Even though she had breast cancer in the past, the writer and journalist Barbara Ehrenreich, 76, hasn’t done a mammogram for the past eight years. As Ehrenreich immediately clarifies, “This was not based on any suicidal impulse. It was barely even a decision, more like an accumulation of micro-decisions: whether to stay at my desk and meet a deadline or show up at the primary care office and submit to the latest test to gauge my biological sustainability; to spend the afternoon in the faux-cozy corporate environment of a medical facility or go for a walk.”
In her new book “Natural Causes,” Ehrenreich deconstructs the systemic attempt to control our bodies and extend our lives. The book’s full title intimates what she’s getting at: “Natural Causes: An Epidemic of Wellness, the Certainty of Dying, and Killing Ourselves to Live Longer.” Put simply, we’re so afraid of becoming sick and dying that we turn our lives into an endless collection of rules, prohibitions and obsessions that, ironically, are liable to make life a misery and cause us to feel like a ticking bomb.
Five years ago, Ehrenreich moved to a residential complex in Alexandria, Virginia, half an hour from Washington. In contrast to the hyperbolic lavishness of the lobby and entrance – gilded chandeliers, outdoor swimming pool, view of the Potomac – her apartment is modest and minimalist. Her back is bent as she opens the door, and she points to a cane that leans against the wall. Ehrenreich has quite a few health problems, including knee and back issues that make walking difficult, but she follows a daily training schedule and adheres to a sugar-free diet, while continuing to publish books and write regularly for American newspapers.
She first got the idea of devoting a book to the American obsession to control body and mind when she noticed that friends and other contemporaries were talking relentlessly about their health. “I was fascinated by what was happening to people in my demographic, who were more and more consumed by their LDL levels,” she says smilingly. “I came from a working-class family that did not have the dietary concerns that upper-middle-class Americans came to have in the 1980s and 1990s. In my family we put butter on everything, including cake.
“At a certain point,” she continues, “I began to think I was eccentric, since people and friends were criticizing me: ‘Are you going to eat a cheeseburger?’ and I would always say, ‘Oh yes, I’m an American.’ So I began to feel a widening gap between me and a lot of educated middle-class people as they became more and more obsessed with their diets and exercise regimes. I was curious to find out where this ‘wellness epidemic’ was coming from.”
It’s easy to dismiss Ehrenreich’s healthy suspicion about the effectiveness and necessity of early-detection tests by suggesting that she’s afraid of positive results, which could well compel her to undergo debilitating treatments, and not for the first time. But Ehrenreich isn’t an advocate of alternative medicine or a pious believer who has decided to rely on a divine power. On the contrary, before she became one of the most respected journalists in the United States – on the back of her books in the ‘70s and ‘80s and her 2001 international best-seller “Nickel and Dimed: On (Not) Getting By in America” – she obtained a Ph.D. in cellular immunology from Rockefeller University in Manhattan.
To research “Nickel and Dimed,” Ehrenreich worked for months in jobs that don’t require education, connections or recommendation letters. She cleaned hotel rooms, worked at a Walmart and washed dishes for the minimum wage of $6 or $7 an hour. As she noted in the book, she wanted to discover firsthand if it was possible to survive in America without an economic safety net. Her conclusions were bleak: Even though she never turned down a job and worked around the clock, her earnings were barely enough to cover the rent in moldy motels. After having no recourse but to sleep in her car and needing painkillers to keep going, she terminated the experiment earlier than planned. The book documented life on the margins in straightforward, accessible language: without health insurance, social welfare or job security. This is America, or at least the America in which millions of people fight to survive.
“Nickel and Dimed” transformed Ehrenreich from a journalist and feminist activist into the standard bearer against abusive employment and worker exploitation. In the book’s wake, legislation was enacted in a number of states against abusive employment. In Israel, the book inspired the 2004 struggle in which supermarket cashiers demanded that management supply them with chairs and let them take a break on every shift.
