The Representation of Breast Cancer in

Contemporary Visual Culture

Alison Baker Kerrigan

BA (hons) in Photography 2012

The Institute of Art, Design and Technology, Dun Laoghaire

School of Creative Arts

The Representation of Breast Cancer in

Contemporary Visual Culture

By

Alison Baker Kerrigan

Supervisor: Dr. Justin Carville

Submitted to the Department of Art & Design in Candidacy for the Bachelor of Arts Honours Degree in Photography, 2012

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Declaration of Originality

This dissertation is submitted by the undersigned to the Institute of Art, Design & and Technology, Dun Laoghaire, in partial fulfilment of the examination for the BA (hons) in Photography. It is entirely the author’s own work except where noted, and has not been submitted for an award from this or any other educational institution.

Signed:_______________________

Alison Baker Kerrigan

Student Number: N00063882

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Abstract

Over the last twenty years breast cancer awareness has become a topic of conversation that enters most peoples’ lives for unfortunate reasons. According to statistics published by the World Health Organisation cancer trends are continuing to rise. Despite the multitude of fundraising events, charitable societies and organistations donating to cancer research there still does not appear to be a cure on the horizon. The purpose of this study is to investigate how medical and advertising imagery is used to create a perception of breast cancer within contemporary visual culture. Michel Foucault’s theory of the medical gaze is central to the framework of this thesis, allowing the reader to navigate the spatialisation of illness from that of the individual out into the wider circles of society. This encapsulates the ‘new medical gaze’ of surveillance medicine that in turn promotes a programme like BreastCheck Ireland.

The research reveals visual literacy difficulties in patient reading of medical imagery but suggests improvements could be adopted starting with mammography x-rays being used for more than just medical diagnosis. The advertising industry is pinpointed for the abuse and over saturation of pink ribbon culture which has become embedded in advertisements projecting awareness for breast cancer but showing little support for the charity itself. By deconstructing the advertising imagery from TIME magazine a pattern emerges whereby the imagery aims to sell a concept almost as damaging to women as the disease it attempts to support. Therefore, the aim of this thesis is to examine how visual imagery relating to breast cancer forms a perception of the disease brought forward by discourse within contemporary visual culture.

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Acknowledgements

I have great pleasure in taking this opportunity to extend my sincere thanks and gratitude to those people who made the completion of this thesis possible.

To my supervisor Dr. Justin Carville, for his encouragement, advice and teaching, who together with Adrian Reilly, introduced me to the exciting world of the archeology of photography. Thank you to my photography tutors over the last four years Daniel de Chenu, Mark Curran, Ian Mitton, Mike O’Toole and David Farrell, for sharing your knowledge, expertise and experiences. Thanks to Jamie and Anson for your technical advice on all types of cameras and support with digital and alternative printing. Also, the library staff in IADT who were always there to assist.

Many thanks to Pauline Forrester, Specialist Nurse in the Irish Cancer Society, BreastCheck Ireland and the National Cancer Screening Service, for taking the time to answer my many questions regarding to Breast Cancer.

A very special thanks goes to my sister Jennifer for her patience and assistance in editing, proofreading and encouragement in finishing my thesis. To Claudi, many thanks for the multiple hours we have spent discussing the ‘ins’ and ‘outs’ of both our arguments, your constant support and friendship continues to be fantastic. I am also grateful to my classmates who are as passionate about photography as I am. It was a pleasure to listen, engage and exchange ideas on photography.

A sincere thank you to all my family, who constantly supported me in my role as a mature student and allowed me the space and time to commit to the course. To Mum, thanks for everything. To Cliona, whose bravery and determination made battling against breast cancer look like a part time job. You are truly an inspiration.

Thank you to Kyrie and Lindsay for reminding me that there is life outside of my office. Lastly, and most importantly I would like to thank my husband John, whose love, support and encouragement ensured I achieved this goal.

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Contents

Title Page

List of Illustrations 6

Introduction 8

Chapter One: Theoretical Basis 13

A Notion of the Gaze The Medical Gaze Reorganisation of Knowledge Surveillance Medicine Chapter Two: Medical Imagery 29

Visual Literacy and Radiology Importance of Medical Image Perception Mammography as an Imaging Modality Patient or Viewer? The possibility of both Chapter Three: Social Imagery 48

The Pink Ribbon A Change in Awareness Sign of the TIME’s? 20yrs: 3 Covers Advertisement Effects

Conclusion 68

Appendices 73 Notice of Care Research E-mails Glossary of Words

Bibliography 79 Book sourced material Web sourced material

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List of Illustrations

Image Title, Artist, Date, Source Page

Figure 1.1 hmpff…, Ultimo Munster, 25th Jan 2012 13 http://www.facebook.com/ultimo.muenster 25/01/2012

Figure 1.2 Illustration of Dualism, by Rene Descartes, 1596-1650. 17 http://commons.wikimedia.org/wiki/File%3ADescartes_ diagram.png Accessed 25/01/2012

Figure 2.1 First Medical X-ray, by Wilhelm Roentgen, 1895. 32 http://commons.wikimedia.org/wiki/File%3AFirst_medical _X-ray_by_Wilhelm_RC3%B6ntgen_of_his_wife_Anna_ Bertha_Ludwig's_hand_-_18951222.gif Accessed 28/01/2012

Figure 2.2 Typical Scanning Patterns of a Lesion Free Mammogram 36 http://www.radiology.arizona.edu/krupinski/eye-mo/role- experience.html Accessed 28/01/2012

Figure 2.3 Typical Scanning Patterns of a Mammogram with Lesion 36 http://www.radiology.arizona.edu/krupinski/eye-mo/role- experience.html Accessed 28/01/2012

Figure 2.4 Analogue Breast Mammograms on Lightbox, M415/0291 39 Geoff Tompkinson/Science Photo Library http://www.sciencephoto.com Accessed 28/01/2012 Figure 2.5 Digital Breast X-ray Mammograms, M415/0482 40 Mark Thomas/Science Photo Library http://www.sciencephoto.com Accessed 28/01/2012

Figure 2.6 Breast Lump, Coloured Mammogram X-ray, C010/4892 43 Zephyr/Science Photo Library http://www.sciencephoto.com Accessed 28/01/2012

Figure 3.1 Non Sequitur, The Birth of Perceptual Fundraising 53 Industry, by Wiley Miller, GoComics.com 2010. http://www.gocomics.com/nonsequitur/2010/10/0

Figure 3.2 Time Magazine Cover: Breast Cancer. 14th Jan 1991 57 http://www.time.com/time/covers/0,16641,19910114, 00.html Accessed 28/01/2012.

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List of Illustrations continued,

Image Title, Artist, Date, Source Page

Figure 3.3 Time Magazine Cover: Breast Cancer. 18th Feb, 2002 58 http://www.time.com/time/covers/0,16641,20020218, 00.html Accessed 28/01/2012.

Figure 3.4 Time Magazine Cover: Breast Cancer. 15th Oct, 2007 59 http://www.time.com/time/covers/0,16641,20071015, 00.html Accessed 28/01/2012

Figure 3.5 Dessert First, Stills No. 4, by Nancy Borrowick. 2010 66 http://lightbox.time.com/2011/10/24/ Accessed 12/12/2011

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Introduction

Living in a consumer driven society where advertising is key, visual imagery is

absorbed at an alarming daily rate. Society has become both accustomed to viewing and

presumes to see multiple images delivered via the media-spheres of magazines, books,

advertisements, films, television and the internet. These agencies of communication all

perform a role in shaping our interpretation of the things we see everyday, which

informs our relationship with contemporary visual culture. Within that understanding

many of these media-spheres project a visual representation of the ‘health and illness’

dualism onto society. Which are readily accepted and feed the universal appetite there

seems to be for this particular subject. The success of medical programmes from ‘Dr.

Kildare’, starring Richard Chamberlain, to the hit series ‘General Hospital’, running for

over 49 years in the United States, or dramas like ‘ER’, ‘Casualty’, ‘Grey’s Anatomy’

and ‘Holby City’, indicate society’s addiction for watching stories unfold depicting

human interaction with medicine.

Further examples of film, theatre, novels and documentary include inspiring stories such

as ‘Calendar Girls,’ a box office hit in 2003, adapted to a stage play in 2008 - iconically

associated with cancer, and the epicenter of the tidal-wave of naked fundraising

calendars that adorn many walls, having successfully raised over £3 million for

Leukaemia & Lymphoma Research1 alone. The best-selling novel and film ‘My Sister’s

Keeper’2 tells the unusual story of a thirteen year old girl fighting for medical

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1 Leukaemia & Lymphoma Research,[www] http://leukaemialymphomaresearch.org.uk/news/ our-celebrity-supporters/calendar-girls/calendar-girls-story Accessed 23/01/2012

2 Jodi Picoult. My Sister’s Keeper, Atria, Washington Square Press, New York, 2004.

emancipation from donating her kidney to save her sister who is dying from leukaemia.

The reason is heartfelt, her sister has had enough and wants to die without further

medical intervention. This movie grossed over $95 million in box office sales.3 Another

example is fly-on-the-wall documentary of Jade Goody’s4 battle with cervical cancer,

the visual representation imitated the path of her disease as it spread across television

screens making the front page on newspapers and magazines, constantly updated on Sky

News until her untimely demise.

So what is the fascination with these programmes? Viewers watch them play out,

becoming involved with the characters most of whom have a common thread of

grasping onto life. The practice of watching the suffering of others, reminds us of the

fine line we all tread, a second dualism of ‘life and death.’ Religiously inclined or not,

the phrase ‘there but for the grace of God, go I,’ explains it most succinctly.

Cancer is the term given to describe a group of illnesses that have common

characteristics which include an over growth of cells and an ability to spread to other

sites in the body. Breast cancer is one of those illnesses. A malignant tumour that starts

in the cells of the breast, the difficulty is catching it before it spreads anywhere else.

According to the BreastCheck Programme Report 2010-2011, ‘Breast cancer is the most

commonly diagnosed cancer in women in Ireland and has the second highest mortality

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3 Box Office Mojo. My Sister’s Keeper, [www] http://boxofficemojo.com/movies/? id=mysisterskeeper.htm Accessed 28/01/2012.

4 Channel Four, Jade: As Seen on TV, [www] http://channel4.com/programmes/jade-as-seen- on-tv/4od Accessed 28/01/2012.

rate. Nearly 2,500 women are diagnosed with breast cancer in Ireland each year.’5

Statistics tend to roll off the tongue until someone you know is included in that number,

then it becomes very apparent that each one of those numbers is a person whose life

expectancy hangs in the balance. The imagery presented in this thesis represents breast

cancer in different ways, the medical image used by physicians for diagnostic purpose

and the magazine image absorbed by society in the advertisement of the disease.

I became aquatinted with breast cancer in 2009 when my sister aged 51, was diagnosed

with the disease after her first routine mammogram with the BreastCheck Ireland

programme. I photographed her regularly to document her journey of recovery, whilst

making these images I became acutely aware of how this worldwide disease is

represented in visual culture. Observing that medical imagery seen by the physician is

not often see by the patients, having almost no presence in the public arena in

comparison to advertising imagery with its enormous public presence. Advertisements

appear to be heavily influenced by pink ribbon culture with a tendency to promote the

body beautiful, avoiding any physical representation of the disease itself. Neither type

of imagery portrays what is experienced up close and personal by cancer patients or of

cancer patients, yet this is how breast cancer is predominately represented through

visual culture which forms societies perception of this disease.

