Pink Ribbon Blues by Gayle A. Sulik: Book Review

Pink Ribbon Blues: How Breast Cancer Culture Undermines Women’s Health. Gayle A. Sulik. OxfordUniversity Press. 2011. 402 pp.

The forward for Pink Ribbon Blues: How Breast Cancer Culture Undermines Women’s Health authored by Bonnnie Spanier PhD, as a microbiologist and molecular geneticist, frames Gayle Sulik’s book as providing “an authoritative, evidence-based approach to distinguishing well-grounded hope from misleading hype,” (pg. viii).  The Pink culture is described as ubiquitous, this statement does not overreach today’s pink climate, the headlines on the internet contain a pink ribbon, your kitchen appliances now come in the appropriate shade of pink, steering wheel covers sport the ribbon, logos pertaining to pink cover collegiate bodies walking to class…. It is everywhere, and for breast cancer ‘survivors’ like my mother this is overwhelming and unwanted external stimulus. Sulik uncovers the optimistic face of breast cancer and the statistical manipulation required to sustain the ‘pink’ optimism.  Mortality rates for women have not changed in fifty years despite the not so ‘new’ progress in treatment and detection while genomics and protemics confuse and obscure twistable data towards the ‘tyranny of cheerfulness” while examining the morality of corporation participation in further embodiment of human medicalization, discourages analyzing the voices that are missing or silenced by this pinked culture. Sulik herself puts it this way; “Lives are at stake. The plausibility of reaching that goal (or ‘cure) has been diminished not through lack of effort, investment, visibility, or will but through misdirection and distraction,” (pg. xiv). Sulik explores the misdirection and distractions and allows those silenced to speak and the missing to be found in an accepting space that does not require a ‘tyranny of cheerfulness.’ Through research and encouragement of co-writers she confronts a challenge of moving outside of the pink box to analyze health information that can empower and or pressure patients into utilizing treatments that may not improve quality or quantity of life.  It is the ‘quality’ that Sulik focuses on as the goal for any sustainable life.

Sulik’s first chapter frames the question; ‘What is Pink Ribbon Culture?’ Her use of visually loaded descriptors is eloquent in her articulation of a doctor’s office maintaining an ambiance of an ‘ultra-feminine pink kitsch’ referencing the ability of pink ushering women backwards into an infantile innocence where it is acceptable to sell grown women ‘pinked’ stuffed animals while men with prostate cancer are not given Mattel toy cars with blue ribbons on them.  This infantilizing bleeds over into every aspect of breast cancer treatment’s promotional consumeristic aura.  The kitsch is an appropriate descriptor of this phenomenon; the direct to consumer advertising has potentiated this kitsch aesthetic. Suvivorship becomes a rite of passage to return these women back to adulthood after the regression to innocent childhood through the transformative powers of disease and its ability to transcend their previous existence into an enlightenment of survivorship.  The transformative qualities of disease create a level of pride earned by successful completion of this ‘rite of passage.’ Sulik places research agendas, promoting profitable systems of screening, pharma and consumerism as counterproductive and in no way reflective of the breast cancer ‘survivor’ experience. Advocacy does not erase the ugly reality it only silences it through maintaining a stigma against ‘bad’ attitudes that undermine the ‘tyranny of cheerfulness. “Sober accounts that reveal realism, cynicism, ongoing struggle, or death often fall on the margins,” (pg. 14).

Breast cancer is not a unitary ‘pinked’ experience nor is the movement unitary yet the facade creates a ‘pinked’ unitary norm.  Gender roles designated at birth by the traditional painting of a little girls room pink creates the ideal of pink enhanced through cultural norms of innocence, nurturance, sensitivity, support and an awareness that expands and reinforces societal gendered expectation through a simple recognition of the color pink.  “Since breast cancer places the social integrity of a woman’s body in jeopardy, restoring the feminine body (or at least normalizing its appearance) is a sign of victory in the war on breast cancer,” (pg. 15). The dichotomy of protecting ‘pink’ values is championed by the war analogy.  Historically women and children are collateral damage outnumbering the deaths of actual acknowledged war related deaths; it is an irony here that breast cancer that kills more women than men is used to sustain a ‘pink’ war attitude.  Feminine and masculine aesthetics merge to create the survivor.  ‘Pinked’ gender norms expand to include strength, courage, and aggressiveness forged through a battle returning victorious, revitalized and ultimately transcended.  Women are better for having had breast cancer. Tragedy can, has and will be utilized to create opportunities for profit through the vehicles sympathy and empathy. Narrowing the expectations of breast cancer through pinking creates specific values and ideas about normalization creating an invisible disease.  Audre Lorde’s army of one breasted or no breasted women does not rise up to defend these women, they are hidden behind and under the wigs and prosthetics erasing the evidence of any war.

