The divergent times of prognoses and mutation

Below is part of a book review I did, the conclusion that discusses what the book did not. I wrote it a while ago, and assume it’s been held up in the journal’s editing processes. But since hearing of a friend’s diagnosis and surgery relating to cancer, I thought I’d post it here as we wait to hear of a prognosis.

[…] In Les temps du cancer (1999), Maria Ménoret argued that time, otherwise synonymous with evolution and therefore mutation, is perceived by patients as both distended (as with waiting for test results) or reduced with regard to the future. In other words, part of this involves the tempo of testing, labour processes within hospital and laboratories, and so on. […]

Clinamen 2013, Céleste Boursier-Mougenot acoustic installation, National Gallery of Victoria.

Clinamen 2013, Céleste Boursier-Mougenot acoustic installation, National Gallery of Victoria.

Which raises the question—if crisis has become norm—what, if any, sense is there in continuing to talk about the abnormal? Indeed, George Canguilhem’s The Normal and the Pathological (1989) presents this very problem in the context of a discussion about the eclipse of qualitative theories of disease (and therefore cure) by quantitative measures. According to Canguilhem, where pathology had once been viewed as an ontologically distinct state from that of health, from the 1800s illness became increasingly defined as a measurable deviation from a norm. Disease and health were no longer seen as antithetical qualities but, instead, approached through the lens of deviation, frequencies, averages and anomaly.

Yet the shifting epistemologies of disease do not exhaust the disease, and this is particularly so in the case of cancer because it is remarkably difficult to distinguish between normal and abnormal cells. The definition of cancer—not a specific and diagnosed cancer which would assume a singular body and clinical context, but cancer—is neither formal nor substantive, and to that extent barely a definition at all. Characterised as a disease caused by the unregulated division of abnormal cell tissue, the distinction between normal and pathological cell division is not so easily discerned in either epistemologies of cancer or the treatments associated with it. Because this distinction has proved troublesome to pin down, in practice the emphasis has fallen to treatments that are far less regulatory of excessive cell division (as the routine definition of cancer might imply they should be) than they are indifferently cytoxic. Conventional chemotherapies, extrapolated from the effects of mustard gas campaigns in the trench warfare of World War One, do not distinguish between normal and pathological cells. They inhibit rhythms of cellular regeneration in the entire body, from hair, skin, saliva, to tissue and blood cells. Likewise, radiotherapies burn subcutaneous tissue, irrespective of whether that tissue is healthy or not. The art of these techniques lies in the fine measure and direction of a series of doses, recommendations based on statistical projections and classifications; and each cancer treatment is simultaneously treatment, experiment, a point in data collection and analysis that, in turn, informs subsequent doses. Surgical interventions, for their part, are always preoccupied with locating the margin between healthy and diseased tissue—a difficult thing to do with precision.

Put another way, there is no qualitative distinction between normal and pathological cell division outside the context of a specific body—and, for that matter, outside a diagnosis in an initial clinical encounter. Cancer does not retain an ontological consistency as pathology, as pathos, outside the context of an individual organism. Around its diagnosis, however, increasingly multi-dimensional arrangements of health care and biometrics have emerged, or as Peter Keating and Alberto Cambrosio have put it (2003), platforms of biomedicine. As a meshing of medicine and biology, biomedicine reduces a “pathological singularity” to a “biological continuum” (2003, 61).

Yet one of their illustrations of the epistemological gap that, despite this reduction, continues to exist between these two terms—and which has driven an increasing complexity in both aetiologies of cancer and biomedical platforms—is the pap smear test. Invented by George Papanicolaou in the 1920s, the pap smear test is not diagnostic tool for cervical cancer, but a classificatory schema. Indeed, its use was resisted in the history of medicine to the extent that it did not involve making a distinction between pathological and normal cell tissue. Keating and Cambrosio emphasise the changing and conflictual labour processes in the history of biomedicine—in the laboratory, clinic and hospital, and as the obstinate expression of “the expert judgement of a pathologist” which “remained singularly resistant to automation (2003, 58) within that milieu. Their study of emerging biomedical platforms concludes by arguing that for their regulation so as to “provide a common measure” (2003, 258), but it nevertheless illuminates the extent to which the conflicts over labour and management processes presume an unreliable conflation between classificatory systems and life.

From an evolutionary perspective however, mutations are a biological fact and integral to its concepts of time—which is to say, there is no concept or vocabulary of pathos. From a social perspective by contrast, pathologies can only be expressed as norms derived from the curve around averages. So while vitalist concepts of society are inclined to present norms in positivist, if not always positive terms, there are far fewer illusions about the ease with which it is possible to distinguish between norms and pathologies in cancer diagnoses and treatment. Hence, the tendency since the late 1960s toward multi-dimensional cancer treatment and care, national cancer centres, or biomedical platforms.

Yet in the individual case, the law of large numbers can be determinative (not least insofar as it shapes health care systems, conditions access, treatment protocols and standards, shifts outcomes and creates them), but it cannot tell you what will happen in that case. Risk is distributed, as is uncertainty. Mutations pose an epistemological problem that has informed the developments from humoural to cellular to biochemical to informational theories of pathogenesis but, at the same time, knowledge, particularly that derived from extrapolations of frequentist norms, simply cannot explain those anomalies which biological scientists call mutations. In other words, even within the cramped conditions of disease management, I do not see how the living are reduced to being “the dead with respite,” to borrow a phrase from Cangilhem (1989, 263).

 

References

Canguilhem, Georges. The Normal and the Pathological. New York: Zone Books, 1989.
Keating, Peter, and Alberto Cambrosio. Biomedical Platforms : Realigning the Normal and the Pathological in Late-Twentieth-Century Medicine. Inside Technology. Cambridge, Mass.: MIT Press, 2003
Ménoret, Marie. Les Temps Du Cancer. Paris: CNRS, 1999.

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