To investigate this perception, chapter one builds a theoretical framework structured

around theories within photographic discourse, which will be useful in the analysis of

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5 BreastCheck 2010-2011 Programme Report. Health Service Executive National Cancer Control Programme. [www] http://breastcheck.ie/sites/default/files/breatstcheck_ programme_report_2010-2011.pdf Accessed 20/01/2012

the photographic imagery introduced throughout this thesis. Establishing a notion of the

gaze and the complexities associated with it, assists in underpinning the placement of

Michel Foucault’s ‘medical gaze’ within the institutional systems of power. How this

affects the individual subject before it, and how the gaze has an ability to expand its

view over communities as a whole as described by David Armstrong’s new medical

gaze of ‘surveillance medicine,’6 which indicates the shifts and changes that have

shaped the healthcare culture of today.

The medical image is not often thought of as being part of visual culture and yet it is the

central image created for the diagnosis of breast cancer. Chapter two introduces the

radiologists’ role identifying society’s expectations of the doctor patient relationship and

highlights the importance of perception in this field of work. Taking a closer look at

what might be seen in a medical image like a mammogram, questions if these medical

images have something else to offer besides the role of diagnostic tool.

Chapter three focuses on the advertising industry, looking at how breast cancer

awareness campaigns have become embedded in society. Over the last twenty years,

TIME magazine has issued three cover pages dedicated to this disease which I will use

by way of example to show how advertising industry’s involvement in the perception of

breast cancer is a dangerous thing. The pink ribbon is a worldwide renowned symbol

used for breast cancer awareness which has established a power that has helped raise

more monies than ever expected. Bringing it under the gaze of those who now oppose it,

opens questions about its effects and loss of direction and perhaps of its future.

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6 David Armstrong. “The Rise of Surveillance Medicine,” Sociology of Health & Illness, Vol. 17, No. 3. 1995. p. 393-404.

The intention of gathering imagery directly related to breast cancer from two visual

arenas, is to indicate and question what perception these images form about the disease

within in visual culture. Hopefully this will open a discussion and develop the idea that

awareness can apply to all areas along the journey. The importance of building a clearer

perception could be of benefit to all concerned from doctor to patient and from reader to

viewer as it is a disease that as of yet, has no cure.

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Chapter One: Theoretical Basis

Figure 1.1 hmpff…, Ultimo Munster, 25th Jan 2012

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An initial reading of figure 1.1 will more than likely deliver the lighthearted anecdote

presented for the viewer’s attention as the doctor examines an x-ray and deduces that

Kermit is in fact, a puppet! The physician’s aged appearance connotes wisdom and

knowledge, whilst the patient appears isolated against the backdrop of the medical

curtain. The image itself becomes the object of the viewer’s gaze, yet it is the exchange

of gazes within the image that builds the viewer’s perception of what is taking place.

Undoubtedly the cartoon could stand alone without words, but the linguistic meaning

expresses a message of authority and reason. Although a simple analysis, this cartoon

highlights many theories I wish to explore further, therefore I intend to return to it at the

end of this chapter and broaden the analysis based on the theoretical framework about to

be discussed.

Medicine and Photography have an inherent relationship in that both derive from

science, have an ability to influence preconceptions and expectations and have the

unenviable characteristic of making those before them anticipate a result. Both

disciplines use imagery to communicate and create the intention of further consideration

of the message signified within. To successfully navigate through the relevant critical

theories of disciplines, it is beneficial to formulate an understanding of the archeology

of medicine, a vastly extensive and discursive subject dating back to Ancient Egyptian

times, with the intention of remaining inside the boundaries of the framework which

will direct focus onto the specific area of medical imagery within the visual

representation of breast cancer. Discovered in the early 19th Century, photography has a

much shorter history than medicine. Since its invention, it has managed to infiltrate

almost every area of visual culture, in particular the world of advertising. However, it is

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the philosophy of photography combined with critical theory rather than its history, that

will assist in underpinning the argument set out in this thesis.

The aim of the thesis is to investigate the visual representation of breast cancer, and to

question the effects those images have in building societies perception of the disease

within contemporary western visual culture. To do so the imagery identified will be

separated into two genres, each with a chapter devoted to specific investigation. The

first genre is medical imagery, focusing on images of the internal body created for

screening and diagnostic purpose, educational material and research as used by the

medical profession. The second genre is social imagery, titled by design to encapsulate

imagery that is available to society in general, such as advertising articles on breast

cancer, charitable awareness campaigns and social documentary photography and so on.

The function of these images is to make an invisible disease like breast cancer become

visible to the public eye. Firstly, it is essential to build an understanding of the gaze

making it more transparent as it is central to the framework set out in this chapter,

which will form the window through which all imagery presented may be viewed and

analysed.

From the time we are born we learn to see in a particular way, visual culture teaches us

how to see as we are looking at it, and as we look, we reinforce ideologies behind it.

The dominant model of vision is western criticism, recognised in visual culture as

cartesian perspectivilism1 which projects the natural experience of sight and is believed

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1 Cartesian perspectivilism has the ability of expressing the ‘natural’ experience of sight, in art this represents what we see onto a two dimensional surface which looks realistic due to the illusion of space and depth. The word ‘Cartesian’ relates to the French philosopher Rene Descartes whose latin name was Renatus Cartesius.

to be the ‘hegemonic visual model of the modern era.’2 This model dates back to the

Renaissance period along with other models of vision such as 17th Century Dutch

Painting3 and Baroque Art4 as highlighted by Martin Jay in his writing on the ‘Scopic

Regimes of Modernity.’ A model that is reinforced over and over by the multitude of

images consumed daily through television, photography, media, fine art, fashion, design

and the internet. Intertwined in the function of how we see naturally, is the moment we

identify with what we see.

The father of cartesian perspectivilism Rene Descartes illustrates this idea in figure 1.2

mind-body dualism. Indicating that when we look at something, signals are passed from

the sensory organs to the brain, triggering the physical response in our body to lift the

hand to point to what we are looking at. This is a connection that can be characterised

by the notion of the gaze, a powerful relationship held between the viewer and what is

being looked at. Sometimes the gaze is described as a way of looking, or a practice of

looking. It presents itself in numerous forms from the intimate gaze of awareness and

identity to the more public gaze of gender and tourism, the multidirectional gaze in

advertisement and art, to the highly classified perceptual gaze of medicine.

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2 Martin Jay, ‘Scopic Regimes of Modernity’ in Vision and Visuality (Ed) Hal Foster, 1988, Bay Press, Seattle. p. 4.

3 The Art of Describing - 17th Century Dutch Painting is a ground breaking book written by Art Historian and Critic Svetlana Aplers noting Dutch attention to detail of interiors and domestic scenes. [www] http://dictionaryofarthistorians.org/alperss.htm Accessed 17/1/12

4 Baroque Art, Classical style, painterly, re-sessional, soft focused, multiple and open. It connoted the bizarre and peculiar, with images containing signs and highly imaginable concepts.

Figure 1.2 Illustration of Dualism by Rene Descartes, 1596-1650.

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A Notion of the Gaze

In psychoanalysis, Jacques Lacan describes the gaze as a state of awareness, when one

knows that one can be viewed, therefore becoming a visible object. This is closely

linked with the Mirror Phase concept5, based on childhood development whereby

children aged between 6-18 months start to develop their ideal-ego (imaginary ego) by

recognising the self, and the external self in the mirror. Johnathan E. Schroeder

comments, ‘the gaze is one of the most influential concepts in the study of

photography’ before offering his definition: ‘that to gaze implies more than to look at -

it signifies a psychological relationship of power, in which the gazer is superior to the

object of the gaze.’6 If this is so, then numerous questions need to be established when

deciphering a gaze such as; who is projecting the gaze, for what reason, and what is

their status? These questions suggest a relationship of power, which similarly suggest

that construction of identity is being established through the gaze, and that too should

be considered in its analysis.

According to Kathryn Woodward,7 identity is often gauged by similarity and difference.

When we are part of a social group, we are considered the same, which highlights our

difference from others. Essentialists’ models of identity construction are based on fixed

elements of identity we possess from birth such as gender, race, nationality, and

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5 Marita Sturken & Lisa Cartwright, ‘Spectatorship, Power, and Knowledge’ Practices of Looking an introduction to visual culture, 2001, Oxford University Press. p 74.

6 Johathon E. Schroeder. Visual Consumption, Routledge, 2002 (1998, p 58)

7 Questioning Identity: Gender, Class, Nation (An Introduction to the Social Sciences) Kathryn M. Woodward (Ed). New York: Routledge, 2000. P.8.

therefore easily enforce stereotypes. However, due to the knowledge of one’s self and

the construction of identity, what is initially seen as essentialist may also alter and

become non-essentialist. Developments in our identity, including where we live, people

we associate with, education, work and indeed personal health may all change over

time. This is an important factor to clarify about self-identity as perception within the

gaze could easily form essentialist ideals, especially when we consider that looking is a

socially constructed practice.

Many theories have developed around particular forms of the gaze in conjunction with

social circumstances that are being explored. An example of this line of thought can be

followed in Laura Mulvey’s essay, ‘Visual Pleasure and Narrative Cinema’ in which she

argues her theory of the ‘Male gaze’ as seen in cinematic Hollywood images depicting

women as objects of the male gaze. She highlights that camera work nearly always

presents from a male perspective with a pleasurable and voyeuristic sense8 attached to

it, thus exploring complex notions of masculinity and how they objectify certain things.

Mulvey’s concern is that if cinematic imagery is being depicted from a male

perspective, it constantly reinforces itself as the dominant model in western visual

culture. This could also portray male dominance over the objectified female which in

turn could lead to a direction of violence against women. Marita Sturken and Lisa

Cartwright are in agreement with Mulvey, noting that ‘looking involves learning to

interpret, and, like other practices, looking involves relationships of power.’9

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8 Sturken & Cartwright, Practices of Looking an introduction to visual culture, p 76.

9 Sturken & Cartwright, Practices of Looking an introduction to visual culture, p.10

In difference to Mulvey’s potentially aggressive gender related gaze, John Urry

describes the ‘Tourist gaze’ in the following way:

When we go away we look at the environment with interest and curiosity...

there is no single tourist gaze as such. It varies by society, by social group

and by historical period - what makes a particular tourist gaze depends upon

what it is contrasted with.10

Society usually contrasts new experiences with whatever is deemed as normal. It is

normal for tourists to be openly excited and assertively interested in the new. Status

difference will have an impact, but overall, these new experiences are associated with

positive connotations. Contrast this with a patient undergoing a medical procedure. New

experience or not, they would be more likely to be concerned and anxious, therefore

associating negative connotations and projecting a passive or submissive gaze, on the

situation. This highlights that the gaze is embedded with emotion albeit passive,

aggressive or assertive depending on the environment and situation being experienced.

Theorists Gunther Kress and Theo van Leeuwen identify how advertising uses the

power of gaze to connect with its viewers in a relationship of either demand or offer11.

A person depicted in an image gazing directly outward, demands intimacy of the

viewer’s attention (as the object of the look)- this is also known as a ‘direct address.’ In

contrast is an image of a person depicted with no eye contact towards the viewer, i.e.

they do not appear to know they are being viewed, which represents an offer to the

viewer to engage with the scene from the advertisers/products position which can be

referred to as an ‘indirect address.’ Both forms of address connect with the viewer.

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10 John Urry, The Tourist Gaze: Leisure and Travel in Contemporary Societies. London: Sage Publications, 1990. p. 1

11 Gunther Kress & Theo van Leeuwen, Reading Images: The Grammer of Visual Design. London: Routledge, 1996. p.121-130

A photographic image or painting could hold a multitude of gazes, all taking place at

once. Catherine Lutz and Jane Collins give an example using National Geographic

photographs, suggesting there are up to seven different gazes that can be accounted for

when ‘exploring the significance of the ‘gaze’ for intercultural relations in the

photograph.’12 They list the photographers gaze, magazine gaze, readers gaze, non-

western subjects gaze, westerner’s gaze, refracted gaze of the other and the academic

gaze. Immediately this confirms how discourse around the gaze is discursive and

multidirectional, but what also becomes clearly obvious is that the practice of the gaze

alters every time, according to and depending on the subject matter, and just like the

tourist gaze, what set of social circumstances are involved. Images are not reality, they

depict a sense of realism and reality but, images by their very nature are simply

representations of what is captured in the image.

