Q&A with Robert Aronowitz

Robert Aronowitz

Peter Tobia

Robert Aronowitz, chair of the Department of History and Sociology of Science, entered the University of Michigan as an undergrad thinking he would be a physics major. But the Sixties intervened.

“It was the ‘60s,” he says. “Well, actually, the early ‘70s. Some people say the ‘60s really happened in the ‘70s. It was a strong anti-establishment time and being a scientist took on a negative valence for many of us, however naïve or foolish that seems now. What I didn’t know then was that I would, throughout my life, be pulled in two directions—toward ‘hard,’ quantitative, scientific things, and also the more humanistic, interpretive way of understanding bodies and society.”

Aronowitz graduated from Michigan with a degree in English literature, and has zigzagged across the sciences and humanities since leaving Ann Arbor.

He spent a year after college working on a kibbutz in Israel before enrolling at Columbia Teachers College. He received his master’s from Columbia taking mostly evening classes, and drove a taxi in New York City during the day.

After Columbia, he returned to Israel, and then applied to graduate school in linguistics at the University of California, Berkeley.

Aronowitz says it did not take him long to realize he wasn’t cut out to be a linguist. He began drifting in a medical direction and, at the urging of his then-girlfriend and now-wife, decided to apply to medical school. He received his MD from Yale and began practicing medicine, all the while maintaining his interest in the humanities.

He found a home for both at Penn, where he is a professor of history and sociology of science with a secondary appointment in the Perelman School of Medicine. He is also co-director of the Robert Wood Johnson Foundation Health & Society Scholars Program.

“It was a long process of trial and error, and self-discovery that got me to the point where I realized I could do both science and humanities, and I probably would only be happy having both parts of my brain and life functioning that way,” he says.

The Current sat down with Aronowitz to discuss his crisscrossed career, the “complicated present” of breast cancer, the HPV vaccine, and his research on prostate cancer that caught the attention of The New York Times.

Q: Tell me about the Department of History and Sociology of Science.
A: We are 10 faculty members who are interested in the historical and social shaping of scientific knowledge and practices. Our department has an over 40-year history and it’s known for treating the history of medicine, science, and technology as equally important, and as interrelated developments. We’ve trained a lot of great students who have gone on to academic careers and work in science museums, and other aspects of public engagement with science.

Q: You mentioned that you got your master’s at Columbia Teachers College while a taxi driver in New York City. How was that experience?
A: It was OK. I know my New York geography very well; I’m from Brooklyn. The competitive skills I developed to get taxi customers also made me very good at finding parking spots in New York and Philadelphia.

Q: What drew you to teaching?
A: I had the idea that my master’s degree would be a license to travel around the world and get different kinds of teaching gigs, and live out my wanderlust by having a way to support myself in different countries. But while at Columbia, I found the linguistics part of that training very interesting. After I finished my master’s, I went back to the same kibbutz where I had lived after college and taught English as a second language, and decided during that time to apply to graduate school in linguistics.

Q: How was Israel?
A: It was a very different time, 1974. It was just after the Yom Kippur War. The society was in crisis—the country is always in some state of emergency—because of the shock of war and the sense that a military defeat could have happened. The way I was raised, I had an interest in the State of Israel, but the real appeal for me at the time was the kibbutz community. It was socialist; people were living out their dreams.

Q: The Sixties dream.
A: Yes, but in a much more mature way. The hippie communal thing that attracted a lot of my friends was back-to-the-Earth, rejection of everything, and was intellectually very simplistic and disconnected from too many important things. The kibbutz wasn’t in opposition to the rest of society, but was its vanguard. At the time, it seemed to me—from a 21-year-old’s perspective—that the kibbutz was a more responsible, serious, consequential way of living out those utopian ideals.

