 billion by the year2000 (Ibid.).Since the WHO redefinition, drug companies have been particularly aggressive and visibly!6 Crawford 1984; Gordon 1988.17 Whately and Worcester 1989.18 Lock 1993:350.19 Office of Technology Assessment, 1995.2OWHo Study Group, 1994.21 Office of Technology Assessment, 1995.22 Marketletter, June 12, 1995.6hostile to one another in their promotional materials, each vying for the largest share of thepotential market for a combined estrogen-progesterone product". The Osteoporosis Society ofCanada (OSC) has recommended that reports ofBMO measurement should "refer to the WorldHealth Organization's recommended definitions of osteopenia and osteoporosis'f", The OSC'srecommendations emerged from a series of consensus conferences, all sponsored bypharmaceutical companies, and were published as a (non-peer reviewed) supplement to theCanadian Medical Association Journal". In the United States, the pharmaceutical industry iscurrently lobbying the American government with a plea that estrogen therapy is necessary to thecontinued health of all women aged forty and over. Most of the specialists whom the U.S.government has called on as advisory consultants are the recipients of research money from thesesame drug companies".WHOs needs are being served?This examination of BMO testing demonstrates how market forces may create andcapitalize on a climate of risk and reassurance, driving the use of health technologies irrespectiveof whether they lead to improved health outcome. The implications of the WHOs redefinition ofosteoporosis for the lives of women is as yet largely unexamined.At the very least, the testing of large cohorts of pre and peri menopausal women and theirlabelling as "abnormal" in BMO is leading to an increased dependency on BMO and associatedinterventions. Repeat testing is necessary, and HRT must be administered over many years inorder to ensure that women retain "normal" levels of bone mineral density. The possible side­effects of long-term HRT are still under investigation.Psychological side effects of BMO testing should also be considered, these may resultfrom being labelled "at risk." As well as the anxiety caused by inundation of media coverageabout a "new" disease, evidence on a variety of preventive technologies has shown thatpsychological distress may result from the procedure itself?7 Goffman, in his classic work Stigma(1963), was the first to argue that being labelled affects identity and shapes the life experiences of23 Lock 1993:358-9.24 Sturtridge et al., 1996.25 Hanley and Josse 1996.26 Lock 1993:351.27 Bloom and Monterossa 1981; Haynes et al., 1978; Marshall 1996; Meador, 1994; Monk 1981;Soghikian and Hunkeler 1981.7those who are thus labelled. It is now well established that being labelled "sick" has an effect onsocial relationships and behaviours of the individual, irrespective of whether the symptoms or thedisease itself have appeared." In the case of BMD testing, being labelled affects individuallifestyles in the absence of symptoms or disease.Equally important are the broader social implications of the WHO redefinition. Beingdiagnosed as abnormal in BMD establishes risk, not a clinical disorder. Low bone mass isasymptomatic and not problematic apart from fragility fractures. The trend toward definingosteoporosis, entirely on the basis of BMD diagnostic criteria, ends up transforming a risk factorinto a disease entity. As Gifford has argued for breast cancer screening, the very act oftransposing the concept of risk from the probabilities of epidemiology into clinical practice meansthat risk is interpreted as something which the patient suffers. Being at risk in itself comes to meanbeing diseased."As the onus for not getting sick falls increasingly on the individual, and individuals strivemore and more to reach the ideal of normality, the area including 'normality' is shrinking, and thearea of 'abnormality,' or less than perfect health, is increasing. The proliferation of diseasecategories and labels in medicine and psychiatry results in even more restricted definitions of"normal". This leads to increasing numbers of people being labelled abnormal, sick, or deviant",Popular and scientific notions of normality, risk, and prevention are continually being transformed,thus perpetuating the need for screening and diagnostic technologies even when they do not leadto known therapeutic solutions. Still largely unexamined are the power relations and privateinterests which are served by this health dynamic. 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