The Medical Gaze

French critical theorist, Michel Foucault was renowned for his extensive studies on

social institutions including the prison system, human sciences, psychiatry and

medicine. In ‘The Birth of the Clinic: An Archaeology13 of Medical Perception’,

Foucault investigated a major historical turning point in medicine at the end of the 18th

Century as marked by the beginning of the institution of clinical medicine, specifically

the teaching hospitals. His studies led to the development of important theory models

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12 Catherine Lutz & Jane Collins, ‘The Photograph as an Intersection of Gazes’, The Photography Reader, Liz Wells,ed. p 354

13 Archaeology is the term Foucault used to describe his approach to writing history. Archaeology is about examining the discursive traces and order left by the past in order to write a ‘history of the present’. In other words archaeology is about looking at history as a way of understanding the processes that have led to what we are today. by Clare O’Farrell [www] http://michel-foucault.com/concepts/index.html accessed 10/04/2011

around the regime of truth, power/knowledge systems and surveillance all of which are

embedded in the two key concepts crucial to the core strength of this theoretical

framework the ‘medical gaze’ and the ‘reorganization of knowledge.’

Firstly, this particular myth of the medical gaze is based on the observational technique

which incorporated a system of signs and immense wisdom of the physicians’ ability to

separate the patient’s body from their identity, to reveal hidden truths. Foucault explores

the ‘medical gaze’ through his questioning of various metanarrative myths concerned

with beliefs of and within scientific medical discourse:

Liberty is the vital, unfettered force of truth. It must, therefore, have a world

in which the gaze, free of all obstacle, is no longer subjected to the

immediate law of truth: the gaze is not faithful to truth, nor subject to it,

without asserting, at the same time, a supreme mastery: the gaze that sees is

a gaze that dominates; and although it also knows how to subject itself, it

dominates it’s masters:14

Foucault believes societies construct a ‘regime of truth’ according to what is believed

and valued. Doctors belong to and specialise in the knowledge and institution of

medicine, which is one of the systems of power. To release the gaze from this power, it

would be a gaze that dominates but only if not ultimately ruled by truth dictated by

politics. He considers the gaze to encapsulate all senses, ‘A gaze that touches, hears,

and moreover, not by essence or necessity sees.’15 Medical staff are trained to look and

see in a particular way, and Foucault based his studies upon those within the teaching

hospitals criticising that those who governed our bodies had developed their own myths

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14 Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, (A.M. Sheridan Smith, trans.) New York: Vintage Books, 1975, p. 39

15 Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, p. 202

in his description of the medical gaze, ‘the art of describing facts is the supreme art in

medicine: everything pales before it...the great myth of a pure Gaze that would be pure

Language: a speaking eye.’16 Again Foucault unveils these myths and reduces them to

normality's held in the grasp of all men. Once they open their minds and sensibilities to

knowledge and endure the rigorous learning practice within the teaching hospitals, the

gaze will in turn open up to them. Trainee physicians would only be capable of

developing this speaking eye when a student ‘now sees the visible only because one

knows the language’17 confirming the student cannot see until he hears and understands

the medical discourse provided by the institutions, taught by tutors until the student

becomes a tutor recycling the position of power. Therefore, the medical gaze can be

thought of as an organised, structured and methodical way of looking, that includes the

use of all sensibilities, knowledge and perception to interpret what is being presented

before the physician.

The Reorganisation of Knowledge

The institution of the training hospital and learning forum was established through the

‘reorganistation of knowledge’ as a structural foundation, allowing medicine to be

thought of as a discipline based around medical discourse. This epistemological 18

transformation from classical medicine to modern medicine took place between the late

18th and mid-19th century. Classical medicine was of the notion that disease was

independent. The symptom of disease inserted itself into the body, but needed to be

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16 Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, p. 140

17 Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, p. 141

18 Epistemology is the theory of knowledge, the close examination of what differentiates between justified belief and opinion.

considered apart from the body, abstract in the physicians thought as opposed to

practice. The separation between disease and patient would allow the physician to make

a clear, well informed diagnosis.

In comparison, modern medicine was of the notion that disease was dependent on the

body and so was inseparable in thought. Since signs and symptoms of illness coincide

with a patient’s self-identity and lifestyle, then sociological factors need to be

considered as part of a diagnosis. This was a new understanding of illness and the body,

‘what was fundamentally invisible is suddenly offered to the brightness of the gaze’,19 a

space where the visible and the invisible become apparent to the physician during

diagnosis, assisted by the shared experience, knowledge base and differing sectors

becoming available, such as pathology within the training hospitals.

To elucidate further, classical medicine could be likened to a flat or single layered,

horizontal, two dimensional space directly contrasted to modern medicine as a multi

layered, vertical, three dimensional space to be penetrated through. What appears

obvious and self-explanatory in contemporary thought, was at the time, ground-

breaking for clinical medicine. Foucault noted: ‘It is as if for the first time for thousands

of years, doctors, free at last of theories and chimeras, agreed to approach the object of

their experience with the purity of an unprejudiced gaze.’20 The structure of a teaching

hospital introduced a format for training medical students by professional experienced

physicians and staff equipped with knowledge, experience and facilities, available to

test and investigate diseases and so on. They no longer had to rely on myths passed

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19 Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, p.195.

20 Michel Foucault, The Birth of the Clinic: An Archaeology of Medical Perception, p.195.

down from generations before them. Doctors were educated in their science, allowing

knowledge to be the basis of interpretation of what they saw and experienced.

Symptoms were interpreted by the physician using a semiotics of diagnosis, and while

using these skills, students were also learning what to look for and how to look. The

clinical environment had an enormous impact on the discourse of medicine as they

developed alongside each other in the teaching hospitals.

This transformation in medicine greatly altered the spatialisation of illness as it evolved

from the primary spatialisation of bedside medicine (a two dimensional framework) in

the natural space of the patients home, where pain was the symptom, a tender stomach

was the sign, together both equalled illness.

Giving way to the dominant model of hospital medicine (a three dimensional

framework) in the neutral space of the hospital. Where pain was again the symptom, a

tender stomach was again the sign, but neither sign nor symptom confirmed an illness

which indicated further investigation, penetrating between surface and depth to reveal

the pathology of the illness which has branched out into laboratory medicine, still

associated by the neutral space of the hospital but requiring a separation for

investigation. This is considered to be secondary spatialisation - a mapping of the

volume of the body, where it became objectified as the focus of medical examination to

locate the lesion on the patient’s body, a post mortem examination would give a final

exact cause of any hidden lesion.

25

Tertiary spatialisation moves away from the individual physical body and becomes

located in the larger body of society. It is the location of illness within the context of

health care and it focuses attention on what is perceived as the new medical gaze of

surveillance medicine.21

Surveillance Medicine

David Armstrong’s theory on the rise of surveillance medicine, adopted Foucault’s

medical gaze and through the evolution of medicine, expanded it from the individual

gaze of the physician to a socially unified gaze of medicine, arriving at a point where

social diseases like TB, VD, childhood illnesses all come under the scope of health care

dealing with a community of ill people in the one location. Armstrong describes the

theory:

This new Surveillance Medicine involves a fundamental remapping of the spaces of illness. Not only is the relationship between symptom, sign and illness redrawn but the very nature of illness is re-construed. And illness begins to leave the three dimensional confine of the volume of the human body to inhabit a novel extracorporeal space. 22

This remapping of illness from an individual status to that of whole communities will

need to consider preventing those communities of well people from becoming ill. It is a

new challenge for the space of illness. Society becoming involved in its own medical

gaze of self-surveillance through screening campaigns and health promotions will

impact on how something like breast cancer is represented and dealt with in western

visual culture.

26

21 David Armstrong (1955) “The Rise of Surveillance Medicine,” Sociology of Health & Illness, Vol.17, No. 3. 1995. p. 393-404.

22 David Armstrong, “The Rise of Surveillance Medicine,” Sociology of Health & Illness. p. 395.

Although the intention for society is to encourage a healthier lifestyle with avoidance of

illness, bedside and hospital medicine targeted ill patients; surveillance medicine targets

everyone - as everyone can potentially become ill. This uncovers the problem of what is

normal between health and illness, highlighting the need for a shift in healthcare to

mediate between the patient in hospital and the widening social area. The broadening of

the medical eye over whole populations is the ideal concept of surveillance medicine,

but with that comes the problem of spatialisation, as now symptom, sign and disease are

combined with a new factor, in the ‘risk’ of illness. There are no guarantees just because

a risk is indicated that ill-health will follow. There is just a possibility that it might,

leaving the new space of illness directly located in the community. A risk of being

unwell alters the individual identity of a patient under observation. Surveillance

medicine identifies a whole group, community or population under inspection, altering a

group identity. This is a new monitoring gaze that penetrates through numbers in an

extracorporeal space for the risk of illness.

The promotion of surveillance medicine in the global society has become part of a

worldwide culture that unusually expands the medical gaze outwards. It involves people

who are not necessarily well educated or knowledgeable in medical matters to partake

in their own health care programme. This raises a fundamental problem with visual

representations produced for specific disciplines such as medicine, in that they exclude

the vast majority of society through what is recognised as scientific visual illiteracy.23

27

23 Jean Trumbo, Making Science Visible in Visual Cultures of Science: Rethinking Representational Practices in Knowledge Building & Science Communication, Ed Luc Pauwels, 2006, Darthmouth College Press.

Returning to figure 1.2 and viewing it now through the theoretical framework set up

offers greater critical analysis of the image, beginning with the gaze. Kermit's gaze

appears transfixed on the doctor as if the x-ray does not exist between them. The x-ray

is the fulcrum of the illustration - an image within an image, held and framed by the

doctor depicting this relationship of power as the information in the x-ray signifies the

truth of the image. Although a transparent object it only appears visible to the medical

gaze, an interpretation is made deducing a diagnosis perhaps by using a methodology of

semiotics. The patient’s facial expression connotes a sense of fear, apprehension and

anxiety, nervously awaiting results. Also emphasised is the sense of objectification and

separation in the doctor/patient relationship. The conversation like the image is one

directional, the information is being delivered, not shared. The x-ray also points to the

concept of medical surveillance of the body that will form part of a medical archive, a

learning tool within medical discourse. Spatialisation has been placed in the doctor’s

surgery, confirming an attachment to an institution within the systems of power.

In teasing out this analysis, the wording becomes ambiguous too. The doctors

acknowledgement in having information that will change his patient’s life forever, is

followed by a question, putting the onus back onto the patient. ‘Are you really sure you

want to know?’ Immediately it becomes more serious, insinuating the diagnosis is poor

whilst drawing attention to the coldness often described by patients when receiving

medical results. Although this image has little to do with breast cancer, it indicates by

way of example how using the theoretical framework can draw a much deeper analysis

of a simple cartoon image.

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28

Chapter Two: Medical Imagery

For some unknown reason there are very few doctors that offer to discuss

mammography x-ray images with their patients, and there are even fewer patients that

request to see the same medical imagery.1 So despite living in an image saturated world

neither doctor nor patient see these medical images as being something worth looking at

together. Yet doctors and patients often engage in discussion around medical images of

x-rays of broken bones, x-rays of teeth, ultrasound scans of the unborn in utero without

any hesitation. So what is different? Is it the presumption that the dualism of ‘life and

death’ maybe connoted by the image or the constant fearful reminders from publications

of statistics that makes society shy away from cancer related medical imagery.