The history of breast cancer is developed in; Chapter 2 The Development of Pink Ribbon Culture.  Breast cancer began as socially stigmatized deviation that the ‘victim’ bore some level of responsibility for.  This assumed deviant behavior responsibility is not an expired notion.  Women still carry a personal form of doubt about what causes breast cancer.  Science has not found the silver bullet explanation and the community of breast cancer has difficulty seeing cause in pyramidal effects. “In addition to high mortality and a corresponding fear that breast cancer was synonymous with a death sentence, the taboo surrounding breast cancer intensified medical and social mores that promoted women’s dependence on paternalistic medicine,” (pg 27).  Outreach communities and bodies of support for breast cancer patients with forums of information and funding raising abilities for a deviant disease was unthinkable. The Breast Cancer Movement created an atmosphere reversing these preconceived notions.  The 1970’s were the decade of empowerment following a decade of uprising demanding empowerment.  Medical knowledge began its public debut through information sharing and informed patient doctor relationships.  Following in the war analogy the Department of Defense Peer-Reviewed Breast Cancer Research Program of 1993 began active participation in ‘defeating’ breast cancer and the growing community of a known breast cancer population, this growing acknowledged population began an erosion of the stigma surrounding the disease.  An optimistic ‘culture of survivorship’ takes root and flourishes through the birth of the pink ribbon that merged advocacy and industry. Medical Consumerism fosters the informed patient consent though Sulik continues to question the validity of the information allowed to be dispersed to the reality of censoring information to steer or manipulate the desired decisions. The 1970’s maintained radical mastectomies that are questioned today as possibly inappropriate health care, “the results were debilitating and produced no real health benefit,” (pg. 33).

Aesthetics and normalization had its foundation in Victorian etiquette.  “Breast cancer was characterized to be a malady of the weaker sex, just another female problem that resulted from women’s reproductive malfunctioning, negligence, sexual impropriety, or some other undisciplined behavior,” (pg. 36).  This was the basis for stigmatization and created a space of assumed accountability and punishment. A multitude of programs were developed from the 70’s that propagated information in censored ways.  “Reach to Recovery even forbade volunteers from discussing medical information to avoid contradicting doctors,” (pg. 38). Focus remained appropriate to Victorian standards a white, heterosexual, and upper class discouraging access here to multitudes of women, just as first wave feminism did. Breast cancer ‘survivors’ were expected to normalize and appear ‘happy, whole, restored, and better than ever.’

Sulik presents three key factors to what is getting in the way of the eradication of breast cancer.  “The known risk factors account for only thirty percent of breast cancer cases,” Secondly “Pink ribbon culture omits, marginalizes, or downplays environmental factors, even though individual breast cancer advocates an grassroots breast cancer organizations have increasingly focused on the environmental links to breast cancer,” Thirdly “Big Pharma uses advertising to exaggerate the benefits of their products, conceal risks, and expand their market base, even though the benefits of chemotherapy are often fewer than we think,” Resulting in a booming cancer industry that performs ‘proper’ citizenship with profits “with the goal of dominating the market, pink ribbon culture provides the organizational structure and cultural resources necessary to gain consumer loyalty and public trust while taking advantage of the good will and intentions of individuals who would like to do something about breast cancer,” (pg 62-63).

The dichotomy created by the pink ribbon is discussed in; Chapter 3 Mixed Metaphors: War, Gender, and the Mass Circulation of Cancer Culture. “Forcing sides in the war enabled the emergent cancer culture to blame women who did not engage properly in battle, castigating women who did not follow the commands of medical authorities,” (pg. 74). Ambiguity is met with the fear of uncertainty creating unmanageable issues that were unacceptable to the ‘pink’ culture, adhering to the business rule of ‘know the answer before you ask the question.’ Culture values are higher for the healthy, normal and pure, while no one fits these categories, all of us only being able to find unity under a title of ‘mutant’ where the abnormal, unhealthy and polluted reside as a population thinking that we are normal even though we acknowledge personal variants that move us away from normal.  Lance Armstrong is brought into play here by Sulik to demonstrate the male ethos of the American Cancer Culture in contrast to Gilda Radner’s female appropriate ethos exemplifying generosity, inspiration and hope as pink femininity is maintained. Sulik uses the term ‘pink femininity’ to describe an assumed softness, innocence, dependence, and virtue of girlhood and true womanhood as they are posed and defined by female deviant traits of opposition to independence, cunning and manipulative seduction. “Pink ribbon culture reminds women that the problem of breast cancer can be solved if women know their place and do what they’re told,” (pg. 99). The She-ro becomes Sulik’s ultimate ‘survivor’ who knows her place and does exactly what she is told exemplifying the perfectly pink role model.

Sulik begins Chapter 4 Consuming Pink: Mass Media and the Conscientious Consumer with “In modern capitalist society, everything has its price,” (pg. 111).  Samantha King’s Pink Ribbons, Inc. is cited throughout Sulik’s writing coming to focus in this chapter.  Women magazines reinforce the ‘pink’ attitude awareness and support for the ‘cure.’  Early attitudes toward health allowed doctors to decide what their patients should or should not be told.  Magazines printed disclaimer statements following guides to self breast examination such as “intended to help you know more about your breast, but not to help you make judgments about your health.  Leave that to your doctor,” (pg. 117). Women’s actions limited to established medical ideals about the feminine body that did not allow for any questioning establishing dependence on men, doctors and husbands. Two events that are credited for expanding and creating ‘The Breast Cancer Audience’ are the 1985 National Breast Cancer Awareness Month and the 1992 branding of breast cancer with the pink ribbon. “Cultural representations (including advertisements, promotional material, and mass media) are a dimension of social reality in which people learn what should frighten them, offer them hope, and make them feel good about themselves and their situations,” (pg. 125).  In 2007 Komen redesigned the pink ribbon into a form that they could patent along with a ‘cure’ logo.  Corporation competition demanded ribbon availability at the price of a donation and Komen desired to distinguish themselves from generic donation.  The ribbon propagates, sustains and expands appropriate ‘pink’ attitudes and actions.