Since then, Ehrenreich has published a number of books, including “Bright-sided” (2009), an unprecedented attack on the “positive thinking” trend that had swept the United States. So it’s not surprising that she terms herself, with a smile, “a myth buster by trade.” She has also authored dozens of essays, many of them on issues of health and gender. She writes in accessible language, which fuses her personal experience with weighty questions concerning inequality, public policy and sexism.
Ehrenreich’s science background also helped her become a prominent voice of the women’s health movement, a grassroots effort that emerged in the ‘60s to battle the paralyzing sexism of the American medical establishment. In addition to effecting change in the health system, the activists aimed to educate women about their bodies, the effect of hormones, contraceptives and gynecological problems.
“When we first started, the medical establishment was incredibly sexist,” Ehrenreich tells me when we recently met at her home in Alexandria. And she’s proud of the impact the movement had on the profession, pointing to the number of women becoming doctors. “It is an increasingly female profession,” she says. “We’ve been successful in some things.”
The pink-ribbon industry
“Natural Causes” (Twelve Books) is a return to the theme of health that occupied Ehrenreich earlier in her career. Like her influential 2001 essay “Welcome to Cancerland,” published in Harper’s magazine, in which Ehrenreich recounted how she coped with breast cancer, her new book makes a point of intersecting her personal story with broader diagnoses about the American health system. This time, though, the reader encounters new and more surprising enemies, beyond chauvinistic physicians or greedy pharmaceutical companies. One of the author’s fiercest attacks is on the popularity of meditation and mindfulness practice. And even in the eighth decade of her life, she avoids the usual clichés.
“I got so angry when I encountered the ‘pink ribbon cult’ that it was easy to write ‘Welcome to Cancerland,’” she tells me as we converse in her living room. “There is an entire industry selling pink teddy bears, cosmetics and pink-ribbon brooches. This cult is an attempt to promote narratives of survivorhood in which personal testimonials are more important than broader political or environmental debates. I was repeatedly told to think ‘happy thoughts,’ but all I could feel was rage. I was furious for not being able to talk about the role environmental pollution plays in the cancer epidemic. The fact that I wasn’t able to find an online forum in which I could express anything other than ‘positive thinking’ made me ever more angry and frustrated.
“Natural Causes,” she continues, “was born from similar feelings of frustration and rage. Generally speaking, when a doctor recommends a new test or procedure, I always pose three questions: ‘What is it?’ ‘Do I need it?’ And ‘What harm can it do?’ I think you should ask these questions about pretty much anything. I was simply not convinced by the breast cancer statistics [regarding the need for an annual mammogram].”
Still, you went through chemotherapy and were eventually cured.
“I’m not sure if I was cured or simply got over it. You just don’t know. In fact, I was having some pretty dramatic symptoms – weakness, fatigue – that might have suggested that the cancer was growing, until I stopped taking hormone replacement therapy and started to feel better. Maybe chemotherapy fixed me, maybe it was the decision to stop taking hormones, maybe the cancer was going to go away by itself. We’ll never know.”
Much of what Ehrenreich has to say in “Natural Causes” may be hard for some to digest, not least her claim that the Western world, and the United States in particular, suffers from an epidemic of overdiagnosis – and not, as conventional wisdom holds, from a lack of access and insufficient budgeting for preventive medicine. Ehrenreich also shares with her readers numerous disturbing examples such as a study suggesting that 70 to 80 percent of thyroid cancer surgeries performed on women in the United States, France and Italy in the first decade of this century “are now judged to have been unnecessary.” And, as she reminds her readers, these “unnecessary” operations are liable to produce pernicious, long-term side effects such as a lifelong dependence on thyroid hormones and a higher risk of chronic fatigue and depression.
Mammograms, Ehrenreich warns, are no less questionable. She cites “huge international studies” that “showed no significant decline in breast cancer mortality that could be attributed to routine mammographic screening.” In many cases, the mammograms found “slow-growing or inactive tumor sites,” and it was these that doctors were treating. “Treating pre-cancer and non-cancer may seem like a commendable excess of caution,” she notes in the book, “except that the treatments themselves – surgery, chemotherapy and radiation – entail their own considerable risks. Disturbingly enough, breast biopsies are themselves a risk factor for cancer and can ‘seed’ adjacent tissue with cancer cells.”