According to the World Health Organisation (WHO) ‘Cancer is a leading cause of death

worldwide, accounting for 7.6 million deaths (around 13% of all deaths) in 2008.’2

Breast cancer is the leading cancer in women in both developed and developing

countries causing a staggering 460,000 deaths. To combat these increasing numbers,

WHO recommends countries establish an effective cancer prevention and control

programme. As part of the National Cancer Screening Service, BreastCheck Ireland 3

was established in 2007 offering a free biannual service to women between the ages of

29

1 Question asked of Cancer Nurse in the Irish Cancer Society during thesis research: ‘Is there a policy in place that disallows or restricts doctors from discussing patients medical imagery with them if it is requested?” The answer was “No, there are no restrictions, but in my experience of 20 yrs few Doctors ever offer and even fewer patients ask to see the images.’ National Cancer Helpline /1800 200 700/ Specialist Cancer Nurse 09/12/2011.

2 WHO., Cancer - Key Facts, Fact Sheet No 297. Oct 2011. [www] http://who.int/mediacentre/factsheets/fs297/en/ Accessed 28/01/2012.

3 BreastCheck Ireland, is a Government-funded programme providing breast screening, offering a free mammogram on an area-by-area basis. The aim of BreastCheck is to reduce deaths from breast cancer by finding and treating the disease at an early stage. [www] http://breastcheck.ie/ Accessed 15/01/2012

50 to 64yrs. Exact target age differs from country to country. The NHS in the United

Kingdom recently extended the age range from 47 to 73yrs, whilst in America the age

group is 50 to 74yrs in accordance with the (NBCCEDP).4 The long term effects of

these programmes have a massive cost saving factor on government spending by

detecting and treating cancers in asymptomatic patients as opposed to the comparative

high cost of treating later stage cancers, proving surveillance medicine is successfully

detecting early stages of breast cancer in patients which increases their life expectancy.

One of the key elements throughout this process is the role of medical imaging is cancer

detection, offering a non-invasive method of investigation with minimal side effects to

the patient. It has become a crucial a driving force in reducing mortality rates. The

advancement of digital imaging offers physicians a more precise detailed image

enabling files to be stored, retrieved or sent for further investigation to any destination

in the world with incredible time saving factors.5 However, the first step involved in

obtaining all the information offered by the image is in the skill of interpretation.

Visual Literacy and Radiology

Visual Literacy is the ability to interpret the meaning of the image. Photographers, like

many visual artists, use a methodology of semiotics (the study of signs) as introduced

by theorist Roland Barthes to decode the rhetoric of the image. Radiologists are doctors

30

4 NBCCEDP, National Breast and Cervical Cancer Early Detection Program provides breast and cervical cancer screenings and diagnostic services to low-income, uninsured, and underinsured women across the United States. [www] http://cdc.gov/cancer/nbccedp/screenings.htm Accessed 15/01/2012.

5 Medical Imaging in Cancer Care - Charting the Progress, US Oncology Inc. 2006. [www] http://healthcare.philips.com/pwc_hc/us_en/about/Reimbursement/assets/docs/ cancer_white_paper.pdf Accessed 28/01/2012.

who specialise in obtaining and interpreting medical imagery of the internal body -

imaging experts who are scientifically visually literate, using a specific methodology

known as Roentgen semiotics to interpret medical imagery. Wilhelm Roentgen6

captured the first x-ray in 1895 of his wife’s hand as seen in figure 2.1 the

representation making the bones visible to the human eye. This early x-ray appears to be

easily readable, most could identify the finger bones and joints but may wonder if the

dark circle is an abnormality or a ring placed on the finger. The fundamental problem

with scientific visual representations is that the majority of society cannot read the

images because they are not literate in visual science as previously mentioned in chapter

one.

The specific function of medical imagery is to make that which is invisible to the naked

eye - visible to the medical gaze. Interpreting this medical imagery uses the perceptual

senses specific to the eyes, as all other senses have been eliminated by the technological

process. Before discussing the modalities used for diagnosis, it may be helpful to

consider the radiologists position in this process.

Breast imaging is a sub-specialty of radiology,7 dedicated to diagnostic imaging and the

diagnosis of diseases in the breast. To realise the high accuracy rates of diagnoses

expected in breast imaging it is necessary for radiologists to achieve an intense level of

specialisation. This however places the specialist radiographer as a hidden intermediary

in the doctor/patient relationship, as will become clear.

31

6 Wilhelm Conrad Roentgen. German physicist invented the x-ray in 1895. The ‘x’ in x-ray stands for the unknown factor similar to solving what is ‘x’ in a mathematical equation.

7 Radiologyinfo.org, [www] http://radiologyinfo.org/en/careers/index.cfm?pg=diagcareer #part_one, Accessed 15/01/2012

Figure. 2.1 First medical X-ray by Wilhelm Roentgen, 1895.

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The Radiology Society of North America (RSNA), indicates ‘the nature of radiology

itself tends to distance the physician from the patient’8 continuing to note that:

In many cases, radiologists do not meet the patients whose diagnostic

images they are interpreting. What we see is not the whole patient but pieces

of the patient's internal anatomy on a computer monitor. All imaging

modalities are associated with the tendency to objectify the patient, with

removal of the subjectivity of biography and personality from the human

being to whom the images correspond.9

Confirming this objectification identifies that both parties experience a sense of

depersonalisation, highlighting the separation not only of body parts but also in the

doctor/patient relationship whilst elevating the doctor/image relationship to a position of

power. There is a sense of longing for human interaction to reconnect the person to the

images taken. A comparison can be drawn alongside the physician/photographer in their

‘relationships of power,’10 directing the gaze onto the patient/subject as both attempt to

capture an image they are trained to look for. Susan Sontag also confirms this

objectification of subject in her discussion on photography by saying, ‘to photograph is

to appropriate, the thing photographed.’11 In determining the extent of the photographic

process, Sontag describes:

The camera doesn't rape, or even possess, though it may presume, intrude,

trespass, distort, exploit, and, at the farthest reach of metaphor, assassinate

all activities that, unlike the sexual push and shove, can be conducted from a

distance, and with some detachment. 12

33

8 Horst Kelly, Radiology RSNA, There Is More to Life than Lifestyle, [www] http://radiology. rsna.org/content/238/3/767.full Accessed 15/1/2012

9 Horst Kelly, Radiology RSNA, There Is More to Life than Lifestyle.

10 Sturken & Cartwright. Practices of Looking: An Introduction to Visual Culture, p. 100.

11 Susan Sontag. On Photography, Penguin Modern Classics, 2008. p. 4.

12 Susan Sontag. On Photography, p. 13.

There is no doubt as to her confirmation that this process has the ability to consume

everything that is available at the moment of capture. When considering medical

imagery perhaps ‘abduction’ could be included in her annotation as patient

objectification continues beyond the point. I would argue that there is a double

objectification, firstly at the moment of capture and secondly, when a presumption is

made that because a patient is unable to read medical imagery, then it is of no benefit

for the image to be seen or shared. Therefore, medical discourse frames the medical

image in a particular way that communicates and enlightens the medical profession

whilst leaving the patient completely detached and in the dark. As with all imagery, the

power remains with the viewer who completes the final process through their reading of

the image, but again this is where radiology differs from photography. The power

constantly remains with radiographers, working in a ‘closed circle of representation’13

collectively they are both creator and viewer.

Importance of Medical Image Perception

Radiologists are not and cannot be expected to be perfect in their perceptions and

interpretations of all medical imagery they encounter. Unfortunately there is nothing to

guarantee against a false-positive or a false-negative interpretation, as this process is

still determined by the human eye. Dr. Elizabeth A. Krupinski, an expert in medical

image perception, notes that ‘General estimates suggest that overall, there is about a

20-30% miss rate (false negatives) in radiology with a 2-15% false positive rate’14

which could also be read as a 22-45% rate of incorrect readings - a frightening thought.

34

13 ‘closed circle of representation’ John Urry explores the notion that tourism and photography are linked, photography promotes tourism, being a tourist encourages photography.

14 Elizabeth A. Krupinski. The Importance of Perception Research in Medical Imaging, Radiation Medicine: Vol. 18 No. 6, 2000. p. 330.

Krupinski in her role as president of the Medical Image Perception Society (MIPS),

advocates a need for research in this area to investigate the cause of errors reported

which include further testing of computer aided detection systems (CAD), eye fatigue,

use of visual feedback systems, and advancement in eye tracking technology.

Figures 2.2 and 2.3 are triptychs of mammogram images, each showing the

mammogram being studied in image (A), followed by the typical scanning patterns of

an experienced radiologist in image (B) and the typical scanning patterns of an

inexperienced radiologist in image (C). Figure 2.2 is a Normal Lesion Free

mammogram whilst figure 2.3 is a Lesion-Containing mammogram. Both examples

clearly indicate a more accurate and tightly focused scanning pattern of the experienced

radiologist in image (B) of the triptychs. These images stand as an example of the

difficulty involved in reading a mammogram showing that after intensive medical

training, the experience of continuous repitition is necessary for diagnostic accuracy.

Krupinski has conducted studies to investigate if radiologists have particular perceptible

abilities in comparison to the lay person when searching (non-medical) complicated

picture scenes of ‘Where’s Waldo.’ Commenting on the results from these studies,

Krupinski indicates that:

‘Radiologists do not seem to possess special search skills that predispose

them to being successful at searching radiographs. Much of what they learn

is through repeated exposure to and practice reading of radiographic

images.’15

35

15 Elizabeth A. Krupinski. The Importance of Perception Research in Medical Imaging, p. 332.

Figure 2.2 Scanning Patterns of a Lesion-free Mammogram (A)

experienced (B) vs. inexperienced (C)

Figure 2.3 Scanning Patterns of a Mammogram with Lesion (A)

experienced (B) vs. inexperienced (C)

36

Confirming ideas about the radiologists image perception but also confirming ideas that

the lay person has a visual literacy and ability to work with a difficult image when given

the criteria of the task. Allowing a perception of the overall image to be built in context

of its meaning to them, and not in context of its meaning to the medical profession

looking at the same image is key. A radiologist sees a medical image as a tool of

diagnosis - the lay person or patient sees a medical image which should not be so easily

disregarded.

Mammography as an Imaging Modality

Medical imaging technologies currently used in the field of breast cancer are

mammogram, breast ultrasound and breast MRI,16 all producing specific imagery to

assist in screening, diagnosis and treatment of the disease. I will focus attention on

mammography 17, as it is the screening modality of asymptomatic and symptomatic

patients. Tremendous technological advancements have taken place in mammography

imaging over the last ten years, mirroring the pathway that photography has shaped. The

analogue film based images produced in physical hard copy were interpreted by

radiologists against a light-box, as seen in figure 2.4, are being rapidly replaced by

digital based soft copy images that appear on computer monitors, see figure 2.5.

The benefits of digital imaging are many, and include reducing under/over exposure

difficulties that could ruin an x-ray film. Higher dynamic range allows for increased

37

16 Mammogram, Breast Ultrasound and Breast MRI - see definitions in glossary.

17 Mammography images were more difficult to obtain than expected, as a series of emails

included in the appendices indicates. The Data Protection Act prevents sharing medical imagery without specific consent from the patient, hence the reason for using medical images from [www] http://sciencephoto.com in the thesis.

analysis through dense breast tissue which was a major difficulty with analogue

imagery.18 A lower dose of x-ray can be administered with no loss of accuracy

benefiting the patient with increased zooming possibilities for close inspection of

masses and calcifications in suspicious areas. Comparing figures 2.4 and 2.5 is it

extremely difficult to believe that a magnifying glass was the only option to enlarge

image detail in comparison with today’s flexible zooming capabilities of computer

software in addition to the digital file benefits previously discussed in this chapter.

A mammography image will assist in illustrating part of the argument in this thesis that

outside of their diagnostic ability, medical images are possibly not used to their full

potential. I am not a radiographer, so no attempt will be made to interpret this image in

a diagnostic manner. Instead I will read the image to see what messages can be

interpreted, and discuss the possible perceptions available to a patient being shown this

type of medical image. Describing the image as seen in figure 2.6 as a lay person, the

image itself appears as an abstract object which could be described in relation to its

colour, shape, form, tone and texture within the composition. A slightly cold toned,

black and white image of a semi-circular shape, presumably the breast, with depth

indicated by shading towards the darkened outer edge. Inside, contrasted areas of light

and dark highlight details that indicate texture. The circular white shape in the upper

right section draws attention, also leading the eye to the other white sections - it is not

clear what they mean. This confirms nothing, about the relevance of the image but it

does describe the image, indicating that the image can be read at a basic level.