Q: What caused your interests to gravitate from linguistics to medicine?
A:
I became very interested in the biological basis of language, and issues of child language acquisition and things like aphasia, which are language disorders that result from organic damage to the brain. Berkeley actually had a small medical school that was attached to the University of California, San Francisco. … I ended up taking a neuro-anatomy class as part of the medical curriculum and was fascinated by what you could do with a MD degree, both in terms of understanding how bodies function and in making some tangible difference in people’s lives. I also met around that time my now-wife of 30-plus years who was, after a couple zigzags of her own, interested in a medical career. She kind of pushed me; she said, ‘You can be a doctor, and you can do this very efficiently and quickly, too.’ What started out as a little thought experiment took on some momentum, and while a graduate student in linguistics, I decided to apply to medical school. Surprisingly, I was a successful applicant. I thought I was going to be viewed as some oddball character that there wouldn’t be a place for, but it turns out, sometimes medical school admission committees are looking for people who don’t fit the mold.

Q: Where did you do your residency?
A: Here in Philadelphia at Pennsylvania Hospital, the oldest hospital in the country. If you go down there, you can see my name on the wall. Every person who has ever been an intern at that hospital has a little plaque, starting with Jacob Ehrenzeller, the first intern. It was a wonderful place to learn medicine because you more or less learned from physicians in practice as well as residents, as opposed to some places like Yale-New Haven Hospital, where, as a medical student, your training came almost exclusively from the other residents. Even then there was a part of me that wanted to do something more scholarly and humanistic, and something that would make sense of the rash of often negative impressions about the inequalities and inhumane things that are part of everyday care, even in a great hospital like Pennsylvania Hospital was in that period. That initially took the form of writing for myself and publishing some book reviews for the Philadelphia Inquirer, and in a very aimless way trying to develop some kind of sustained critique about things that were going on.

Q: When did you first become involved with Penn?
A: After my residency, I became a Robert Wood Johnson Foundation Clinical Scholar here at Penn. At the time, the main focus of the Clinical Scholars Program was to produce health service researchers, giving doctors Wharton training—often getting an MBA—with the larger goals of creating a cadre of physician leaders in the then-emerging field of health care management and health care services. This wasn’t for me, but I learned a lot by hanging around with economists and epidemiologists. I was able to use that same structure to get mentoring and training in the history of science. At Penn at the time were two faculty members from the same department I’m in now—Charles Rosenberg and Rosemary Stevens—who later became my colleagues. They provided great mentorship and encouraged me to turn my troubling clinical experiences into something more scholarly and more valuable. I started writing up some case studies on the history of disease that eventually became chapters in my first book. It took me some time, but I found that combining historical scholarship with clinical practice was a reasonable way to satisfy the different interests that I previously thought were contradictory. Almost everything, then and now, that I’ve been interested in researching or writing about has started off by my being upset by something I or close friends or family members experienced or observed in clinical settings.

Q: Where did you begin practicing medicine?
A: Upon graduating from the Clinical Scholars Program, I spent nine, almost 10 years across the river in Camden at Cooper Hospital, where two of my clinical teachers from Pennsylvania Hospital, Ed Viner and Steve Gluckman, had recently become the chief of medicine and the chief of general internal medicine, respectively. They were trying to give the training of residents and medical students a higher academic profile, and encourage more research from the attending physicians. They knew me and liked me and thought that I could contribute something. They took a chance on me and cut me some slack in terms of the balance of clinical, teaching, and research time. Camden is and was a very tough place and clinically very interesting. Also, the kind of residents we attracted in internal medicine were from all over the world, so it was a real global experience inside and outside the hospital. I  spent a big chunk of my time doing clinical medicine, but also teaching, as well as historical work in disease. I finished my first book while I was an attending physician at Cooper.

Q: How did you end up in the Department of History and Sociology of Science?
A: Around 1998, ‘99, there were stirrings of the need and opportunity to create a program at Penn that would make visible what was largely invisible—the work of different faculty members in the social sciences and humanities who studied health and society issues. If you were a student, you could take a course with Renee Fox in sociology or Charles Rosenberg in the history of science, but there was not an organized way of constructing an undergraduate major out of these courses. Similarly, there were a lot of people who had shared interests in health and society research, but there was no easy way to get together for teaching and research. I was hired in 1999 with an appointment in both [the School of Arts & Sciences] and the Medical School to start what became the Health and Societies Program. With Janet Tighe, who is now a dean in the College, and with the support of then-SAS Dean [and a leading demographer] Sam Preston, we were able to start, in the first year I was here, what is now one of the largest undergraduate majors in the College.

