Dear Alistair Richards,
My name is Christina, I’m studying MSc Biosocial Medical Anthropology at University College London. My discipline examines the many different factors – cultural, socioeconomic, political and biological – that contribute to a person’s susceptibility to disease and understandings of health. I am a strong supporter of the amazing work North West Cancer Research (NWCR) does to better understand and address how cancer occurs in North-West England and North Wales. It is an issue that is incredibly close to my heart. I am writing to you as CEO of NWCR because I’d like to share some personal experience and academic research with you that could offer interesting and useful perspectives to the work your charity is doing, which could in turn help you to achieve the goals set out in your 2022-27 Strategy document (NWCR, 2022c).
The week this letter was written, my mother’s oldest and dearest friend, ‘P’ turned 58. They grew-up and went to school together in Lancashire and have remained the firmest of friends ever since. P is living with advanced bowel cancer and in her second year of ongoing treatment. She was diagnosed just days before Christmas in 2021, at which point it was already advanced. I remember the phone call; time stopped and the world fell away. The wave of sadness, frustration and anger was too much to contain. We sat and cried long after the phone call because we couldn’t make sense of it. P is young, she is really active, she doesn’t drink or smoke and she eats well – why did this happen to her?
Cruelly, bowel cancer is no stranger to our family, so there was a sense of helplessness with P’s diagnosis – why did this disease seem to continually affect people in our closest circles? Questions such as this have led me to pursue my current area of study, which has allowed me to explore the myriad of factors that can explain why certain populations have differing and/or higher incidence of certain diseases.
In your Summer 2022 blog post (NWCR), you state that the reasons why cancer patterns differently in the North West are ‘both simple and complex’ and rightly point out that the factors that impact a person’s likelihood to develop cancer range from genetic components to socioeconomic factors, such as their wealth, lifestyle and environment. These factors can also become entangled, co-influencing each other in complex ways, such as the relatively new field of epigenetics, as explored anthropologically by Gibbon (2018). Biosocial and/or medical anthropology is dedicated to tracing, unpicking and understanding how these many factors occur simultaneously. It can provide valuable insight as to why and how diseases occur, to inform better interventions for reducing and preventing ill-health. For these reasons, leading academics in the field of anthropology write frequently on the subject of health inequality, specifically the ‘upstream’ socioeconomic factors that determine an individual’s ability to make and enact informed decisions about their health (Smith et al., 2015). Other disciplines such as epidemiology go some way to identify these health inequalities, evidenced on a national level with bodies of work such as The Marmot Report (Marmot, 2020) and more pertinently for your charity, the ‘All Together Fairer’ report (Marmot et al., 2022) examining the ‘health equity and the social determinants of health in Cheshire and Merseyside’. This was commissioned in response to the heightened levels of social inequality observed in the North West which, as you well know, is unfortunately home to some of the most deprived populations in the UK.
Medical anthropologists have offered the critique that whilst disciplines such as epidemiology, which utilise predominantly quantitative methods, can describe health inequalities, they are less useful at determining their specific causes (Smith et al., 2015). Anthropology employs mixed methods approaches, but specifically utilises the qualitative technique of ethnography to truly understand the depth, nuance and variation in how certain populations live. Where statistical analysis often outlines the ‘what’ and the ‘where’, ethnography uncovers the ‘why’ and the ‘how’. As an example, Yates-Doerr’s (2015, p5-6) ethnographic makes observations of a woman in Guatemala who found governmental advice on nutrition somewhat unwelcome and difficult to adhere to for sociocultural reasons, including its impact on established standards of beauty, historically-shaped eating behaviours and the religious significance of certain words used in key communications. As more than just a statistic denoting non-compliance to government advice, this woman’s life story and lived experience can help us understand the reasons why that advice was ignored and therefore suboptimal in promoting better public health.