38

18 National Cancer Institute, Digital vs. Film Mammography in the Digital Mammographic Imaging Screening Trial (DMIST),[www] http://cancer.gov/newscenter/qa/2005/dmistqandA Accessed 25/01/2012

Figure 2.4 Analogue Breast Mammograms on Lightbox, M415/0291,

39

Figure 2.5 Digital Breast X-ray Mammograms, M415/0482,

40

Applying a methodology of semiotics to decode the message will bring another layer to

the image reading. The x-ray image is a signifier which also helps to indicate the

message being read is to do with the language of medicine. The breast represented in

the image as an object also becomes a signifier. Objects can double up as signs which

construct meaning, themselves becoming the signified. In this case, what is signified by

the breast is the concept of disease. The combination of the signifier (x-ray image) and

the signified (concept of disease) equal the sign (testing for breast cancer). A similar

interpretation can be achieved by considering what is denoted and connoted in the

image, i.e. an x-ray image of a breast being examined for signs of cancer. The

connection to medicine links the message with wider themes and associations such as

hospitalisation, medical insurance and terminal illness concepts that gradually become

more diffuse, entering the arena of general beliefs and social ideology. This reading

indicates how the medical image has ability to expand from a descriptive level into an

interpretive level with social effect.

Continuing the reading in another direction particular to the nature of photography, the

image seen here is not an x-ray - it is a photographic representation of an x-ray. It

maybe presented to the reader as an image printed onto paper or perhaps it is visible on

a computer screen. The indexical nature of the photograph is represented in what is

present and visible at this moment, which is also of the past. The historical

understanding of the image is tied to the time and purpose of its making but ‘a

photographic meaning is not fixed in history, it is the historian who does that: meaning

is fixed by the discourse of history,’19 because the image is polysemic. In relation to the

41

19 David Bate, Photography: The Key Concepts, Berg, Oxford, 2009. p. 21/22.

mammogram image within a medical context, it could be read either semiotically by the

radiologist for a diagnostic purpose or iconographically by the patient, as a symbol of

life or death.

Photographic images are also perceived as a true reality because the image traces what

is being seen in-front of the viewer and the physical object of the photograph assists in

confirming its materiality. Digital medical imagery appear to present difficulties as

images of the internal body are not recognisable and they cannot depict the usual scopic

regime of western criticism. This questions the indexical nature and the materiality of

the digital photograph which seem to have disappeared. According to Martin Lister, if

we ‘reflect on our felt experience of images… the difference between the chemical and

the digital photograph again ceases to be important.’20 In relation to the materiality,

‘Digital images become signs for photographs,’21 explaining that technology has simply

presented alternative but socially acceptable forms of viewing.

Examining the image through the theoretical framework set up in chapter one firmly

indicates the role of the medical institution and the systemised, structured medical gaze

upon it whilst recognising the patient’s passage through systems of spatialisation, like

surveillance medicine for the image creation itself. Looking at figure 2.6, the most

important factor is finding any indication of cancer, therefore confirming that medical

imagery functions in a particular way that is best interpreted by a radiologist.

42

20 Martin Lister, Photography in the Age of Electronic Imaging (in) Photography: A Critical Introduction, Third Edition, (Ed) Liz Wells, Routledge, London, 2008. p. 332.

21 Martin Lister, Photography: A Critical Introduction, Third Edition, p. 335.

Figure 2.6 Breast Lump, Coloured Mammogram X-ray, C010/4892,

43

Considering all the layers of meaning that can be interpreted from an image, does this

mean medical imagery should only function for the purpose it has been made? I believe

not. Although the previous readings discussed could never be used for diagnosis they

still help to build an important perception of the image. Earlier I put forward an

argument of double objectification of the patient. When a presumption is made that the

image cannot be read, it completely overlooks any personal or emotional attachment the

patient might have with the image. The x-ray represents part of the patient’s identity - it

is of their body. If disease is identified it would be within them.

Exclusion depersonalises, isolates and increases a sense of loss of control. Waiting for

results is often described by patients as the most excruciating time of a cancer journey -

feeling powerless, out of control and lost. It has a deep emotional effect on realising

one’s own mortality - a diagnosis can appear like a death sentence. Lesley Fallowfield

conducted over one thousand in-depth interviews with women suffering from breast

cancer to give insight of the disease from the woman’s perspective, noting ‘for many

women the diagnosis represented a major emotional catastrophe.’22 She also reported

that differing consulting styles of physicians ranged from ‘old-style paternalism to

modern-day clinical glasnost’, which respectively resulted in patients feeling either

‘deeply distressed or… reassured and comforted’23 when they were included in an open

dissemination of information.

44

22 Lesley Fallowfield, with Andrew Clark, Breast Cancer: The Experience of Illness Series, Routledge, London, 1991. preface ix.

23 Lesley Fallowfield, with Andrew Clark, Breast Cancer: The Experience of Illness Series. p. 115.

Patient or Viewer? The Possibility of both

Every stage of a medical process constructs an image in the mind of the patient,

drawing a comparison to John Urry’s concept in the tourist gaze. Destination images

connote the idea of travel, encouraging the tourist to pre-visualise a destination before a

journey begins, influencing expectations, preconceptions and the ‘anticipation of new or

different experiences from those normally encountered in everyday life.’24 A patient’s

gaze is not dissimilar; cancer connotes a journey towards a destination of life or death -

a journey that is full of expectations, preconceptions and anticipation. Susan Sontag

suggests the journey of illness requires taking up a passport in ‘the kingdom of the

sick.’25 Signifying that the patient’s identity has changed, which could also be construed

as meaning the current source of identification is the medical image - an image the

patient does not possess, recognise, and in most cases has not seen. Although Sontag is

speaking metaphorically, cancer patients experience economical and political

ramifications when purchasing travel insurance,26 as these companies now see them in a

high risk category. This refers to a financial power system in society, using information

provided through surveillance medicine generalising that all cancer patients are seen as

being high risk. It seems there are so many negative consequences associated with a

cancer diagnosis, what benefit is there to a patient by building a clearer perception of

their diagnosis by seeing their medical imagery?

45

24 John Urry, The Tourist Gaze-Leisure and Travel in Contemporary Societies, Sage Publications, London, 1990. p. 14.

25 Susan Sontag, Illness as Metaphor and AIDS and Its Metaphors, Picador, New York, 1989. p. 3.

26 Irish Cancer Society, Travel Insurance and Cancer - Information Factsheet, Web pdf. 2008. [www] http://cancer.ie/publications

Simply put this is not, a new concept. Patients understanding more about their diagnosis

diminishes stress and has positive effects as previously mentioned by Fallowfield in her

book ‘Breast Cancer’. Most GP’s surgeries have models of the heart, knee, spinal cord

or the womb that can be disassembled and explained to patients. They are helpful visual

tools in building a patient’s perception of the body part being discussed. Consider the

example of ultrasound during pregnancy. Not only will the patient be shown a

sonograph image, but most are offered a printed image to take home. It would be fair to

think this is because of the happy occasion as there are natural positive connotations in

the experience. However, this is not the case. A patient who has the unfortunate

experience of discovering they have miscarried during an ultrasound, may still be

offered a copy of the image, and encouraged to bring it home. These are just some

examples of patients being regarded as partners in their health/illness management

programmes. The days of the physician dictating instructions with no questions asked

are thankfully becoming a thing of the past.

Although it is agreed that the primary function of medical imagery is for screening and

diagnostic purpose, the medical image has been highlighted as being polysemic, yet it

still appears to be channelled in one direction only - despite the above examples

showing it can also serve a very important and useful secondary function. Patients

seeing and having their medical imagery explained to them, assists in building a clearer

more focused perception of their individual cancer. A perception indicates an

understanding. Understanding indicates a sharing of knowledge, and with that comes

inclusion and a momentary break in the struggle of power relations.

46

Most people are related to or know of someone who has experienced breast cancer, but

consider for a moment how often medical images like those highlighted in this chapter

actually penetrate visual culture through the internet, movies, television programmes,

magazines and everyday life, despite the multitude of examples given of medical

programmes in the introduction. The answer is not that often. There is a complete over-

saturation of imagery about breast cancer but there are also many images not seen in the

public arena because they fall under the radar of medicine, and have stringent data

protection act restrictions upon their usage. The increased numbers partaking in

screening programmes like BreastCheck Ireland, indicate that society understands the

importance of taking up this challenge to be involved in something that could possibly

save their life. To ensure it continues, there will be a need for further education and

sharing of knowledge so all the pieces of the puzzle become visible to the patient.

Stepping away from the private, systematic, organised medical arena and into the very

fast paced, multidirectional world of consumerism, chapter three explores how breast

cancer is represented in the public arena of advertising. Advertising presents a

challenging role, in a multi-million euro market that is constantly changing, always

open for criticism and under the gaze of all. What are the social effects of these images

as advertising removes the cold clinical gown that shrouds medical imagery and

replaces it with the warm hopeful glow of the ubiquitous pink ribbon?

______________________________________________________________________

47

Chapter Three: Social Imagery

The foremost concept behind advertising is to communicate a message that persuades

an audience to take note, which is predominantly made possible through the use of the

photographic image. Increased sales are typically the driving force behind this multi-

million euro commercial industry, targeting consumer awareness, behaviour and

lifestyle. The visual image combined with linguistics and embedded product names

cleverly designed into labels, logos, signs, symbols and trademarks, navigates a

pathway into the mind of the consumer that is absorbed both consciously and

subconsciously. Rance Crain, Editor of Advertising Age suggests ‘only 8% of an

advertisement’s message is received by the conscious mind. The rest is worked and

reworked deep within the recesses of the brain.’1 Regardless of profit or non-profit,

every company, business, and organisation is selling something, be it a product, service,

idea or cause. When advertising successfully constructs a sociocultural identity as being

wholesome and supportive, it enables the targeting of society who will openly respond

and react to a worthy cause.

One such cause began its public profile in 1974 when the First Lady Mrs. Betty Ford

‘became the first important public figure to utter the words “breast cancer” following

her diagnosis and radical mastectomy.’2 Over the next decade, many personalities

advocated for breast cancer awareness (BCA) but perhaps the most noted today is

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1 Jean Kilbourne, Killing us Softly 4: Advertising’s Image of Women, Media Education Foundation. Film, [www] http://mediaed.org/cgi-bin/commerce.cgi?preadd=action&key=241 Accessed 08/12/2011

2 Oncology Times, “Betty Ford’s Momentous Contributions to Cancer Awareness,”Vol. 33- Issue 15- p. 7-8. 10/08/2011 [www] http://journals.lww.com/oncology-times/Fulltext/2011/08 100/Betty Fords_Momentous_Contributions_to_Cancer.5.aspx Accessed 04/02/2012

Nancy Brinker, who lost her sister Susan Komen to breast cancer back in 1982. Spurred

on by her loss, Brinker established the Susan G. Komen Breast Cancer Foundation3

(Komen). The campaign for awareness slowly gathered momentum with October 1985

marking the first BCA month in America, seven years prior to the addition of a

symbolic ribbon.