These days, she points out, a debate is raging among physicians about the effectiveness of tests for early diagnosis and of periodic testing. “There are many possible hazards of preventive screenings: You could get a false positive, which happened to me on my last mammogram eight years ago. I got a call and they told me, ‘You had a bad mammogram.’ My first thought was, ‘Oh God, am I going to go back to breast cancer?’ I spent weeks in acute anxiety, and then they finally said, ‘It’s not cancer. It’s just that now we have new, high-resolution digital mammography and it tends to produce a high rate of false positives.’ Did I have to undergo this? Was this worth my stress and anxiety?”
Still, countless women will tell you, “That mammogram saved my life.”
“We simply don’t know what saves or doesn’t save our life. I don’t know if my life was saved by the medical procedure I had when I was diagnosed with breast cancer or whether it was already going away.”
But we do know for certain that early diagnosis, before a tumor has spread to other organs, can save lives or at the very least improve them.
“But mammograms and biopsies are not innocent, harmless things. Biopsies can lead to other problems. In fact, I found some suggestions that cutting into a tumor during biopsies might free tumor cells, which can then spread around the body.”
Are you comfortable telling women to forgo tests for early detection?
“I’m not telling anyone what to do. I’m just saying, ‘Let’s look at the evidence first,’ and in my case it’s not very persuasive for a lot of the tests that doctors have been trying to push on me.”
Death as a scandal
The controversial arguments put forth in “Natural Causes” won mixed reviews for the book. A reviewer in The New York Times praised Ehrenreich’s direct language and noted the importance of the issue, but added that “more than 27 million Americans without health insurance would surely be glad to have the checkups and colonoscopies that Ehrenreich has chosen to forgo.” Asked whether the most urgent problem of the American health system was limited access to preventive medicine and not overdiagnosis, she said no.
“We have to increase the amount of health care available so we can reach everyone who needs it,” she says. “But it’s not necessarily the same health care we have now. Poor people need more prenatal screenings, not colonoscopies.”
It’s important to note that Ehrenreich didn’t wake up one morning and decide that she would now politely refuse annual examinations to determine whether her body was working properly. The major argument of “Natural Causes” dates back to a decade or so ago. At that time, Ehrenreich came across a new study in a medical journal that dealt with macrophages, white blood cells in the immune system that eliminate foreign particles by swallowing and dissolving them. Ehrenreich’s doctoral thesis happened to be about macrophages.
As a doctoral student, she says, macrophages (the term comes from the Greek words meaning “big” and “to eat”) were “my favorite cells,” and she studied them as “cells that can help us.” That’s why a decade ago she was “so taken back” to learn that macrophages “actually go over to the other side with cancer and promote the spread of the tumor.” She recalls, “That was a stunning blow for me. We tend to think of our bodies as harmonious, with everything doing its part to promote the well-being of the organism. And when you find out that, in fact, different groups of cells are following their own agendas, that changes the whole picture. The biology of multicellular creatures has to be rethought. There is nothing controlling them in totality and keeping them all in line. We need to find out what influences their decisions.”
However, most Americans, and especially the upper crust or the CEOs of Silicon Valley, refuse to think of their body as a conflict-riven battlefield where every attempt to establish complete control over it is doomed to failure. In the book, Ehrenreich quotes Larry Ellison, co-founder and chief technology officer of Oracle, and one of the world’s richest people, who said, “Death makes me very angry.” Ellison is not alone. The Russian media tycoon and billionaire Dmitry Itskov declared in his early 30s that he intended to pass Methuselah and live for 10,000 years. And Chris Crowley, author of the best-seller “Younger Next Year,” has stated that he views death as an “outrage.”
Though the combination of technology and science in an attempt to solve the “problem of death” has gained momentum this century, the “wellness epidemic” that Ehrenreich is trying to map began, she says, in the ‘70s. That was the decade of a serious crisis of confidence in the American political system due to the Vietnam War and Watergate. In “The Complete Book of Running,” first published in 1977 and considered the bible of the new fitness advocates, Jim Fixx wrote, “Having lost faith in much of society, government, business, marriage, the church and so on – we seem to have turned to ourselves, putting what faith we can muster in our own minds and bodies.”