Q: What work have you done at Penn Medicine?
A: On the Medical School side, I saw patients, and got funding for and led a training program to develop primary care researchers. Not long after being here, an opportunity presented itself from the Robert Wood Johnson Foundation. Their mission has been to improve the health and health care of Americans. People inside the foundation had slowly come to realize that what was ailing Americans was not just the lack of access to high-quality health care—that, of course, is important—but also the type of communities people live in, the structural, social, and economic factors. They realized those factors shape health as much or more than personal health services. They decided to put their money where their new insight was and literally divide the foundation into health care and health divisions. The foundation had been well-known for successfully developing what they call human capital. They had  training programs, and funded career and research opportunities on the health care side for both nurses and doctors. They decided to now focus on what we were calling population health, an intellectual and policy domain that aimed to understand and positively intervene in the social determinants of health. They made an appeal to 20 universities to make proposals to become a training and research site. With my friend and former clinical scholar colleague, David Asch, who’s now head of health care innovation in the Health System, we devised the program and were successful at getting the funds. A good part of my life at Penn has been contributing to this program and its goals. We’ve been able to have some of the best young minds—usually from the social sciences but sometimes from medicine and the humanities—come in for a two-year training program, plus we’ve been able to give pilot grants and sponsor conferences and build relationships among people around Penn. This program has been very satisfying and fun. The program is ending this year and I’m very sad about it. I am hoping that the 25 or 30 or so Health and Society Scholars we’ve trained remain lifelong colleagues and friends.

Aronowitz Robert

Peter Tobia

Q: Am I correct that your main research interests are the history of 20th century disease, epidemiology, and population health?
A: Yes. Another way to slice that pie is that a lot of my work, certainly in the last five or 10 years, has been focused on the problems of risk and efficacy in medicine. The second book I wrote, ‘Unnatural History: Breast Cancer and American Society,’ tried to explain how we got to the very complicated present by starting with early 19th century America, and looking at continuity and change, and what’s pushing continuity and change at the beside, in the laboratory, in the clinic, but also in the world outside of medicine. Breast cancer has always been a terrible thing and a source of suffering for women and some men, but it was not a big, public visible concern in the early 19th century. People suffered in private and there certainly wasn’t a great societal angst and fear like we have today. Cancer in the breast was thought to be very rare. I wanted to see how we got from that world to a world where one in seven, one in eight women are affected by the disease. The business pages, the front pages, the arts and leisure pages of newspapers on any given day have cancer stories that give a glimpse of our partial understanding of the causes, risks, and best treatments for cancer. There is a kind of paradox that so much change has happened, not just in breast cancer, but in other similar cancers and other diseases, and yet the biological impact of the disease in a population and in people’s bodies has not necessarily changed very much. From about 1930 through the early ‘90s, the age-adjusted mortality for breast cancer—its death rate—hadn’t really budged. But many technological innovations and changed behaviors had greatly increased the incidence of the disease. Thankfully, breast cancer mortality started dropping in the 1990s and people debate the reasons. I wanted to use the change and lack of change to write a history of the disease that made clear some fundamental tensions and decisions we face today. In a way, it’s a history of fear, how the disease came to be feared. In addition to getting the history right, I hope to help some people make very complicated decisions about prevention and treatment.