The history of the ribbon is associated with awareness and support. Penney Laingen

borrowed the idea from the song ‘Tie A Yellow Ribbon Round The Old Oak Tree,’ and

did just that to show support for her husband being held hostage during the Iran Crisis

in 1979. Yellow ribbons suddenly appeared across the country. The concept continues to

show support of those involved in Desert Storm, the War in Afghanistan and

remembering those lost after the 9/11 attacks. The Red Ribbon was introduced by the art

group Visual AIDS in support of those living with HIV, as worn by actor Jeremy Irons

at the 1991 Tony Awards, targeting the attention of celebrities at the event - as well as

the television audience. In previous years, Komen, inextricably linked with the use of

pink products, gave out pink visors to participants running in the New York City ‘Race

for the Cure,’ but in 1991 she astutely swapped them for pink ribbons.

The launch of the Pink Ribbon in support of BCA followed shortly after as Alexander

Penney editor of ‘Self’ magazine, and Evelyn Lauder of Estee Lauder Cosmetics

amalgamated forces with Komen’s Pink Ribbon in a national campaign to place the pink

ribbon on cosmetic counters everywhere. This moved the disease of breast cancer out

49

3 Susan G. Komen Breast Cancer Foundation set up in 1982 by Nancy Brinker in memory of her sister and her battle with breast cancer. In 2007 the organization changed name to Susan G. Komen for the Cure, with a new logo of a pink ribbon that resembles a runner in motion.

under the spotlight where it needed to be, successfully raising awareness and delivering

much needed funds for cancer research, education and treatment. Witnessing something

quite phenomenal, ‘The New York Times declared 1992 the Year of the Ribbon,’4 which

in hindsight was also the birth of what is referred to today as ‘Pink Ribbon Culture.’

The Pink Ribbon

Komen’s choice of ‘Pink’ became a colour that symbolised so much more than the

definition of the word. It culturally connotes femininity, from the moment a baby girl is

born, wearing pink encodes a gender seal understood by all. It symbolises love and

emotion, attributed easily to women as they encapsulate it in all relationships of lover,

mother, daughter, sister and friend. Beauty cannot be overlooked either - often enhanced

by feminine elegance, mirrored in the elegant lines of the pink ribbon symbol. As

previously discussed, the ribbon has a strong association in symbolising awareness,

hope and support, traits particularly noted as feminine qualities, with the majority of

caring roles being held by women in society. The pink ribbon symbol5 sends out many

messages, one that is hopefully recognised by many aims to encourage women to

partake in a BCA mammogram screening programme. This assists in the promotion of

the monitoring gaze of surveillance medicine, but unfotunately it is not always the first

message interpreted by viewers of the symbol.

And what of the people who do not belong to the sociocultural norm within the realms

of surveillance medicine? Females under fifty or over seventy, the homeless, social

50

4 Sandy M. Fernandez, “History of the Pink Ribbon,” Think Before You Pink, 07/1998. [www] http://thinkbeforeyoupink.org/?page_id=26 Accessed 05/02/2012

5 Pink Ribbon Symbol is internationally recognised with an unusual status of public domain, allowing all breast cancer awareness organistations, charities, societies etc use the symbol.

minorities and what about men? They also suffer from breast cancer. How does

advertising deal with these minorities? The persuasive power of advertising deals with

minorities by sheer bombardment of ‘pinking’ the majority of society. To pink ‘means to

link a brand or a product to one of the most successful charity campaigns of all time.’6

Pinking is visible everywhere even on political and historical buildings like the White

House, the Brandenburg Gate and the Walls of Jerusalem’s old city that become bathed

in pink transmitting messages beyond political, economical and historical social

ideologies. Sports stadiums in the NFL like the Dallas Cowboys Stadium seats over

80,000 spectators has been awash with pink clothed spectators, pink goal posts, pink

cheerleaders, pink wristbands, pink towels - the list is endless. With so much good

taking place for altruistic purpose, minorities fade into insignificance.

Pink October lasts for a month, an opportunity not to be missed in the advertising world

as it has become obvious that the power of pink can instantly open doors across global

markets. Companies foresee an opportunity to improve public perception whilst raising

incredible amounts of revenue and funding for BCA however, the tide appears to be

turning against the overuse and abuse of pink ribbon culture. Believing that a new level

of transparency is needed Dr. Gayle A. Sulik recommends that society must become

more aware of where funding is going and exatly what it is being spent on before

consumers make purchases thinking they are supporting BCA.

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6 New York Times, “Welcome Fans to the Pinking of America”, 15/10/2011 [www] http:/nytimes.com/2011/10/16/business/in-the-breast-cancer-fight-the-pinking-of- america.html?pagewanted=all Accessed 05/02/2012

A Change in Awareness

In her book, ‘Pink Ribbon Blues: How Breast Cancer Culture Undermines Women’s

Health’ Sulik suggests that the pink ribbon has become an excuse for consummerism of

pink product shopping. She references numerous astounding examples of companies

whose profit margins have risen during a worldwide recession as a result of consummer

relations with cancer research. Interestingly, the field of medical imaging as discussed

in chapter two shows revenue increases of over $6 billion in the last 10 years: an

economic principle of supply and demand with the forecast set for continued growth.

Sulik notes; ‘Oncology drugs represent the largest share of the global drug market, with

sales projected to reach $75 to $80 billion by 2012.’7 These figures are staggeringly

high, yet experts report they are not any closer to finding a cure for breast cancer as

incident rates increase yearly. So the question needs to be asked, what percentage of

funding goes back into research? Sulik quotes figures for massive corporate companies

like Yoplait Yogurt, Ford Mustang and American Airlines who have all ‘done their bit’

for BCA and appear to have received quite a bit back in return. In short, profits are up,

profits are way-up.

Cartoonist Wiley Miller cleverly indicates the growing distaste and worrying consensus

of multinational corporates partaking in this over commercialisation around breast

cancer through pink ribbon advertisement in a bid to increase profit margins. (See figure

3.1). The cartoon perfectly illustrates Sulik’s concerns - subtlety supported by the

choice of publishing date coinciding with the first of October being BCA month.

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7 Gayle Sulik, “Birth of the Perceptual Fundraising Industry”, Pink Ribbon Blues, 15/10/2010 [www] http://gaylesulik.com/2010/10/perpetual-fundraising-industry/ Accessed 05/02/2012

Figure 3.1 Non Sequitur, by Wiley Miller, GoComics.com 01 Oct, 2010.

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Sulik comments on the cartoon. ‘Non sequitur? (Latin - meaning ‘it does not follow’) I

think not. The conclusion easily follows from the mountains of evidence that companies

within, and outside of the cancer industry are profiting from the cause of breast cancer.’8

Another organisation in complete support of Sulik’s opinion is Breast Cancer Action,

(BCAction) who launched a campaign in 2002 called ‘Think Before You Pink’ (TB4UP),

clearly stating its reasons for doing so is;

In response to the growing concern about the overwhelming number of pink

ribbon products and promotions on the market. The campaign calls for more

transparency and accountability by companies that take part in breast cancer

fundraising, and encourages consumers to ask critical questions about pink

ribbon promotions.9

The TB4UP website offers consumers a downloadable ‘Toolkit full of resources,

information and tools to understand the truth behind pink ribbon marketing’10

pinpointing the major questions that constantly need to be asked about the perception

the media is depicting of breast cancer, by use of the pink ribbon. Launching over ten

campaigns since 2002, TB4UP has influenced giants like Eureka and American Express

who have now stopped cause marketing. Other examples include the Komen 2008

‘Yoplait: Save Lids to Save Lives’ campaign, which was highly criticised when

customers had to send lids back to General Mills (GM) costing .39 cents per postage

with a .10 cent donation per lid going to Komen. However, it must be noted that Yoplait

donated $1.5million to BCA, but at the same time Yoplait increased annual sales by a

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8 Gayle Sulik, “Birth of the Perceptual Fundraising Industry”,Article No. 19. 20/10/2011 [www] http://gaylesulik.com/2011/10/19-birth-of-the-perpetual-fundraising-industry/ Accessed 3/2/2012

9 Breast Cancer Action, Think Before You Pink, http://thinkbeforeyoupink.org/ Accessed 04/02/2012

10 Breast Cancer Action, Think Before You Pink, http://gaylesulik.com/wp-content/uploads/ 2011/10/toolkit_learn_timeline.pdf Accessed 10/02/2012

massive 14% that year Concurrently, TB4UP ran an alternative campaign called

‘Yoplait: Put a Lid on It,’ demanding GM to remove rBGH (a biosynthetic growth

hormone) from their dairy produce, which was successfully achieved by the group

because of the questionable links this hormone has with cancer. Now GM and Dannon

produce rBGH free products.

In 2010, TB4UP launched a letter campaign regarding the hypocrisy of the Kentucky

Fried Chicken partnership with Komen called ‘Buckets for the Cure,’ when obesity is

one of the key factors associated with breast cancer. Komen received over 5,500 letters

from consumers and BCAction received huge media coverage, and the attention of the

Colbert Report. It is always shocking when the companies involved in these campaigns

are household names and part of the consumers everyday life. Advertisement branding

within western visual culture is so powerful that giants like American Express,

American Airlines, Yoplait and KFC do not always need to rely on an image to

represent them. Sometimes hearing their name mentioned is enough to recall an image

in the subconscious. Jean Kilbourne reports in her studies that the audience needs to pay

attention to how powerful advertising is, stating that: ‘its quick, it’s cumulative and for

the most part it’s subconscious.’

In addition to the regular power of advertising, when a highly recognisable branded

product image appears before the viewer, and the brand has been ‘pinked,’ it culturally

adopts the values associated with the pink ribbon. Trustworthy, honest and supportive of

a wonderful cause, - why would anyone look for an alternative product? The

unfortunate reality in the above examples is that consumers who buy into eating KFC or

55

Yoplait yoghurts, do so with the comfort of this background knowledge when actually

they are increasing their own health risks whilst supporting the continuation of cancer

causing foods. It appears the over saturation of pink has numbed society into believing

this is how to fight against breast cancer and how to help in finding a cure. The

perception of breast cancer is blurred by the complexities of pink ribbon culture making

interpretation of the image and what it connotes about BCA most difficult for the viewer

to read. Perhaps taking a closer look at magazine advertisements that do not promote the

pink ribbon, will clarify the viewers perception.

Sign of the TIME’s? 20 yrs : 3 Covers

TIME Magazine is renowned as a reputable publication that highlights political news

coverage from around the world. This weekly periodical is now available in both print

and on-line, running since the 3rd of March, 1923 with weekly publishing figures

estimated at over 3.3 million copies.11 In the last twenty one years, TIME has published

three front cover images specifically devoted to breast cancer which coincide with the

timing of the launch of the pink ribbon. However, the magazines objective nature

remains intact by not endorsing the pink ribbon or any specific foundation, society or

cause. The three cover issues are dated 1991, 2002 and 2007 respectively (see figure

3.2, figure 3.3 and figure 3.4.) I will interpret these cover images both collectively and

individually, regarding similarities of their messages as they appear to establish a

pattern that can be seen in these covers.

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11 Audit Bureau of Circulations, Paid & Verified Magazine Publisher’s Statement, Time-The Weekly Newsmagazine (04-1200-0), [www] http://timemediakit.com/pdf/abc-statement-time-1H11.pdf Accessed 12/02/2012

Figure 3.2 TIME Magazine Cover: Breast Cancer. 14th Jan 1991

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Figure 3.3 TIME Magazine Cover: Breast Cancer. 18th Feb, 2002

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Figure 3.4 TIME Magazine Cover: Breast Cancer. 15th Oct, 2007

59

Immediately reading over the three images, a repetitious style becomes apparent as they

all feature the naked female body. Not only does this send out a tone of sexualisation

but it stands as a stark reminder that TIME magazine is of course a product being sold

and one proven way to elevate sales is by ‘selling sex.’ All humans are naturally drawn

to gaze at the naked body. Presented on a magazine cover, the intention is to cause a

spectacle, by successfully capturing the viewer’s attention. It could be suggested that

cropping of the female body objectifies it more, lending it towards the perspective of

Laura Mulvey’s theory of the ‘male gaze.’ Sulik agrees that presenting women in this

way is highly problematic, but notes that ‘Sexualizing women in the name of breast

cancer is only one of the detrimental consequences of many pink ribbon

campaigns...they also emphasize their traditional social roles.’12

Although this is not a pink ribbon campaign, the same sexualised image signifiers are in

place as if it were. The traditional roles associated with identity construction of the

female could be seen as passive, submissive, weak and sentimental, all of which could

be attributed to these cover images making them injurious to female self-esteem.