Ehrenreich cites a large number of examples about the way American neoliberalism helped spread the myth that everyone can and should exercise control over their life, body, weight and mental and physical health. The myth of a “self” that can be managed, controlled and become ever more efficient was the raison d’etre of the most recent incarnation of American capitalism. In the ‘70s, for example, the number of gyms and health clubs surged.
But there was another reason, beyond the decline of trust in institutions, that the obsession with fitness and nutrition became a national epidemic. It was because in the ‘70s millions of Americans started to get health insurance through their employers. Now, insurance premiums were liable to rise if the employee was part of a group of insurees containing smokers, alcoholics or others with health problems that were perceived as risk factors. In 1977, the president of the Rockefeller Foundation, John H. Knowles, tapped into the new zeitgeist: “The cost of gluttony, alcoholic intemperance, reckless driving, sexual frenzy, and smoking is now a national, not an individual, responsibility. One man’s freedom in health is another man’s shackle in taxes and insurance premiums.”
Instead of treating medicine as a system that can save lives and provide a response in an emergency, Ehrenreich relates persuasively how the yuppies started to cultivate a tough training regimen and new diets in an attempt to prevent any medical problem that might shorten their lives. Four decades later, that “solutionist” approach has become the common sense of Silicon Valley and among other American elites. In one of the most amusing – and disturbing – sections of the book, Ehrenreich surveys the Spartan regimen of nutrition and fitness training of technology gurus such as the futurist Ray Kurzweil, who takes no fewer than 250 nutrition additives daily in order to “reprogram my body’s biochemistry” – and hopefully live forever.
Regrettably, history proves that even the strictest nutrition regimen hasn’t yet managed to ward off the angel of death. As Ehrenreich recalls, Lucille Roberts, who established a successful chain of women’s gyms in the United States, who worked out every day and “wouldn’t touch a French fry, much less smoke a cigarette,” died of lung cancer at age 59. Jim Fixx, who in his day was a very famous fitness guru, died at 52. Even Steve Jobs, who ate raw and vegan food and embittered the lives of employees and colleagues who were less stringent about their nutrition, died of cancer at 56.
Ehrenreich refers to these cases in order to make the point that not even money, ambition, iron discipline and access to the most advanced medical services can guarantee a long life. Having scientific training herself, she says, “I want the scientific search for answers to go as far as it possibly can. But I also want to reassure people. You can’t control every aspect of your body. So just relax a little bit. This cookie is not going to kill you.”
If you could, would you want to live forever?
“I’ll take what I can get. Maybe 15 more years would be sufficient.”
What would be your ideal way to die?
“I had some scary experiences kayaking in storms and rough water and I was close to death. And I thought, ‘This would be a good way to go.’”
Basing herself on numerous scientific studies, Ehrenreich recommends to her readers, especially the women, to clarify all the possible risk factors of every test that’s suggested to them. She also assails the attempt to achieve control over our consciousness through techniques such as meditation or mindfulness practice. Contemplating the 500 smartphone apps that offer guided meditation, she notes that no study has yet found a definite connection between the use of meditation or meditation apps and health advantages such as a decline in illness or an increase in lifespan.
I ask her why she’s attacking an accessible, cheap and effective method to reduce stress. “I’m sure these techniques have some effect,” she replies, “but the studies that I cited in the book show that meditating for 15 minutes is no better for you than having a chat with a friend over a glass of wine.”
How do you explain the fact that millions of people practice meditation or mindfulness?
“Meditation creates the illusion that if we only want to, we can control our consciousness and our body – and illusion is always bad. Why not let people enjoy positive thinking? Because it’s based on illusion. I guess I’m very hard-nosed about truth, reality and other things we seem to have forgotten about recently in this country.”
But the alternative – which is “we’re all gonna die” or “old age is a massacre,” as Philip Roth wrote – is simply too morbid and depressing. These are difficult truths to cope with.
“So I should tell lies?”