Q: How did we get to this ‘complicated present’ regarding breast cancer?
A: A lot of people would say it’s something that happened in the last 20 years. But in history, you can always go back further and further, and there are often plausible, good reasons to do so. To answer your question, we need to go back to the late 19th and early 20th century. That’s when many things really start to change. One of the agents of change was intellectual; the revolution in thinking that led to our understanding of most suffering is due to specific diseases, with their unique causes in germs and physiologic dysfunction. But while mortality from infectious disease was dropping for over a century, there was, if anything, higher mortality rates and more cancer being diagnosed. Out of that frustration, and also a sense of potential progress and hope, gynecologists and general surgeons banded together to start a campaign to do something about the cancer problem. A campaign was developed that I call the ‘Do Not Delay’ campaign. It was the American Society for the Control of Cancer, and they implored people, mostly women, to survey their bodies for cancer danger signs, and to seek medical attention if any were found. This message was connected to the idea that if cancer was caught early enough and subjected to radical surgery, cures were possible. Part of the change was the construction of a natural history model for cancer for which there wasn’t much direct evidence. It was as if a lot of still shots—bits of knowledge and beliefs about cancer—were turned into a movie whose plot was that cancer always started as one bad cell, and grew locally, and harmed the local part of the body, but was not a danger to the rest of the body until it metastasized. You needed this localized model to rationalize surgery because there was no reason to subject someone to a brutal operation for a disease that was likely to be all over the body. Medical pessimism about a cure was so deep that if you had a cancerous lump removed by surgery, and you lived for a long time afterwards, a lot of doctors assumed that the lump had not been cancerous after all. That pessimism had to change; there had to be a certain model for cancer that rationalized surgery. Later, gynecologists and surgeons got together and forged a public health message that argued for the efficacy of radical surgery for cancer detected early. This produced an autocatalytic change, or a self-reinforcing reaction, or positive feedback loop in which women’s compliance with this message increased the perception of the ‘Do Not Delay’ campaign’s efficacy, leading to more compliance, and so on. A supporting player in this dramatic change was defining earlier stages of cancer and lowering the thresholds for what constituted cancer pathologically. As a result of these cycles, even though the cancer mortality was largely unchanged, many more people were diagnosed with cancer. Cancer was not only more prevalent, but more curable. By the 1960s, these paradoxes were recognized and some physician skeptics—some of whom identified themselves as ‘pre-determinists’—suggested that the fate of many people with cancer was determined at the time of diagnosis and medical intervention had little impact. This was a very nihilist message. Out of that period of optimism and fatalism, progress but no progress, things shifted. Just looking for early warning signs of cancer wasn’t going to cut it. People started searching for technological means of early detection but retained similar assumptions about cancer’s natural history. Things like pap smears and mammograms were developed in the 1950s and 1960s. As a result of their rapid diffusion, cancer prevalence increased further and, as before, without much of a dent in the mortality rate. That’s what I mean about things changing and yet not changing. You have to understand this cycle of change and continuity to understand so many controversies today, especially in cancer screening and early detection, which retain many of the same elements as the past. We have inherited a century of selling fear and the efficacy of prevention and treatment. There are, thankfully, some effective treatments in cancer, and we need more of them. But in other cases we’ve created a mirage that obscures our ability to make the best individual and societal decisions.

Q: In 2010, you co-edited ‘Three Shots at Prevention: The HPV Vaccine and the Politics of Medicine’s Simple Solutions,’ which explores the contentious disputes surrounding the controversial HPV vaccine. What does your book discuss?
A: With some wonderful colleagues, Keith Wailoo, Steven Epstein, and Julie Livingston, we got this idea of using HPV as kind of a dipstick into a set of problems—cancer, vaccines, fear again, bio-medicalization, the pharmaceutical industry—that, at the time the new HPV vaccines started hitting the market, had produced all kinds of controversy. The controversy was typically framed as whether or not it was a good idea to give young girls a vaccine for a sexually transmitted disease they might acquire later in life. A lot of people didn’t like the heavy-handed marketing of the vaccine that combined direct-to-consumer advertisements with aggressive tactics to influence state legislatures into mandating its use. There were a lot of different narratives happening at the same moment. We thought getting together a bunch of anthropologists, historians, sociologists, and media studies people in the same room, and eventually in one volume, would lead to more discussion of deeper issues raised by these vaccines and their controversies. I was particularly interested in the way in which these vaccines had a kind of double identity. On the one hand, they were like other vaccines where there is a compelling case to subsidize and even softly compel people to use them in order to prevent a serious health problem. At the same time, these HPV vaccines were developed and marketed as risk-reducing drugs, like statins or blood pressure pills, which have large markets, irrespective of their scientific efficacy, because they promise to reduce fear and restore peace of mind about a known and feared danger.

