Robert Aronowitz

Books.

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Selected Papers.

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Contingent Knowledge and Looping Effects — A 66-Year-Old Man with PSA-Detected Prostate Cancer and Regrets

Robert Aronowitz, M.D., and Jeremy A. Greene, M.D., Ph.D
The New England Journal of Medicine , 2019; 381:1093-1096 || Link

A 66-year-old man with PSA-detected prostate cancer undergoes prostatectomy that leaves him impotent — a decision he regrets when new evidence becomes available. How can the largely social processes by which we identify diseases transform diseases themselves?

Cultural reflexivity in health research and practice

Aronowitz, Robert; Deener, Andrew; Keene, Danya; Schnittker Jason; Tach, Laura
American Journal of Public Health , 2015, 105 Suppl 3:S403-8 || Link

Recent public health movements have invoked cultural change to improve health and reduce health disparities. We argue that these cultural discourses have sometimes justified and maintained health inequalities when those with power and authority designated their own social practices as legitimate and healthy while labeling the practices of marginalized groups as illegitimate or unhealthy. This "misrecognition," which creates seemingly objective knowledge without understanding historical and social conditions, sustains unequal power dynamics and obscures the fact that what is deemed legitimate and healthy can be temporally, geographically, and socially relative. We use examples from research across multiple disciplines to illustrate the potential consequences of cultural misrecognition, highlight instances in which culture was invoked in ways that overcame misrecognition, and discuss how cultural reflexivity can be used to improve health research and practice.

From skid row to main street: the Bowery Series and the transformation of prostate cancer, 1951-1966

Aronowitz, Robert,
Bulletin of the History of Medicine, 88.2 (2014): 287-317 || Link

Between 1951 and 1966, more than twelve hundred homeless, alcoholic men from New York's skid row were subjected to invasive medical procedures, including open perineal biopsy of the prostate gland. If positive for cancer, men typically underwent prostatectomy, surgical castration, and estrogen treatments. The Bowery series was meant to answer important questions about prostate cancer's diagnosis, natural history, prevention, and treatment. While the Bowery series had little ultimate impact on practice, in part due to ethical problems, its means and goals were prescient. In the ensuing decades, technological tinkering catalyzed the transformation of prostate cancer attitudes and interventions in directions that the Bowery series' promoters had anticipated. These largely forgotten set of practices are a window into how we have come to believe that the screen and radical treatment paradigm in prostate cancer is efficacious and the underlying logic of the twentieth-century American quest to control cancer and our fears of cancer.

The rise and fall of the Lyme disease vaccines: a cautionary tale for risk interventions in American medicine and public health

Aronowitz, Robert,
Milbank Quarterly, 2012, 90 (2):250-277 || Link, Download PDF

Context:Two vaccines to prevent Lyme disease (LD) were developed and tested in the 1990s. Despite evidence of their safety and efficacy in clinical trials and initial postmarketing surveillance, one vaccine was withdrawn before the regulatory review and the other after only three years on the market. An investigation of their history can illuminate (1) the challenges faced by many new risk-reducing products and practices and (2) the important role played by their social and psychological, as distinct from their biomedical or scientific, efficacy in how they are used, and their ultimate market success or failure.

Methods: This article reviewed medical and popular literature on LD vaccines, analyzed the regulatory hearings, and conducted interviews with key participants.

Findings: Even if proved safe and effective, LD vaccines faced regulatory and market challenges because the disease was geographically limited, treatable, and preventable by other means. Pharmaceutical companies nevertheless hoped to appeal to consumers' desire for protection and control and to their widespread fear of the disease. The LD advocacy community initially supported the vaccines but soon became critical opponents. The vaccines' success was seen as threatening their central position that LD was chronic, protean, and difficult to treat. The activists' opposition flipped the vaccines' social and psychological efficacy. Instead of the vaccines restoring control and reducing fear, demand was undermined by beliefs that the vaccines caused an LD-like syndrome.

Conclusion: The social and psychological efficacy of many risk-reducing practices and products, such as new "personalized vaccines," is to provide insurance and reduce fear. Yet the actions of self-interested actors can easily undermine this appeal. In addition to evaluating the scientific efficacy and safety of these practices and products, policymakers and others need to understand, anticipate, and perhaps shape the potential social and psychological work they might do..

The Framingham Heart Study and the Emergence of the Risk Factor Approach to Coronary Heart Disease: 1947-1970

Aronowitz, Robert,
Revue d'Histoire des Sciences, 2012, 64: 263-295 || Link

The Framingham heart study is generally considered to be the first large modern cohort study of chronic disease and the major impetus for recognizing different coronary heart disease (CHD) risk factors. Using interviews with Framingham investigators and documents from the planning and early years of the study, I demonstrate that the novel methodological aspects of the study emerged without a great deal of individual agency or consciousness. Beginning as a cardiac control program similar to many older tuberculosis public health campaigns, Framingham investigators innovated in small steps in response to its changing institutional base, the needs of its various supporters and audiences, and new concepts and tools. While Framingham was crucial in uncovering CHD risk factors, the study was itself shaped by many of the same social influences which were leading to a more individualistic and quantitative style of understanding and intervening in CHD and other chronic diseases.