“The absolute risk of dying from breast cancer as decreased about 0.05 percent from 1990 to 2005.  Yet a woman diagnosed with invasive breast cancer gets more treatment spends more money, and has about the same chances of dying from the disease as she did 50 years ago.  Why aren’t we winning the war?” (pg. 1  59).  Sulik asks this question in Chapter 5 Consuming Medicine, Selling Survivorship, after already providing the answer.  The ‘cure’ would collapse and multibillion dollar business, why would they want a ‘cure.’ “The force of profitability of breast cancer detection and treatment cannot be ignored as a key element of society’s failure to eradicate breast cancer,” (pg. 160).  Prevention is rarely advocated in these circles although society is applying pressure to reverse this standard.   Mammography exposes women to 5 years of radiation if the protocol of one every two years starting at the age of 40 is followed.  The Institute of Medicine reports that 75% of ‘positive’ mammographies are false positive, and that they miss on average 25-40% of cancerous tumors,” (pg. 181). These errors lead to over diagnosis, under diagnosis and overtreatment. The cost benefit analysis leads one to believe that screening may not be ‘worth’ it. General Electric’s revenues from mammography increased from $3 billion in 1997 to $9 billion in 2007.  Pharma statistics paint a similar picture only exchanged billions for trillions.  The amount of money produced through the ‘disease’ of breast cancer with minimal change in mortality rates is a sobering reality supported by Sulik’s data.

Chapter 6 Under the Pink: Optimism Selfishness, Guilt and Chapter 7 The Balancing Act, are emotional personal stories of women that either adhered to the ‘pink’ rules or were deviant, supporting Sulik’s previous 5 chapters with analyzed testimony. Sulik develops the Feeling Rules.  Feeling the Rule I: Optimism (Incorporation of the She-ro and Rejecting the She-ro) advocates normalizing, avoiding complaints and empowerment; Feeling Rule II: Selfishness (She-roic Selfishness (i.e., Rational Coping Strategy) and Selfishness as Confessional) promoting sisterhood, symbolic activities and transformation supporting mental health and Feeling Rule III:  Guilt (The Inadequate She-ro, Embodied Social Stigma and Family Disruption) failed she-ro attempts, embodied social stigma and being a burden.  These rules access how a woman should or should not feel or act, and the consequences of following or deviating.

“Today’s breast cancer culture dictates the terms of women’s shared experience in ways that marginalize those who do not passionately participate and cheerfully comply with the culture’s rules of survivorship.  There is no room for lackluster support, contemplation of scientific controversies, inquiry into conflicts of interest between cancer advocacy and the cancer industry, alternative ways of coping that do not involve pink consumption, or public health strategies that do not rely on the mass proliferation of screening programs,” (pg. 274).

Truth is sought out and defined in; Chapter 8 Shades of Pink.  The truth presented by Pink Ribbon Blues is the silenced and marginalized section of women that are left out of the perky pink parade.  War remembers the victors and conquerors not the fallen or the unpopular, or as the old radio talk show celebrity Paul Harvey used to say “and now we know the rest of the story” that Sulik is unveiling.  The rest of the story for breast cancer exists underneath of and pushed out to the margins waiting for their time and their voices to be heard.  The women whose experiences are exhibited here speak of the inaccuracy of being a survivor, they won’t feel that they have survived unless their death is caused by something else and they do not wish to survive, they wish to live.  These sentiments echo the message that Audre Lorde gave voice to in the 1980’s.  She feared that normalization and the dogma of appropriate cause and effect relationship between women and breast cancer would be exploited for profitability.  Sulik confirms Lorde’s fears.

The ideology that being against pink ribbons translates to being against women with breast cancer is resituated in; Chapter 9 Rethinking Pink Ribbon Culture.  We can think of the yellow ribbon here as well. Just because you are against the war does not default to a reality that you’re against the solider.  Anti-war sentiment can and have been taken as a personal assault towards the soldier and the soldier’s family, this may not be accurate, as the soldier is ‘victim’ in the machinery just as the breast cancer war ‘victim’ is.  Presenting an anti-war against those in charge of said war could present a new avenue that is needed to change the tide in favor of those ‘victims’. “The worst thing a person can ask about any war is whether those who died, died in vain,” (Sulik, pg. 363).

Sulik’s arguments are well placed and grounded.  She utilizes a variety of sources and experts to evaluate the breast cancer culture that has grown and continues to grow at amazing rates.  The book is stimulating and readable for most who are interested in ‘the rest of the story’. This book is a productive addition to any woman’s library.

For more of January

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