However, the power of advertising will still capture the attention of female readers, as

they will be interested in accessing the information about this destructive disease but

also because the women depicted in the images turn their gaze away, drawing empathy

from the viewer by their indirect address, as discussed in chapter one.

There are visual suggestions of the medical gaze throughout all the images. Most

graphically represented in figure 3.2, in what appears to be a simulation of thermal

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12 Gayle Sulik, Pink Ribbon Blues, Oxford University Press, 2011. p. 373.

imaging detecting heat on the affected breast area. Considering the previous discussion

regarding scientific visual literacy, Jean Trumbo reminds us that;

‘Advertisers use images of X-rays or CAT scans to invoke the authority of

science to sell products. The question is whether any of these images are

accurate representations of science and, more importantly, what special

literacy skills are required to understand them.’13

This particular scientific visual reference is placed over the breast without any follow up

referencing of what the test could possibly be, how it is performed or what is its purpose

of use. Figures 3.3 and 3.4 appear to advocate the gentle but determined strength of the

female partaking in a practical self-breast exam, expanding the concept to all women

across the globe with a suggestion of doing the same.

The depiction of spatialisation and surveillance medicine is evident when continuing to

interpret the cover images in a chronological order. It moves continually forward,

beginning with the individual body part and continuing with the female participating in

a breast check and ending with the suggestion of global surveillance in parallel to the

movement of BCA. However, the wording of ‘Breast Cancer’ moves in the opposite

direction as it physically reduces in size over the years as if a metaphor for its medical

reduction, or perhaps the acceptance of the disease slipping away without a cure being

found. It remains highly questionable.

Other similarities to be noted include a shift of focus on the breast, the wording used

with the images, and the gradual appearance of pink in the advertisements. Beginning

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13 Jean Trumbo. Making Science Visible in Visual Cultures of Science: Rethinking representational practices in knowledge building & science communication, (ed) Luc Pauwels, Darthmouth College Press, 2006.

with figure 3.2, awareness is drawn away from the person and directly onto the female

body part. The breast is isolated, alone under the spotlight of testing. The wording is

bold and harsh - these are facts being dealt with, taking a forceful political stance

against it. The colour pink is not present anywhere on the cover, which was issued the

year before it became internationally associated with BCA.

In figure 3.3, the attention is focused onto the woman's elegantly poised body against

the aesthetics of the clinical blue background connoting a sense of self check with a

metaphorical backup of clinical medicine. Importantly, the three pink bullet points use

‘girly’ feminine wording of ‘smartest, gentlest, latest’ in a fashion orientated manner.

Pink begins to invade the cover space, and is highlighted strongly against the blue

background.

Lastly figure 3.4, cleverly concentrates on the profile of the female face, with her hand

protectively cupping her breast while the map is laid out across her body to mimic the

spread of the disease around the world. It must be noted the map directs viewer’s

attention towards eastern countries, where statistics of breast cancer are significantly

lower than their western counterparts. This could connote a more positve outlook for the

American readers (although the inside story reports on a Mongolian woman suffering

breast cancer). There is a defeatist, questionable tone in the wording used, increased by

the negativity of the models eyes being closed. Lastly, pink invades the cover space

straight across her face of the model, as the magazines title TIME is officially ‘pinked.’

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Advertising Effects

Therein lies a detailed reading of the cover images, but to really unearth the powerful

message advertising projects through the image demands further interpretation.

Drawing attention to specific meanings contained within, I would like to discuss how

these images portray women? Firstly, returning to the idea of sexualisation, the most

important factor that advertising is selling in these images is how women should look.

The answer is clearly seen by the models they use in the images - the ideal female

beauty. They look really good - each one with perfect skin, elegantly slim, no sign of

fat, spots, wrinkles, lines, or aging - instead the viewer can concentrate on manicured

nails, plucked eyebrows and perfectly groomed hair.14 For any reader who has had

breast cancer or knows of someone having had breast cancer the comparison to the

models used are too ridiculous to contemplate. There is no representation of a

mammogram, an ultrasound or an MRI examination. There is no scar, no biopsy, no

lumpectomy, no tumour, no lymphoma, no surgery, no mastectomy, no chemotherapy,

no alopecia, no radiation, no IV lines, no steroids, no exhaustion, no drug treatment not

even a sign of a hospital gown.

In fact these images have no associative representation of cancer, nor its treatments or

its after-effects. The models show no visible flaws. If they have any, then photoshop and

airbrushing has sorted them out for good. The images project a sense of well-being with

cancer. The indexical nature of the photograph transmits the truth of the image, making

them believable. Regardless of these advertisements supposedly being about breast

cancer, they are first and foremost magazine covers. The viewer is presented with a

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14 Jean Kilbourne, Killing us Softly 4: Advertising’s Image of Women,

flawless finish - anything else would simply not sell. The reality behind this situation is

in the problem that begins when women read these signs as being normal, comparing

themselves to what advertising indicates as normal.

Who do these images affect? Unsurprisingly, they have detrimental effects on female

self-esteem, especially when others, including men, consider this body image to be

normal too. Why wouldn’t they, when they are subjected to the same advertising that

presents this image of the female body. The idea continues to spiral out of control as it

impacts on the minds of young girls and young boys. It is particularly difficult when we

live in an environment that is obsessed with breasts as can be seen in advertising of

cosmetics, clothing, sports-wear, holidays and of course cosmetic surgery - so if they

are not perfect, you can still fix them! The message being transmitted in western society

through visual culture is that young girls need to be beautiful, stylish, sexy and not just

thin but super thin - size 0 or 00 is what to aim for. The fact is, these images effect

everyone. The cover page advertisements span over twenty years, and in that period

they do not provide the viewer with an image clearly depicting breast cancer.

Difficult as it may be to tolerate these misleading images, it is equally arduous when the

words in the accompanying article are flagrantly disrespectful. The accompanying story

to the 1991 cover page (figure 3.2), noted ‘Breast cancer struck the most evident of a

woman's assets, where the motherly and the erotic are joined. And treatment of the

disease was a nightmare of pain, disfigurement and uncertainty too terrifying to

contemplate.’ If the objectification of the image was somehow missed, there is no doubt

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about the blatant objectification of a ‘woman’s assets.’ They can be used for

breastfeeding, comfort or sexual pleasure.

As for the second part of the quote, the words sadly would be better associated with

figure 3.5. This image did not make the front cover of TIME magazine. It does not meet

the requirements of advertising needs and styles, but because of the many media spheres

constantly opening to visual culture, there is a place closeby where it can exist in its

own right - a concept that brings together visual news that cross over with art

photography which would suggest that ‘art photography’ can be excused from

advertisement rules and regulations. That place is ‘LightBox - a new blog by TIME’s

photo department, will explore how photography, video and the culture of images define

today’s world.’15

This photo-essay appeared on LightBox in October 2011, described as ‘A

Photographer’s Intimate Account of Her Mother’s Cancer Ordeal.’ A series of fifteen

images in total, accompanied by a multimedia video piece, narrated by the

photojournalist Nancy Borrowick - her mother and her father describing the feelings

that emerge during an ordeal like this. The images vary in content from being harshly

graphic to personal, showing a sensitivity that touches everyday life. Despite featuring

online in the middle of October ‘BCA month,’ there is no sign of any ‘pinking.’ Neither

is there a need for text across the photographs, and even the most basic visual literacy

skill will interpret a clear enough meaning from reading the image. How does this

image portray a woman?

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15 TimeLightBox, [www] http://lightbox.time.com/about/ Accessed 15/02/2012.

Figure 3.5 Dessert First Project, Stills No. 4, by Nancy Borrowick. 2010

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It says she is strong but not invincible. She is perfectly real without conforming to being

‘really perfect.’ She is brave in exposing reality and deals with the normalcy of her own

everyday. Having a breast removed from her body does not remove the woman, only the

breast. Who does this image effect? It should effect everyone who sees it for what it is -

a successful photographic representation of a cancer patient undergoing radiotherapy.

There is no vanity, no false perfection, no promise of an absolute cure and no distraction

of a pink ribbon it appears in this case honesty delivers a clearer perception.

______________________________________________________________________

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Conclusion

Although totally separated by their disciplines, the examples of medical and social

imagery foregrounded in this thesis are no different to any other image, in that they are

created for the attention of the viewer. The mammogram x-ray image is produced

specifically for those medically trained in the practice of radiology whereas the

advertisement image is produced for all members of society who will consume it. Both

image genres rely on the viewer's ability to read the message within the image which is

begins with the act of the gaze. Once the gaze is categorised by type it takes on

particular characteristics, ready to interpret the signs available. This interpretation

process is central to all forms of the gaze.

Similarly, in its simplest form, a photograph is perceived to be a picture of reality: with

the application of theory it becomes a lexicon of visual imagery, a representation made

by the photographer of the subject, for the viewer tripartite. Combining these

ingredients of the gaze and the image forms a method for building perception. Both

photographic genres sit easily beside each other under the umbrella of the gaze, but

begin to move away from each other in the way they present a perception of breast

cancer. It seems the medical image is being under used in building a perception for the

patient, whereas the advertising image is being overused, building a misleading

perception of breast cancer within visual culture.

The mammogram x-ray proves to function best as a diagnostic tool when being read by

a radiologist. However, this use excludes those outside of the medical arena, due to

scientific visual illiteracy. Often it is the patients themselves that are excluded from

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seeing and/or sharing their personal medical imagery. This suggests the message in the

x-ray has only one singular meaning (made by the radiologist) and is somehow different

to all other imagery by not being polysemic, or open to a secondary meaning, for

instance, by the patient. Examples of how other medical imagery such as ultrasound is

used in building a patient's perception through discussion and sharing of knowledge,

raises questions like, why is this not protocol with mammography imaging also? Being

female presents the possibility of having between 7-10 mammograms with BreastCheck

Ireland during the target age range. It is possible that after a 14-20 year span of

mammograms, a patient is no wiser as to what can be seen in those images.

Medical image perception is very highly regarded and respected within radiology,

requiring constant testing and investigation, and yet there is little to no regard for the

patient’s image perception. The irradiation of this particular objectification would surely

improve doctor/patient relationships, benefiting the patient in constructing a clearer

perception of the disease as indicated by patients themselves in lowering their stress

levels. This is not to say the medical image is prophylactic, but rather highlight the fact

it can offer more, than what it is being used for at present. Perhaps the continuation and

expansion of surveillance medicine programmes for the detection of other cancers will

become the catalyst behind the development of a patient's gaze. As populations are

becoming more involved in their personal medical healthcare, the opening of channels

of communication, knowledge and interest will perhaps utilise medical imagery in other

ways.

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Advertising imagery is the antithesis to medical imagery. It aims to target the majority

of consumers in society, communicating and selling a lifestyle, whilst depending on the

polysemic value of the image to maintain as many viewers as possible. Economics plays

a massive role in the industry, with millions spent on the creation of professional

advertisements that successfully persuade consumers to purchase products or support a

cause whilst penetrating viewers conscious and subconscious minds. Visual culture is

bombarded with the pink ribbon branding, which stands as an automatic symbol of

positivity, hope, awareness and support for the cause of breast cancer. However,

advocates of Breast Cancer Awareness (BCA) such as Think Before You Pink (TB4UP)

have uncovered problems posed by certain advertising campaigns linked with pink

ribbon culture, that benefit industry giants more than the charity they claim to be

associated with. It is a long and arduous battle, fighting against these difficulties to

break down the walls of false advertising is extremely difficult, highlighting the need

for greater transparency within the industry.