Q: Do you think young girls should get the HPV vaccine?
A: I do. But I worry about the fact that if you mix up the public health rationale with another that has to do with selling freedom from fear and stigma, you are potentially doing damage to the public trust in science generally and important public health programs like trust in the overall vaccine enterprise. Another important issue raised by these vaccines is their architecture and high cost. They are effective, but not effective enough, for places where cervical cancer does so much more relative harm and other means of prevention are unavailable.

Q: In October 2013, your research on prostate cancer was featured in The New York Times due to your findings about the Bowery study in which an urologist experimented on more than 1,200 homeless and alcoholic men from New York City’s Bowery neighborhood in the 1950s and ‘60s. The Times said you ‘stumbled upon the Bowery study.’ How did it come to your attention?
A: I was on sabbatical in New York at the Russell Sage Foundation writing a book on the question of efficacy in Western medicine. I think there is a social, cultural, and economic history to how we make judgments about efficacy. I wanted to find some case studies that would advance this history and argument. Having just finished a book on breast cancer, I promised myself a break from thinking and writing about cancer. But there was a treasure trove of evidence about the social influences on how different people and groups judge current means of preventing and treating prostate cancer. As a historian and as a doctor, I wanted to understand where these interventions came from in the first place. I started researching the history of prostate cancer and learned that as recently as the early 1980s, doctors had very little faith in early detection or curative treatment for prostate cancer. Why? The situation was so different than what had been true of largely female cancers like breast and cervical cancer. I started reading through sequential editions of urology textbooks from different authors and different eras. In the 1950s and early ‘60s, there were a bunch of references to this thing called the Bowery study. This seemed to me to be one of the first attempts to screen asymptomatic men for cancer and try to cure those diagnosed with radical surgery. The ethics of taking alcoholics from homeless shelters in the Bowery and subjecting them to very invasive biopsies and treating them with radical prostatectomy, surgical castration, and hormones was very troubling. Yet not only was it done for over a decade, published in leading medical journals, and heroically depicted in a Life magazine photo essay, there were many haunting parallels to our present practices. Luckily for me, the chief investigator of these studies [Perry Hudson] was still alive in his mid-to-late 90s and was willing to talk to me. There were people who worked with him and knew of the work, older urologists who  also were willing to talk to me, and there were some archival records at the [National Institutes of Health] and elsewhere. In the two articles I published, I not only reconstituted what happened and the context for what seems to us—but few contemporaries—as wrong, but stressed continuity between the science, the practice, and the problematic ethics of what happened to these men with the world we live in today. The New York Times focused, understandably, on the more sensational story of a decade-and-a-half of massive experiments done on vulnerable populations, exposing them to undue risk. That’s all true and I document it. But in my mind there’s a continuity between what Perry Hudson tried to do with the Bowery experiments and what we do today. Instead of 1,500 asymptomatic men over the course of a decade-and-a-half, over 1 million men are biopsied each year today. And yet, until very recently, long after our modern screening paradigm was well-established, there wasn’t any conclusive evidence that this program was efficacious, that there were benefits that outweighed the obvious harms of treatment. When the evidence was produced, which is, of course, always subject to interpretation, my reading was that the harms outweigh the benefits, which, in terms of saving lives, may not even exist. I have some sympathy for what urologists are doing today, but also for what Perry Hudson was trying to do. He was aghast at the lack of progress in prostate cancer, and that these people were dying terrible deaths without anybody helping them. He thought he was helping these men. He has his own ethical critiques of a lot of present practices. It’s a much more complicated story than what was in The New York Times. Understanding this complexity gives me, and I hope others, a better handle on what is at stake—ethically and clinically—in the way we produce a lot of medical knowledge, and diffuse and come to believe in the efficacy of different interventions.

Originally published on February 13, 2014