In your blog post, you go on to say that early detection of cancer is a critical factor in the efficacy of treatment and the prevention of mortality. In this vein, many biomedical research efforts are focusing on the development of better screening technologies, specifically the identification of new biomarkers. Through an ethnography of scientists working on early detection, Arteaga Pérez (2021) has examined this biomedical approach and the politicised drivers behind ‘seeing cancer before it exists’, which for the individual patient would create a ‘pre-cancerous’ state; a new form of medical condition or identity to understand and come to terms with. Other anthropological authors have explored the broader emotional implications that continual screening, testing and awaiting results can have on the individual (Street and Kelly, 2021 and Frumer et al., 2021).
In short, it is unwise to consider the quest for more advanced screening technologies as a succinct solution to early detection. We must also understand how these technologies will be perceived and whether people will willingly engage with them. As an example, a meta-ethnography of qualitative research into the factors influencing peoples’ decisions to attend cancer screening appointments (Young et al., 2018) highlights many factors that shed light on why uptake can be poor. Key themes include shame, fear, disgust, lack of knowledge or understanding and negative prior experiences. Under the subheading of ‘Religious faith’ it is noted that the word ‘occult’ in ‘faecal occult blood test’ (screening for colorectal cancer) was perceived as having ‘demonic connotations’. Drawing parallels with Yates-Doerr’s aforementioned observation on the inference of language in relation to faith, single words can be enough to alter a person’s perception and influence their likelihood to engage with healthcare intervention. These important sociocultural insights are gathered through ethnography and qualitative research, not through biomedical investigation.
You also make the observation in your 2022 Summer Blog Post that the rates at which cancer is detected early (at stages 1 or 2) can vary significantly from place to place. You provide the example of two towns in Cumbria, just 24 miles apart; Kendall (“famous for mint cake”) at 57.1% and Barrow (“with its ship-building and heavy industrial prowess”) at 45%. As an anthropologist, I found the inclusion of these anecdotal references for each town incredibly interesting. It hints at just how different two towns so close to each other can be; the type of work undertaken, potential exposure to environmental pollutants, influence of tourism, local diets etc. It is ripe for anthropological investigation as these factors are biosocial, meaning that they shape and are shaped by local socioeconomic and political landscapes which have direct impacts of the bodies and health of the local populations.
The medical anthropological concepts of ‘local biologies’ or the newer ‘situated biologies’ (Niewöhner and Lock, 2018), theorise that an individual’s health and body are both shaped by and shaping their sociocultural environment. Lock’s seminal work on the varying experience of menopause in Japan and North America (Lock, 1993, cited in Niewöhner and Lock, 2018) is a key example of this, demonstrating that a globally understood condition such as menopause can be experienced through entirely different somatic symptoms on a local level. From this we understand that localised populations can experience differing symptoms for the ‘same’ medical condition and/or understand changes in their bodies in differing ways, so it is important that these phenomena are understood thoroughly.
I chose to write to you today because when I was looking for answers to why P is having to live with cancer and why certain cancers seem to disproportionately affect certain populations, I came across something you said in NWCR’s 2022 Regional Report:
“…cancer cannot be effectively tackled without a highly localised approach that understands the multi-faceted, complex and evolving nature of the challenges at hand. No two villages, towns or cities are exactly alike, and so we cannot take a one size fits all approach to cancer around the country.”
It resonated with me, both personally and professionally. I want to reach out to you to advocate for the localised perspective of anthropology, and its methodology of ethnography. I believe, as you yourself have identified, that these rigorous and localised approaches are essential tools in enabling you to achieve your strategic goals for 2022-27 (NWCR, 2022c). Specifically in relation to the three key areas discussed above; tackling health inequality, facilitating early detection and understanding localised populations.
Thank you very much for your time. It would be wonderful to hear what you think.