Examination of advertising the topic of breast cancer is also problematic in that the

message behind the image is doing little for the perception of the disease, but is

managing to sexualise and portray the body-beautiful instead. A closer look at examples

of cover pages of TIME magazine over a twenty year period reveals many problems that

are not just isolated to that news publication, but are to be found in many others like it.

These issues open up into a wider discourse of advertising’s depiction of women, that

interlink through the use of photography but can only be noted within the confines of

this thesis. A documentary image clearly indicates some of the harsh after effects of

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breast cancer treatment, which has the impact to speak volumes, but alas, it may be

quite some time before an image like this ever makes the cover page of TIME magazine.

Considering the imagery of the mammogram, the advertisement and the documentary

photograph - it appears each image has its place within visual culture. The mammogram

functions to indicate the presence of disease to the physician. The advertisement

functions by communicating information to society and the documentary image

functions as a visual narrative of the effects experienced by a cancer sufferer. Both the

advertisement and the documentary image differ from the mammogram in that they

have the ability to trigger a reaction in the viewer into thinking about their own personal

health which could then lead to seeking medical advice, a mammogram x-ray and so the

process ideally continues in a cyclical form.

Although neither genre of medical or social imagery is transparent, I would argue that

both have the potential to assist in building a clearer perception of the disease of breast

cancer for the patient/viewer and society, which can only be realistically achieved if the

institutes of power initiate a protocol to demand such clarity for the benefit of all

exposed to this disease.

A particular result I am delighted to have gained from writing this thesis is how the

research of literature has impacted on my photography. In the past I have often

considered myself as being objective when photographing, but from the moment of

considering an image, long before picking up the camera, I believe my reasons are of

course subjective. The result of this process has developed a more informed knowledge

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of theory, (and a realisation of a need to continue it) which has moulded the concept of

perception and awareness. This will greatly impact on the reason for making an image,

part of which is considering the viewer's final reading of the message contained within

the image. Adopting this into my philosophy of photography and applying it to my

photographic practice will hopefully provide a fundamental difference to the depth of

the image I will create.

In conclusion to my findings, my research and investigation has raised many questions

with regard to the perception of breast cancer. Although I have presented two areas for

discussion, many areas became of interest during the research. One such area I consider

in need of investigation is the series of ‘Factsheets’ and ‘Booklets’ published by The

Irish Cancer Society, as they particularly target the asymptomatic and symptomatic

patients alike. My initial observation is that the photographic imagery used to illustrate

these publications include many images of flowers or happy smiling people, all printed

in pink. Most imagery resembles advertisements for a woman’s knitting magazine or a

smiling competition, the only medical image that appears is of a male doctor holding a

chest x-ray, there is no representation of a mammogram or other testing modality

illustrated. Conducting a survey of patient reaction (both asymptomatic and

symptomatic) to these images could prove very interesting, considering the point of

dissemination is from breast cancer clinics, hospitals and doctor’s surgeries where the

patient is likely to experience them whilst experiencing a heightened sense of

awareness.

______________________________________________________________________

72

Appendices

Notice of Care

If you are concerned about the health of your breasts please have them checked as soon

as possible by your own GP or make contact with your nearest Breast Cancer Clinic or

Hospital. For further information regarding Breast Cancer you may find the numbers

listed below helpful.

Name Phone

Irish Cancer Society & 1800 200 700 Freephone

Action Breast Cancer

Website: www.cancer.ie/cancer-information/breast-cancer

Breast Check Ireland 1800 45 45 55 Freephone

Website: www.breastcheck.ie

Ireland’s Eight Specialist Cancer Centres -

National Cancer Control Programme.(NCCP)

Beaumont Hospital - Dublin

Mater University Hospital - Dublin

St. James’s Hospital - Dublin

St. Vincent’s Hospital - Dublin

Cork University Hospital - Cork

Waterford Regional Hospital - Waterford

Mid-Western Regional Hospital - Limerick

Galway University Hospital - Galway

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Research Emails: Difficulty in obtaining Medical Imagery

During the course of searching for breast cancer images to include in chapter two, I

discovered that it was becoming very difficult to obtain good quality medical images for

use in my thesis. I wrote to many cancer organisations, seeking the use of breast related

imagery and mammogram images. I heard back from The Irish Cancer Society in

November 2011, who were very helpful in answering questions I raised in regard to

breast cancer but they reported not to have an archive of images. They use stock

photography when designing information brochures and leaflets which they forwarded

on to me (see email below). Upon receiving the Cancer Information Factsheets I

discovered they do not have a photograph of what a mammogram image looks like in

any of their literature. There is one x-ray image that exists in a Breast Pain Factsheet

which depicts a doctor looking at a chest x-ray.

Email from The Irish Cancer Society.

On Tue, Nov 29, 2011 at 4:15 PM, Pauline Forrester

<pforrester@irishcancer.ie> wrote:

Dear Alison,

Thank you for your email.

I hope you found our telephone conversation helpful. I am forwarding our breast related

literature with visual imagery to you by post today.

Do not hesitate to get back to us if you require anything further.

Kind Regards

Pauline

Cancer Information Service Nurse | Irish Cancer Society.

43 /45 Northumberland Rd, Dublin 4.

National Cancer Helpline Freefone 1800 200 700 (Mon - Thurs 9 - 7, Fri 9 'til 5 )

E: helpline@irishcancer.ie

W: http://www.cancer.ie / Message Board / Cancer Chat

Registered in Dublin no. 20868 CHY 5863

______________________________________________________________________

74

I followed up my research with another series of telephone calls and finally made contact with the National Cancer Screening Service who said they would look into my request and suggested contacting the Irish Cancer Society and Breast Check Ireland which I had previously done. They replied by email with the following information attached.

Email 1 National Cancer Screening ServiceOn Mon, Jan 23, 2012 at 10:57 AM, Clare Manning <Clare.Manning@cancerscreening.ie> wrote:

Hi Alison,

Further to your call on Friday re accessing BreastCheck mammography images, unfortunately it’s not as straightforward as I originally thought. Due to Data Protection laws and the consent process that a woman agrees to when she attends for a BreastCheck mammogram, we are unable to share any information on a woman (including her mammography images) with parties outside those identified to the woman at consent – namely her GP, other health agencies or the National Cancer Registry of Ireland – even anonymously.

What I can suggest is that you put your request in writing to the acting director of the programme – Majella Byrne – for consideration as part of an ethics committee meeting.

Kindest regards,Clare Clare ManningCommunications ExecutiveNational Cancer Screening ServiceKing's Inns House200 Parnell StreetDublin 1 Tel: 01-865 9300 main lineTel: 01-865 9339 direct lineEmail: clare.manning@cancerscreening.ie The National Cancer Screening Service encompasses BreastCheck - The National Breast Screening Programme and CervicalCheck - The National Cervical Screening Programme.

______________________________________________________________________

75

Email 2 National Cancer Screening Serivce On Mon, Jan 23,2012 at 11.58 AM, Alison Baker Kerrigan

<alison.bk@gmail.com> wrote:

Hi Clare,

Thank you for your reply. I fully understand and respect your position and obviously I

also wish to comply with Data Protection Law. Could I ask how often a meeting like

this might take place, (an indication time wise would be most helpful) as I am under

time constraints? If it would not happen for a number of weeks I may have to use the

images I have accessed on the web even if they are not of the best quality. The main

criteria for me is that I represent the images to the best of my ability, and as discussed I

am attempting to source them in Ireland.

I look forward to hearing from you, and many thanks for your assistance.

Alison Baker Kerrigan

Undergraduate Photography Student

IADT Dun Laoghaire

CO. Dublin

______________________________________________________________________

Email 3 National Cancer Screening Serivce On Mon, Jan 23, 2012 at 3:05 PM, Clare Manning

<Clare.Manning@cancerscreening.ie> wrote:

Hi Alison,

I appreciate your time constraints, however the next meeting is not scheduled until the

end of February/early March.

Kind regards,

Clare

______________________________________________________________________

Email 4 National Cancer Screening Serivce On Mon, 23, 2012 at 3:11 PM, Alison Baker Kerrigan

<alison.bk@gmail.com>wrote:

Hi again Clare,

That is really helpful to know as my submission date is the 23rd of February 2012 so

that brings my line of enquiry to an end in this circumstance.

Thank you again for your assistance in this matter.

Kind regards

Alison

______________________________________________________________________76

Glossary of words in and around breast cancer

Alopecia: Loss of hair where you normally have hair.

Assessment: Further investigation of a mammographic abnormality or

symptom reported at screening. BreastCheck offers a triple

assessment approach which is a combination of clinical

examination additional imagery (mammography or ultrasound)

and cytology.

Asymptomatic: A patient being screened for a potential disease but is not

experiencing any symptoms of that disease is considered to be

asymptomatic.

Asymptomatic Breast x-ray (mammogram) used to look for signs of disease such

Screening: as cancer in women who are symptom free to detect a breast

cancer at an earlier stage.

Benign: Not cancerous. Cannot invade neighbouring tissues or spread to

other parts of the body.

Biopsy: The removal of a sample of tissue or cells for examination under a

microscope. Biopsy is used to aid diagnosis.

Cancer: A general name for more than 200 diseases in which abnormal

cells grow out of control. Cancer cells can invade and destroy

healthy tissues and can spread to other parts of the body.

Carcinoma: Cancer that begins in tissues lining or covering the surfaces of

organs, glands or other body structures.

Chemotherapy: Treatment using anti-cancer drugs.

Clinical Breast A physical exam by a doctor or nurse of the breast, underarm and

Exam: collarbone area.

Initial Screening: A woman’s first visit to a BreastCheck unit.

Invasive Cancer: Cancer that has spread to nearby tissue, lymph nodes under the

arm or other parts of the body.

Leukaemia: Leukaemia, lymphoma and myeloma are all malignancies that

arise from blood cells or from cells that go to make up blood.

These cancers are also known as haematological malignancies.

Lumpectomy: Surgery to remove the cancer and a small amount of normal tissue

around it.

Lymphoedema: A swelling of your arm after surgery or radiotherapy for breast

cancer. It can occur if the lymph is not draining properly fro your

arm, because the underarm lymph nodes have been removed.

Malignancy: Malignant tumours can invade surrounding tissues and spread to

other parts of the body.

77

Mammogram: An x-ray of the breast using low levels of radiation to diagnose

and locate abnormalities in the breast. The same test is performed

for asymptomatic screening and diagnostic breast exams needing

further clarification.

Mastectomy: Removal of your breast by surgery.

MRI Scan: A test that uses radio frequency (rf) waves in a powerful magnetic

field, the patient lies down as the table passes through a tunnel

like machine. These waves force the tissues and organs of the

body to release radio waves of their own translating the

information into 3D images of sections of the body on a computer

screen. Can also be used as an evaluative exam to check the status

of a tumor or the response of a tumor to treatment.

Radiologist: A doctor with special training in the use and reading of diagnostic

imaging.

Radiotherapy: The treatment of cancer using high-energy rays.

Scarcomas: Are malignant tumours that arise out of cells in the supporting

structures of the body (e.g. bone, muscle and cartilage).

Symptom: Any evidence of disease.

Tumour: An abnormal growth of tissue caused by an overgrowth of cells.

Tumours may be either benign (not cancerous) or malignant

(cancerous).

Ultrasound: A test that uses high frequencey sound waves that bounce off

internal tissues and organs producing an echo, this forms a

sonogram image on a computer monitor. Excellent at

differenciating between fluid filled cysts and solid tumors and

indicating how far a tumor has spread. Also used for image

guidance of fine needle aspiration or biopsy.

Glossary Sources

The Irish Cancer Society, http://www.cancer.ie/cancer-information accessed 23/01/2012.

Breast Check Ireland, http://www.breastcheck.ie/ accessed 23/01/2012.

______________________________________________________________________

78

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