This blog is based largely on a recent paper in the
Perspective series of the prestigious New England Journal of Medicine by US
cardiologist Lisa Rosenbaum, entitled:” ‘Misfearing’ – Culture, Identity and
Our Perceptions of Health Risks”[1].
First let me explain the term “misfearing”.
It is characterised by two attributes. It describes the widespread human
tendency to base fear on emotive reasons and not on fact. It is also
characterised by fear of dreadful events, which catch headlines and which are
quite often rare (plane crashes, nuclear accidents, severe weather, HIV-AIDS
etc.) rather than by fear of the familiar such as heart disease, obesity,
smoking which are common and which occupy a great % of the health budget.
Rosenbaum discusses this concept of misfear in relation to women’s health and
specifically female cancer and female heart disease.
The majority of women would say that breast cancer is a
bigger threat to women’s health than heart disease. However, the facts are the
reverse, hence the concept of misfearing. In the US, over the period 2006 to
2010, the number of cases of all
cancers in women was 2.8 million. The comparable figure for heart disease was
12.7 million, 4.5 times greater. The data skeptics will immediately argue that
the heart disease data are flooded by statistics on high blood pressure, high
blood cholesterol as well as actual cases of heart attack. So let us consider deaths from cancer and
heart disease in women. During this same period, 40,000 US women died from all forms of cancer. The comparable
figure for deaths from heart disease was 410,000. Now, as regards mortality,
the difference between all causes of female cancer and female heart disease is
10 fold. Ten times as many graves of
women who died of heart disease compared to all forms of cancer combined.
Why therefore is female health to a considerable health
dominated by cancer, specifically breast cancer? The answer is largely
sociological. But first consider the power and emotion behind the misfear of
breast cancer. Rosenbaum points out that in 2009, the US Preventative Services Task
Force recommended that the frequency of mammography in younger women should be
reduced noting “…the potential harms
outweighed the benefits”. The reaction among women was powerful. USA today
conducted a poll of women aged 35 to 49 years and 84% intended to ignore the
recommendations. So powerful was the backlash that the Affordable Care Act
ignored the task force’s recommendations requiring insurers to base coverage on
previous screenings. This perpetuated in law, a policy that the experts deemed
did more harm than good. Rosenbaum writes: “Have
pink ribbons and Races for the Cure so permeated our culture that the resulting
female solidarity lends mammography a scared status? Is it the issue that
breast cancer attacks a part of the body that is so fundamental to female
identity that, to be a woman, one must join the war on this disease?”
I Googled the term “Famous women who have had breast cancer”
and from the 20 listed, here are the ones whose names I recognise: Singers
Kylie Minogue, Olivia Newton John, Sheryl Crow, and Carly Simon, actresses
Cynthia Dixon of Sex and the City, Dame Maggie Smith, and Angelina Jolie. I did
the same for “Famous women who have had heart disease” which oddly was dominated
by men but I found one female name I recognised, Nancy Reagan. To me, it is
understandable why women care more about breast cancer than heart disease. It
is a disease that is unique to women and to womanhood. It is thus an extremely
emotional thing. Heart disease is for all humanity. However emotional the issue
of breast cancer may be, the census of the dead shows that female heart disease
is ten times that of all female cancers combined. Men also have their emotional
links with a cancer that has an incidence rate way below that of heart disease,
namely prostate and testicular cancer. Indeed it’s a man thing to grow a
moustache for a man’s cancer charity in “Mowvember”.
Rosenbaum explores her explanation in our commitment to cultural
groups. It is a distinctive mark of human society that we alone cooperate
beyond families and into groups and societies. What we lose as individual or
selfish rights, we gain as communal rights[2].
Group identity is central to human society. For a group to thrive, it needs to
support and reinforce the very reasons why it is a group. Misfearing is based
not on fact but on emotions. It is what keeps opponents of pylons, fracking,
intensive agriculture, fast food and the like together. She ends her article
thus: ”Certainly, understanding of one’s
risk for any disease must be anchored in facts. But if we want to translate
into better health, we may need to start talking more about our feelings”.
Years ago during my two decades as a member of the EU Scientific
Committee for Food, I learned the difference between fear based on facts and
fear based on emotions. The social groups opposed to food additives and
pesticides share this common misfear theme and pouring facts into this group is
a waste of time. However I might see their “facts” as nonsense or unfounded or
disproved, they see them as central and moreover, they see mine as threatening
to the central belief of their group.
So how does public health and in my case, public health
nutrition, tackle the misfearing among women who wrongly, if facts are the
basis of truth, put breast cancer well ahead of heart disease as a threat to
their health. Imagine if a mammography test required a prior blood lipid
profile test and an ambulatory test? Would that not capture the problems of
heart disease in women? Maybe so but the majority of cases of heart disease in
women are among the poorer and the more socially disadvantaged. And thus the
answer is not so obvious. Diet and lifestyle changes have a far greater link to
the reduction in risk of heart disease than they do of most cancers. We need to
advertise the fact that for every female death that arises from any cancer, ten
times more women will die of heart disease. Simple measures such as blood lipid
screening and blood pressure monitoring must be promoted among women. And the promotion of healthy eating for heart
disease prevention needs to gain as much print and social media as that which
links diet and cancer, where, like it or not, the strength of evidence is much
weaker.