Arteaga Pérez, I. (2021) “Learning to See Cancer in Early Detection Research.” Medicine Anthropology Theory 8 (2): 1–25, DOI: 10.17157/mat.8.2.5108 Last accessed: 20th March 2023
Frumer, M., Andersen, R., Vedsted, P., & Offersen, S. (2021). ‘In the Meantime’: Ordinary Life in Continuous Medical Testing for Lung Cancer. Medicine Anthropology Theory, 8(2), 1-26. DOI: 10.17157/mat.8.2.5085 Last accessed: 20th March 2023
Gibbon, S. (2018) “Calibrating cancer risk, uncertainty and environments: Genetics and their contexts in southern Brazil.” BioSocieties 13, 761–779. DOI: 10.1057/s41292-017-0095-7 Last accessed: 20th March 2023
Lock, M. (1993) Encounters with Aging: Mythologies of Menopause in Japan and North America. Berkeley: University of California Press.
Marmot, M. (2020) “Health Equity in England: The Marmot Review 10 Years On” BMJ 2020;368:m693 Available from: doi.org/10.1136/bmj.m693 Last accessed: 19th March 2023
Marmot, M., Allen, J., Boyce, T., Goldblatt, P. and Callaghan, O. (2022) “All Together Fairer: Health equity and the social determinants of health in Cheshire and Merseyside.” London: Institute of Health Equity. Available from: https://www.instituteofhealthequity.org/resources-reports/all-together-fairer-health-equity-and-the-social-determinants-of-health-in-cheshire-and-merseyside Last accessed: 20th March 2023
Niewöhner, J., Lock, M. (2018) “Situating local biologies: Anthropological perspectives on environment/human entanglements.” BioSocieties 13, 681–697. DOI: 10.1057/s41292-017-0089-5 Last accessed: 20th March 2023
NWCR (2022a) ‘CEO’s Blog Summer 2022’ Accessible from: https://nwcr.org/about-us/latest-news/2022/ceoblogaug22/ Last accessed: 26th June 2023
NWCR (2022b) “North West Regional Report 2022”. Available from: https://nwcr.org/media/2448/0000nwcr_northwest_regional_report-050722.pdf Last Accessed: 20th March 2023
NWCR (2022c) “Strategy: 2022-2027” Available from: https://nwcr.org/media/2303/nwcr-22-27-strategy.pdf Last Accessed: 26th June 2023
Smith, Katherine, Clare Bambra, and Sarah E. Hill (eds). (2015) “Background and introduction: UK experiences of health inequalities”, in Katherine E. Smith, Clare Bambra, and Sarah E. Hill (eds), Health Inequalities: Critical Perspectives (Oxford, 2015; online edn, Oxford Academic, 21 Jan. 2016). DOI: 10.1093/acprof:oso/9780198703358.003.0001 Last accessed: 20th March 2023
Steet, M and Kelly AH. (2021) “Introduction: Diagnostics, Medical testing, and Value in Medical Anthropology.” Medicine Anthropology Theory 8 (2): 1–16, DOI: 10.17157/mat.8.2.6516 Last accessed: 20th March 2023
UCL News (2022) “Growing social and economic inequalities across north-west England are directly impacting health.” Available from: https://www.ucl.ac.uk/news/2022/may/growing-social-and-economic-inequalities-across-north-west-england-are-directly-impacting Last accessed: 19th March 2023.
Yates-Doerr, Emily (2015) “The Weight of Obesity: Hunger and Global Health in Postwar Guatemala.” Berkeley: University of California Press. Accessible from: https://ebookcentral.proquest.com/lib/ucl/detail.action?docID=2025593 Last accessed: 20th March 2023
Young B, Bedford L, Kendrick D et al. (2018). “Factors influencing the decision to attend screening for cancer in the UK: a meta-ethnography of qualitative research.” Journal of Public Health (Oxf). Jun 1;40(2):315-339. Available from: doi.org/10.1093/pubmed/fdx026 Last accessed: 20th March 2023
 ‘Masa’ in Spanish is used to mean biological ‘mass’, but also refers to a regularly eaten foodstuff affiliated with the local religion’s story of creation. Therefore, reducing one’s ‘masa’ can present an uncomfortable concept. (Yates-Doerr, 2015, p5-6)