Decision Making and Fear in the Midst of Life

Aronowitz, Robert,
The Lancet, Volume 375, 9724: 1430 - 1431, 2010 || Link

The converged experience of risk and disease

Aronowitz, Robert,
Milbank Quarterly, 2009, 87(2): 417–442 || Link

Context: One underappreciated consequence of modern clinical and public health practices is that the experience of being at risk for disease has been converging with the experience of disease itself. This is especially true for certain chronic diseases, in which early diagnosis and aggressive treatment have led to symptom-less and sign-less disease and in which treatments have largely been aimed at altering the disease's future course.
Methods: This article reviews the historical scholarship and medical literature pertinent to transformations in the chronic disease and risk experiences.
Findings: The experience of chronic disease increasingly resembles or has become indistinguishable from risk because of (1) new clinical interventions that have directly changed the natural history of disease; (2) increased biological, clinical, and epidemiological knowledge about the risk of chronic disease; (3) the recruitment of larger numbers into chronic disease diagnoses via new screening and diagnostic technology and disease definitions; (4) new ways of conceptualizing efficacy; and (5) intense diagnostic testing and medical interventions.
Conclusions: The converged experience of risk and disease has led to some unsettling and generally underappreciated consequences that might be subjected to more clinical and policy reflection and response: (1) some puzzling trends in medical decision making, such as the steep and uniform increase in the numbers of women across a broad spectrum of risk/disease in breast cancer who have opted for prophylactic mastectomies; (2) a larger and highly mobilized disease/risk population, resulting in an expanded market for interventions and greater clout for disease advocates; (3) shifts in the perceived severity of the disease, with ripple effects on how people experience and understand their illness and risk of disease; and (4) interventions that promise both to reduce the risk of disease and to treat its symptoms.

Framing disease: an underappreciated mechanism for the social patterning of health

Aronowitz, Robert,
Social Science & Medicine, 2008, 67 (1): 1-9 || Link

The emerging fields of social epidemiology and population health seek to understand the social determinants of health. Especially, with regards to how income inequality causes health disparities, attention has been focused on material and psychosocial mechanisms. I use examples from the epidemiological and social science literature to argue for a third broad etiological framework: the role played by the ways we generally recognize, define, name, and categorize disease states and attribute them to a cause or set of causes. These framing effects shape population health by influencing: health and illness beliefs; patterns of consumption and other behaviors; perceptions of what interventions and policies work; class, ethnic, and other social dynamics; and clinical and public health practices. Important characteristics of many framing phenomena are their capacity to be self-perpetuating and their performative power. A better understanding of framing effects can lead to deploying them more deliberatively and flexibly to improve individual and population health.

Do not delay: Breast cancer and Time, 1900-1970

Aronowitz, Robert,
Milbank Quarterly, 2001; 79 (3): 355-386 || Link

Until the 1960s, the central public health message about breast cancer was that women should not delay seeking medical attention for breast problems. Epidemiological, pathological, public health, and clinical writings, movies, and doctor-patient correspondence are analyzed in order to understand the durability and centrality of this “do not delay” message. Problematic assumptions about the natural history of cancer, the efficacy of surgery, and individual responsibility for disease contributed to the durability of the “do not delay” message. More important, the message catalyzed or sustained changes in the routines of ordinary women, general practitioners, surgeons, and pathologists, which led to the perception that the campaign against cancer was working. Thus a powerful set of reinforcing perceptions and behaviors maintained the centrality of the “do not delay” campaign until the era of mammography.

When Do Symptoms Become a Disease?

Aronowitz, Robert,
Annals of Internal Medicine, 134(9): 803-808, 2001 || Link

When do symptoms become a disease? Are there rules or norms, currently or in the past, that tell us when a particular collection of largely symptom-based criteria has enough specificity, utility, or plausibility to justify the appellation disease? The history of numerous symptom-based diagnoses in use today suggests partial answers to these questions. The 19th-century shift to understanding ill health as a result of specific diseases, increasingly defined more by signs than symptoms, led to a loss of status for illnesses that possessed little clinical or laboratory specificity. Nevertheless, clinicians then and now have used symptom-based diagnoses. Some of these diagnoses owe their existence as specific diseases to the norms and practices of an older era much different from our own. Others have not only thrived but have resisted plausible redefinition done by using more “objective” criteria. Many strategies, such as response-to-treatment arguments, quantitative methods (for example, factor analysis), and consensus conferences, have been used to find or confer specificity in symptom-based diagnoses. These strategies are problematic and have generally been used after symptom-based diagnoses have been recognized and defined. These historical observations emphasize that although biological and clinical factors have set boundaries for which symptoms might plausibly be linked in a disease concept, social influences have largely determined which symptom clusters have become diseases.