Pass the kombucha
Despite its assertiveness and uncompromising commitment to sometimes painful truths, “Natural Causes” is a book filled with love of humanity, compassion, even optimism. If the thought that we can control our body and our future is a result of historical cultural and political transformations that began in the ‘70s, the realization that complex biological processes exist that are hidden from the eye can help us live a more liberated life.
In a chapter devoted to smoking and fast food, Ehrenreich urges her readers, most of whom can be presumed to be from the upper-middle-class bourgeoisie, to stop preaching to the working classes and trying to change their eating habits by force. From her perspective, the justified war against cigarette smoking and its hazards quickly became a campaign against lower-income groups.
“I see in a lot of these initiatives around health – such as the Jamie Oliver Food Foundation [aiming to “combat childhood obesity”] – class prejudice, a failure to take into account what people have traditionally eaten and what they like, a failure to understand the conditions of their lives. It’s just the snobbish element of it all that bothers me. We have to understand why people smoke, drink or eat fast food. People have the information to quit or change their habits. I would say, ‘Don’t smoke,’ but I won’t say it in an arrogant, upper-middle-class way. Perhaps the cigarette break is their only opportunity to talk to other workers or relax a bit.”
I return to the question of personal responsibility. The financial costs stemming from longtime smoking are ultimately borne by the public. Why should the taxpayer have to underwrite a way of life that clearly heightens the risk of cancer, asthma and other illnesses?
“Compare those self-inflicted injuries with all the other hazards that working-class people are facing, from injuries on the job to pollution of various kinds. It is really unclear which of these conditions are most problematic. Rather than harassing individual smokers and making them feel guilty, maybe we should talk more about the water crisis in Flint, Michigan? Working-class communities face more pressing threats than smoking.”
Taking your argument to its extreme, I can say we have no control over our bodies or our cells. And that opens the door to the claim that the government doesn’t have to invest in public health programs since everything is random. Why even try to educate people? That approach could lead to fatalism and determinism.
“I’m not saying we have no control. Things going on at the cellular level are going on for their own microscopic reasons. We just don’t have control over that. But I think it would be a good thing if more of the affluent people of the world who are obsessed with their cholesterol levels would just relax a little. That way, we could sit down and think about what we can change collectively – like air pollution.”
And in the meantime shouldn’t we educate people to abandon fried food in favor of fresh vegetables and a low-calorie diet?
“I’m not sure we really know what the right thing to eat is. In the 1990s the big enemy was fat, so people switched from French fries to ‘fat-free’ cookies. They started eating more sugar, and that’s one explanation for the obesity epidemic.”
But there are recommendations for which there’s a consensus, such as to eat more fresh food and less processed food, or to reduce the intake of carbohydrates.
“Yes, and personally, I don’t eat sugar. I just think that there are too many trends one after another. I had a friend staying here lately and she brought a bottle of kombucha. I asked her, ‘What the hell is this?’ and she couldn’t answer. And we’re not finished with kale, are we?” she says with a wink.
These days, Ehrenreich is working on a new book on the rise of narcissism, and also devoting a lot of time to the Economic Hardship Reporting Project, an organization that commissions articles covering issues related to poverty and inequality. The pieces are then placed in established publicatons. “We’re trying to counter some of the horrible things going on in journalism, like the fact that nobody wants to pay journalists,” she explains. “If you’re affluent enough, as I am right now, you could do it for free because it’s important for you. But you can’t do that if you struggle to pay your rent. This is where we come in: We say ‘you do this piece of work and we’ll see that you’ll get about a dollar per word just as you would have gotten 20 years ago.’
“What gives me hope is some of the individuals that we have supported, and how their lives have improved,” Ehrenreich continues. “Take Stephanie Land. When we first met her she was a single mother and a cleaning lady. She wanted to write about it and we worked with her to polish her stuff. We got something into The New York Times and now she’s got a book coming out called ‘Maid,’ which I think is going to be very important. There are a lot of people like that. For me that means ‘I’m old. I’m getting out of the way and you gotta take it from here.’ That’s my idea of immortality.”